Researchers studied the outcomes of appeals from 1998 through 2000 (Studdert and

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.

What is your recourse if your health care is denied?

Explanation / Answer

I would first find out what led to the denial of coverage and learn my insurer`s procedure for appeals.
I would need to documents to reconstruct what lead to the rejection and also the denial letter.

The other thing I would need is a copy of the benefits on the insurence I have.

with all this information I would go immeditately to health insurance consumer advocates from my state

Ask for help from the doctor by him writing a letter on my behalf to prove the threatment is medically necessary.

With all the informaiton I would submit it to my insurer.

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