When health insurance companies deny coverage for necessary treatments, the repercussions can be devastating. Yet, alarmingly, many individuals simply accept these denials as final, surrendering to an unjust system that prioritizes profit over the well-being of its clients. This silent acquiescence must end; we must bring to light the often-overlooked process of external appeals that can hold these corporate giants accountable and fight for our rightful health care.
A recent case from North Carolina exemplifies the cruel reality that many face when seeking mental health care. Teressa Sutton-Schulman and her husband, who has been granted anonymity, found themselves battling against Highmark Blue Cross Blue Shield after the insurer denied vital psychiatric treatment for her husband following two suicide attempts within just over a week. The couple’s struggle highlights a systemic failure in our health care system — one that often leaves desperate individuals without the support they need.
The process for an external review, which can overturn insurer denials, was frustratingly buried in legal jargon and fine print. In their denial letter, buried on page seven, was a glimmer of hope — guidance for requesting an independent review. This kind of obfuscation is not uncommon; insurers rely on consumers’ confusion and lack of awareness to maintain the status quo of denial.
Sutton-Schulman, skeptical yet hopeful, took a leap of faith and requested an external review. The outcome was a significant victory when Dr. Neal Goldenberg, an independent reviewer, overturned Highmark’s denial, forcing them to cover the treatment that had already cost the couple over $70,000. This case is a testament to the effectiveness of external appeals, yet only a fraction of those who are denied coverage even know this option exists.
Highmark’s claim that they are “passionate about providing appropriate and timely care” rings hollow when coupled with their history of denials. Such statements illustrate the chasm between corporate rhetoric and reality. The troubling truth is that many patients never appeal their denials, often feeling defeated or misled. Kaye Pestaina, a vice president at KFF, succinctly captures the essence of the battle ahead: “Appeal, appeal, appeal, appeal.” This mantra should echo in the minds of all who find themselves denied necessary care.
While the Affordable Care Act (ACA) expanded access to external reviews, the legislation has been compromised through relentless lobbying by insurance companies. The weakening of protections means that only a small percentage of denials qualify for external review, leaving patients vulnerable and at the mercy of their insurers. The lack of transparency in denial processes further compounds this issue, as insurers are not held accountable for their decisions.
Karen Pollitz, who helped draft these regulations, pointed out the myriad ways that the system could be improved. She stated there is a pressing need for stronger laws that hold health plans accountable. The ACA provided a framework for state consumer assistance programs, yet many states have not prioritized funding these essential resources. States that have maintained such programs are better equipped to help patients navigate the labyrinth of insurance denials.
The disparity in state responses is glaring. While some states have enacted legislation requiring insurers to clearly state the right to appeal at the top of denial letters, others lag behind, leaving patients in the dark. Maryland’s recent law mandates that denial letters prominently display this crucial information, a step that has already shown results in increasing awareness of appeals.
Connecticut’s Office of the Healthcare Advocate is another model of accountability, boasting an 80% success rate in resolving denials in favor of patients. Their approach demonstrates that when consumers are equipped with knowledge and support, they can effectively challenge the insurance industry. As Kathleen Holt, the state’s health care advocate, emphasizes, insurers often gamble on consumers’ reluctance to appeal, assuming that the overwhelming complexity of the system will deter them from pursuing justice.
To empower patients, experts suggest a few critical steps when facing a denial. Start with gathering all relevant information and documents, including denial notices and medical records. Next, check if your state has a consumer assistance program, which can provide invaluable support in understanding the denial process. Knowing the specifics of your denial — whether it pertains to medical necessity, coverage terms, or other issues — is vital for crafting an effective appeal.
Engaging with health care providers can also bolster your case, as many will support their patients through the appeal process. Filing internal appeals is often a prerequisite to external requests, but these steps are crucial in the long journey toward securing the care deserved.
Finally, a successful external appeal can lead to binding decisions that require insurers to uphold their obligations — if the system works as intended. Yet, the reality remains that the system is fraught with obstacles, and the risk of denial continues to loom large for countless individuals.
It is time to demand accountability from health insurance companies and advocate for a system that prioritizes health care over profit. External appeals are a tool for empowerment, but they highlight the need for systemic reform. Every individual deserves equitable access to health care without the fear of being denied due to corporate greed. The fight is far from over, but knowledge is power, and we must harness it to reclaim our rights.
This article highlights the importance of Against Insurance Denials.
