Obamacare: Can I Appeal?

Written for the National Association of Professional Women
Springfield, Mo Local Chapter in Legal Corner Monthly Spotlight

By: Heather Rooney McBride and Danielle R. Kerckhoff

The news and social media have inundated us with stories and opinions about the Patient Protection and Affordable Care Act (“ACA”), otherwise known as Obamacare. Whether you lean right or left politically, the hours spent listening, arguing, or discussing the successes or failures of the ACA can be exhausting. There is one ACA story that many news outlets and social media posts fail to share. In preparation for writing this article we came across this relatively unknown provision of the ACA: a required internal and external appeals process for patients whose claims have been denied.

The right to an appeal is engrained in this country’s criminal and civil justice system. Judges and juries make mistakes; as a country we have recognized the need for the right to an impartial, separate review of court decisions to ensure that justice is properly served. It is no stretch of the imagination, then, to find that health insurance issuers may also make mistakes when determining whether to accept coverage for a claim. In addition, coverage decisions are made by biased health insurance issuers who realize financial benefits when claims are denied. The ACA recognizes this unbalanced relationship and requires health insurance issuers to have a claims appeals process for appeals of coverage determinations.

Prior to the ACA, the right to appeal a health care claim denial varied from state to state and plan to plan. There was no uniform right of an internal or external appeal. As a last resort, a patient was forced to file a lawsuit against the health insurance issuer so that a court of law could determine coverage. Litigation, however, is costly for the patient and time consuming for all.

The ACA specifically requires health insurance issuers to have both an internal appeals process and an independent external appeals process. The appeal process is permitted for both pre-service and post-service denials, reductions, terminations, and failures to make a payment on a claim. The ACA also implements shortened deadlines for health insurance issuers to respond to appeals requests. For example, a health insurance issuer is now required to notify a covered patient within seventy-two (72) hours whether a particular urgent care matter will be covered under that patient’s health care plan. All internal appeals are also required to be free of charge to the patient.

Most importantly, the ACA requires health insurance issuers to provide an external, independent appeals process to patients. If a patient’s internal appeal is denied, the patient now has the right to appeal that decision to an outside, impartial third party. In Missouri, the external review is conducted by an Independent Review Organization consisting of physicians who practice and are certified in the relevant health care field associated with the patient’s condition. The external decision must be made within sixty (60) days after the appeal request was received from the patient. The decision made by the impartial third party is binding on both the patient and the health care insurer.

What does this mean for you? If your health care insurer denies your claim, you now have a right to both an internal and external review. One study found that external reviews of claim denials resulted in a win for the patient approximately forty (40%) of the time, meaning that nearly half of all coverage denials are overturned upon review by an external organization. (U.S. Gov’t Accountability Office, GAO-11-268, Private Health Insurance: Data on Application and Coverage Denials (2011)). If you feel that a claim was improperly denied, you might consider filing an internal appeal with your health insurance issuer and, if necessary, an external review.

This article is not intended to be an exclusive discussion of the ACA. In addition, this article should not be construed as providing legal advice. If you have any questions on a particular situation, please contact your attorney who can provide you with legal advice or to your health care insurer who can answer your immediate questions.