Did you recently have a medical claim denied by your employer sponsored group health insurance plan? Did you breast enlargement procedure go horribly wrong and people now call you Frankenboob? You might be entitled to get the claims decisions appealed!
On January 1st of this year, all 44 million Americans on a group plan which is self insured by the company are entitled to an external appeal due to the health reform bill. A self insured plan simply means that the company is large enough to underwrite their own claims instead of using an insurance company to pay claims.
This external review process includes an arbiter that has no skin in the game so to speak (no gain or loss comes from the decision) and decides if the medical procedures are necessary and thus covered by the plan. The GAO is finding that 54% result in a change in the decision which is binding and final (not able to be appealed).
The main issue now though is that no one knows about the review process!
Part of the reason for the blackout on information is that the government didn’t require the employer to inform members about the change this coming July 1st, and because most plans renew annually in January, employees won’t even know till next year.
Even worse news is that patients only have 180 days from the date of the denial to appeal. From there if the appeal is denied they get another 180 days to appeal to the external arbiter. Obviously, this is creating an incentive to keep the change in the appeal process quiet for employers. Of course some plans are making the effort at least to inform their employees/members.
Another Obstacle
The next obstacle in this situation is a lack of accredited review organizations. There are 14 getting accredited though and if you are an entrepreneur this sounds like a potentially lucrative field. Still, with an expected 2500 reviews at an increasing rate till January 1st there will be a shortage. By next year this number will get significantly higher by January 1st. Each self insured plan is legally obligated to contract with at least three review organizations to make this process as quick possible.
As of now this last obligation has already been reduced to one.
