Understanding the Appeals Process

August 3, 2017

A hallmark of our society is allowing all U.S. citizens to have “their day in court” or fundamental “due process” to make sure their rights are protected. One would hope – even expect – the same would be true when a patient (or their ordering healthcare provider) requests insurance coverage for a life-saving treatment. When a patient does not receive the expected covered care, the appeals system is tested.  The effectiveness of the health insurance appeals process, however, has come under significant criticism in recent years for being ineffective, fragmented and subjective. And, patients may not even know they have the right to appeal. Bottom line: the ability to get an impartial and meaningful review of an adverse benefit determination where a patient’s care is limited or denied simply no longer occurs for many cases.

Part of RegQuest’s mission is to stabilize key areas of the medical management system, including the appeals process, through education with trend reports and detailed regulatory summaries that underscore wide variation and regulations that have not kept pace with modern healthcare delivery. This information can help all stakeholders better understand what is going on and potentially, how to fix a broken situation to the benefit of all participants.  No one benefits if the health insurance appeals process falters as health plans, providers and other industry stakeholders are negatively impacted by the instability and inconsistency of an ad hoc appeals process.

Understanding the fundamentals of the process is a good starting point:

  • Internal Appeals. The utilization management (UM) process starts with a request for a claim for services of benefits on a prospective, concurrent, or retrospective basis. When an adverse determination or denial is made, the patient or the attending provider has a right to appeal the health plan’s decision. The appeals process, however, is extremely complicated and fragmented, making it difficult to understand and navigate properly. There are specific requirements for timeframes to file an appeal, provision of certain documents and more.
  • External Appeals. In many cases, the internal appeals process must be exhausted before one is “eligible” to move to an external review. Typically, there are two entry points to initiate an appeal: clinical/medical necessity appeals or administrative/grievance procedure appeals. After the internal appeals process has been exhausted, the consumer can file an external appeal. The external appeals process varies by state and the type of insurance coverage one has including self-funded, Medicare, etc.
  • Parity Appeal. If an adverse benefit determination involves a claim or treatment for mental health or substance use disorder services, a parity appeal may be filed. Parity appeals may address denials based on medical necessity and questions of coverage determinations or exclusions. To learn about parity appeals, please visit thekennedyforum.org and review the Parity Resource Guide.  In addition, to file a complaint, go to www.parityregistry.org where you can find resources in your state – including groups to help you file with the right state agency – as well as log your complaint with The Kennedy Forum.

Within these different appeal levels, the regulatory requirements are often inconsistent in terms of how complaints are defined (e.g., “medical necessity” versus administrative denials), timeframes allotted, documents required, and much more. With so much variability, even industry experts (never mind consumers who may also be facing an illness requiring immediate treatment) struggle to comply with all of the regulations and accreditation requirements.

The solution to a system that works for all – from patients, providers, health plans, regulators and more –calls for streamlining and integrating appeals systems and regulatory requirements. However, until the day arrives that we can create a more unified appeals system, perhaps with national standards, there’s a practical need to access and understand specific state regulations. RegQuest offers the resource of an up-to-date database with information about each state’s unique appeals process. RegQuest also provides subscribers with instant access to information on utilization management, external review, and grievance procedures. With easy online navigation, you can review state surveys, trend reports, blogs and more. Please visit www.regquest.com to become a subscriber or contact us for more information about subscribing or renewing your subscription.