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

When the insurance company denies your insurance claim, for the reason that the claim was not covered under your policy. You should call your insurer and make sure that no errors were made while filling the policy. Most of the denials are because of administrative errors. If not, review your policy and make sure you understand exactly what it covers.

If you still think that you should get the claim, you can go ahead with the appeal process.

If your appeals are denied, the next step is to contact your state regulator. Some states have an ombudsman who can guide you through the process. Your state's department of insurance will be able to tell you exactly how much assistance they can provide. To find out who to contact in your state, go to the National Association of Insurance Commissioners Web site. You will also want to file a complaint about the insurer at your state's department of insurance.

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