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New Rules Help Consumers Challenge Health Claim Denials

Health Claim Form

— Tetra/Getty Images

Fighting back when your health insurance company denies a claim just got a little easier, thanks to federal rules recently issued under the health care overhaul law.

The new regulations expand consumers’ rights to appeal denials, including the right to an independent, external review board. Consumers can also use the appeals process when their coverage is canceled.

Previously, rules regarding a patient’s right to appeal varied by insurer and state. The change creates consistency in the appeals process and—for the first time—extends the external review guarantee to employees of companies that offer their own health plans without contracting with an insurance provider.

The regulations will apply to new health insurance plans starting Sept. 23.

“Until the [health care law] reform, only a select number of states honored external review,” says Erin Moaratty, a spokeswoman with the nonprofit Patient Advocate Foundation (PAF), which helps patients navigate the appeals process. “Now every state is required to have a process for external appeals.”

The Hampton, Va., foundation helped Rona Dondzilo, 60, of Spokane, Wash., get an external review after she had been denied coverage for treatment of endometrial cancer. “The insurance company said it was a preexisting condition because I had been spotting before I was diagnosed,” Dondzilo explained.

She appealed using the insurance company’s internal process, then turned to PAF to help her get an external review. She eventually won.

To date, external review boards have reversed about 45 percent of appealed denials, according to the Kaiser Family Foundation.

In order to successfully overturn a denial, Moaratty stresses, consumers must keep careful track of paperwork and phone calls. The three most important tips PAF tells its clients:

Keep records. In a notebook or binder, carefully write down the date and time of each call to your insurer, whom you talked to and what you discussed.

Watch deadlines. Make sure you meet the insurance company’s deadlines for filing an appeal. The deadlines are spelled out in the insurance contract. If you miss a deadline, it may be impossible to file an appeal.

Follow up. Don’t assume that something will be done just because you made a phone call or sent a fax. And if you mail information to the company, make sure you send it certified so that you get a receipt showing it was received.

Remaining determined is also key, says Dondzilo.

“People get a denial and think they won’t win, but they need to take it as far as they can,” she says. “It’s their right to keep pursuing an appeal.”

Candy Sagon writes about health and nutrition for the Bulletin.

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