Have you ever stepped up to the pharmacy cash register only to learn your new prescription will cost you hundreds of dollars — instead of your typical $25 copay — because your insurance doesn’t cover it? Or received a painfully high bill for a medical test because your health plan didn’t think it was necessary?
Most people have, but only a tiny fraction ever appeal such decisions. In 2017, for example, enrollees in federally run Affordable Care Act marketplace plans appealed fewer than one-half of 1% of denied medical claims, according to an analysis by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)
If you do appeal, your chance of getting the health plan’s decision overturned is a lot better than you might think. “About half of appeals go in favor of the consumer,” says Cheryl Fish-Parcham, director of access initiatives at Families USA, a health care consumer advocacy group.
There’s no sugarcoating it, though: Getting to “yes” with your health plan can be an ordeal, and you may need help from friends, family members, your doctor, insurance counselors, even legal aid societies.
In California, health plans are supposed to help facilitate the appeals process. When they deny coverage, they must inform members in writing how to appeal. And when they receive enrollee complaints, they are required to acknowledge them formally, which sets the clock ticking on a series of steps to resolve the dispute.
Unfortunately, insurers don’t always comply with these requirements.
Last month, the Department of Managed Health Care fined Anthem Blue Cross $2.8 million in a settlement covering more than 200 grievance and appeal violations. In some cases, Anthem classified grievances as “inquiries,” which means many enrollees did not get important information about their appeal rights, says Shelley Rouillard, the department’s director.
Mike Bowman, an Anthem Blue Cross spokesman, says the company “is making significant changes in our grievance and appeals process.”
Rouillard says Anthem has had more grievance and appeal violations than other insurers, but “this happens with all the plans.”
Regardless of the type of insurance you have, you can do several things to strengthen your position even before you file an appeal.
For starters, get organized. You will need up-to-date medical records, as well as all communications with your doctor and health plan and any other paperwork that might bolster your case.
“Don’t do anything over the phone. Do everything in writing. You need a paper trail,” says Maria Binchet, offering her hard-earned wisdom from the trenches.
Binchet, a resident of Napa County, has a rarely diagnosed and disabling illness called myalgic encephalomyelitis/chronic fatigue syndrome. Because none of the doctors in her Medicare HMO network has expertise in the disease, she says, she has requested referrals to outside specialists on numerous occasions over the past 22 years, been turned down each time and appealed nine times. After one of those appeals, the health plan allowed her a single visit to a specialist — but he wasn’t taking new patients.
“You have to be persistent and resilient,” she says.
Binchet also advises that you request from customer services the unredacted notes of the health plan’s internal discussion about your case. The notes can help you determine how extensively your case was considered, who made the decision and whether that person was medically qualified to do so.
A letter or phone call from your doctor to the health plan can provide valuable support. “It’s important that you get someone involved who can talk about the medical evidence, because that’s what this is really about,” Fish-Parcham says.
When your paperwork is ready, you must appeal first to your health plan. For most private plans, your deadline for filing the appeal will be 180 days after care is denied. The insurer then faces a deadline — usually 30 days — to render its decision. If it upholds its initial decision or doesn’t meet the deadline, you can take the matter to the agency that regulates the plan within 180 days. If your health is in imminent danger, you can generally get an answer in a matter of days rather than weeks.
Unfortunately, different plans have different regulators, with varying appeal procedures. If you don’t know who regulates your health plan, call customer services and ask.
A large majority of Californians have policies regulated by the Department of Managed Health Care, but millions of others are in plans regulated by other state agencies, such as the California Department of Insurance or the federal government.
A good place to start is the Department of Managed Health Care (888-466-2219 or HealthHelp.ca.gov). Even if it is not your regulator, it can direct you to the right place, Rouillard says.
If you are one of the 26 million Californians in plans regulated by the department, you can request a free review of your case by outside medical experts if your appeal to the health plan failed or was not answered by the deadline.
These independent medical reviews are for cases in which a health plan doesn’t think a type of treatment is medically necessary or refuses to cover it because it is experimental — or won’t pay for emergency medical services after the fact.
An archive on the department’s website (https://wpso.dmhc.ca.gov/imr/) allows you to search past decisions for cases like yours. The summary language in those decisions might help you frame your arguments.
You can also request an independent medical review through the California Department of Insurance (800-927-4357).
If you are one of the 5.5 million Californians in a federally regulated employer plan, your regulator is the U.S. Department of Labor’s Employee Benefits Security Administration (866-444-3272 or www.askebsa.dol.gov).
As you wade through this process, there are organizations that can help.
One of them is the Health Consumer Alliance (888-804-3536 or www.healthconsumer.org), which can assist people in public and private health plans. It offers free advice, can help you get your documents in order and provides legal services.
Medicare enrollees can get free assistance from the Health Insurance Counseling and Advocacy Program (800-434-0222 or cahealthadvocates.org/hicap/).