Appealing A Denial

If a health plan does not cover a specific intervention or treatment, and it is explicit in the policy that this is the case, it is unlikely that an appeal to receive coverage will be successful. However, there are many instances when a denial is basically a difference of opinion as to the value of a treatment. When this is the case, proceeding with an appeal is not only recommended, it is often very successful.

The first thing you must do is review your policy and be absolutely clear about the appeal process. All health plans must specify the avenues to follow in order to have the plan reconsider its decision. This is true whether it be a private plan, Medicaid, or Medicare. It is important that these procedures be followed, particularly in terms of time limits, to be sure that your appeal is not summarily dismissed.

An important part of any appeal is documenting your position. The better you know MS and your particular disease course, the better you will be able to advocate on your own behalf. Use a health journal to document changes in your health status and your response to treatments and medications. Gather materials and peer-reviewed literature that can support your position. (Your National MS Society or

Paralyzed Veterans of America chapter can assist you with this.) Engage your physician as a partner in advocating for reconsideration of the denial.

If you complete your health plan's internal appeal process and continue to be dissatisfied, there are still other alternatives to pursue. Your next step will depend on the type of plan you have and what governmental entity oversees the plan. At this point, it is very important for you to know, if you have employment-based insurance, whether your plan is "fully insured" or "self-insured," as described on page 153.

If you have a "fully insured" employer group health plan, your plan is regulated by your state's Department of Insurance and is subject to state regulation and legislation with regard to patient rights. Questions about your protections and rights can be addressed to your state Insurance Department. If you have a fully insured plan, and you have exhausted the internal review process, most states have an external review option, which you can pursue.

Federal legislation, called the Employee Retirement Income Security Act (ERISA), prevents states from legislating "self-funded" employer plans. It says that states can regulate insurers but cannot regulate employers. Therefore, these plans are not subject to state overview or external review. They are regulated by the U.S. Department of Labor. Although these plans must provide an internal appeals process, the only recourse following an internal appeal is the filing of a lawsuit.

It is important to remember that it is ultimately the employer who determines the health insurance plan that is offered to employees. Therefore, it might also be appropriate to appeal directly to your employer to make sure that he understands the hardship of a particular decision or denial.

Medicare has its own external review option that is described in your Medicare handbook. It begins with an independent contractor, proceeds to an administrative law judge, and then on to the Department of Health and Human Services Appeals Board. For those covered by Medicaid, state external review does not apply, but the right to a fair hearing is in place.

Although the process of appeal may seem daunting, and you may require assistance in going through the process, it can often be a worthwhile effort and result in the reversal of a denial.

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