Question

Researchers studied the outcomes of appeals from 1998 through 2000 (Studdert and Gresenz, 2003; Gresenz and Studdert, 2004). The researchers abstracted information from 3,519 appeals lodged against two of the largest health maintenance organizations (HMOs) in the country. The enrollees were disputing the plans’ decisions.

Of the appeals, 1,774 were pre-service appeals (Studdert and Gresenz, 2003). Preservice denials occur before the services enrollees are seeking have been provided. The researchers classified the pre-service appeals into five types: out-of-network, contractual coverage, medical necessity, administrative issue, and not evident reason. Enrollees were most likely to win appeals in cases in which the reason for the denial was not evident (52.7 percent) or which involved medical necessity (52.2 percent). Enrollees were least likely to win cases involving contractual coverage (33.2 percent). Overall, enrollees won appeals in 41.9 percent of the cases.

Questions:

1. Research the web and find out the process for appealing health care claims in your state. (Indiana)
2. Explain the steps that you would take to appeal a health care claim.

Answer 1

Process for appealing health care claim:

1. Health care insurer refuse to pay claim or ends your coverage you have the rights to appeal the division and have it renewed either internally or by a third party.

2. You ask insurance company reconsider its decision. Insurer have to tell you why they have denied your claim or ended your coverage. And they have to let you know how you can despute the decision.

3. There are two way appeal the health plan decision:

Internal appeal:

If your claim is denied or insurance coverage is cancelled. You have a right to an internal appeal. You can ask your insurance company to conduct full review if its decision. If the case is urgent your insurance company should speed up the process.

External appeal:

You have a right to take your appeal to third party for review. This is called external review.

Steps:

1. Review your health plan and know the details of your insurance appeal process.

2. Get your entire claim file.

3. Get written help from your treating doctor.

4. Take detail notes when you speak with your insurance company.

5. Write down your arguments.

6. Follow up with your insurance company.

7. Your appeal is denied file case in the court.