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Health Insurance Answers

Insurer did not approve what your doctor wanted? Here’s what you can do.

As the first subject of Health Insurance Answers I will discuss the issue of when your insurance plan rejected a test, a procedure or a medication, ordered by your doctor. You have your rights! If any of this is very important to both you and your doctor you need to start an appeal process with the insurance company.

This is a problem that will confront each of us at one time or another. You need this issue of Health Insurance Answers.

Now, most health plans are guided by your state’s insurance regulations. When a member’s request for a procedure or test is declined or rejected by the plan you have rights. These are called APPEALS, and you can appeal the decision.

The health insurance companies have usually TWO levels of appeals, generally a first and second level. Here is some background that will help.

In the first level of appeal the original information provided by your doctor and any additional important information dealing with the case needs to be submitted from your doctor or yourself and can be reviewed again and another decision rendered. This is reviewed by a physician who had no part in the original decision. If after the first level appeal your request is again denied you have the right to ask for a second level of appeal.

In the second level appeal all the information will again be reviewed by another doctor who had no contact with the case. Sometimes at this second appeal level you, the member, can come to the meeting to give your side. The timeframes for an answer is relatively short but vary with the regulations of the state.

If you are still not satisfied with the decision and want to pursue your request you may be allowed to have your case reviewed by an external appeal party (one not employed by the health plan). This is usually overseen by the state department of health or insurance. You should expect that the test, procedure or medication may need to meet a certain dollar minimum usually $500 before the case can be reviewed by the outside party. In most states you need go through the entire appeals process of the company. Some states like New York you do not.

I need to explain what is an ERISA plan. ERISA means the Employee Retirement Income Security Act which is a federal law for companies that fund their own health benefits. Under this act employers are able to define the health benefits that they will have for their employees.

They do not have to follow the rules or mandates that a state may impose for non-ERISA health plans. For example, Massachusetts has a mandate that requires health plans to pay for infertility treatment. ERISA based insurance plans do not have to follow this rule.

Today most ERISA plans do have some form of appeals for there employees. This typically is run by the administrator of the plan. The administrator is the entity that actually pays out for the medical claims for the employer health plan.

So, as health insurance members you certainly do have rights. In my experience anywhere from 40-60% of appeals come out in the members favor.

It is difficult to find a good book on health care Insurance but here are a few I would recommend. Take a look!

Health Insurance (Made E-Z)

Pricing the Priceless: A Health Care Conundrum (Walras-Pareto Lectures)

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