Published on May 27, 2019
If your insurer refuses to pay for your cancer treatment or services, you have the right to appeal. When you receive a medical treatment or service, your doctor or pharmacist must send a bill to your insurer. Sometimes, for any number of reasons, insurers can refuse to pay for the medications or services ordered. Insurers often assert that the treatments or services were not medically necessary or that the claim for reimbursement contained errors. When a claim for reimbursement is denied by your insurer, it is known as an “adverse benefit determination,” and you have a few options to ensure you are able to receive the care that is appropriate for you.
You Can Request an Appeal
Depending on the type of insurance coverage that you have, the appeals process will be slightly different. However, all types of health plans will have some way for you to seek further review of the insurer’s decision.
If you receive your health coverage through your employer, you are entitled to a “full and fair review” of decisions made by your employer. There are strict rules regarding the appeals process, including: setting the timeline for which an appeal must be submitted, the type of staff who can review the claim on behalf of the insurer, mandatory disclosure of all information relevant to the adverse determination, and specific information that must be communicated to the patient in the claim determination and appeal determination letters. While health plans are required to offer one level of review, they can choose to offer additional reviews at their own discretion. The U.S. Department of Labor has published a guide to help consumers through this process.
ACA Marketplace Plans
If you are enrolled in a marketplace plan (also referred to as a Healthcare.gov, exchange, or Obamacare plan), you have the right to request an appeal of an adverse benefit determination. This first appeal will require the health insurer to reconsider its decision to deny reimbursement for the healthcare service. If the health insurer maintains its refusal to reimburse the provider, you can request further review from an independent review organization, which will either uphold or overturn the insurer’s original determination. The rules governing the appeal will be different depending on the state that you live in. Aimed Alliance has published resources to help consumers navigate this process.
If you receive your health coverage through Medicare, you have the right to appeal adverse benefit determinations with a five-level appeal process that becomes more rigorous with each step. This appeal process requires: the plan to redetermine the coverage determination; review of the adverse determination by an independent review entity; a hearing before an administrative law judge; review before the Medicare Appeals Council; and judicial review before a federal district court. CMS has published a guide book to help patients navigate this complex process.
Patients who are covered by Medicaid have a unique process for appealing adverse determinations. Medicaid beneficiaries are entitled to a fair hearing before the agency that administers the Medicaid program in the state where the patient lives. Patients are eligible for a fair hearing if the agency denies services or does not act upon a request for services in a timely manner, if the agency has acted wrongly in reducing or terminating the patient’s Medicaid eligibility, or if the agency has acted wrongly in reducing or terminating the services covered by the program.
Once a Medicaid beneficiary requests a hearing from the agency, the state has the option of providing a less rigorous evidentiary hearing on the local level. If the agency rules in favor of the beneficiary, the decision is implemented. If the agency does not rule in favor of the beneficiary, the matter is escalated to a full state-level fair hearing before the agency. If the agency rules in favor of the beneficiary, the decision is implemented. If the agency does not rule in favor of the beneficiary, they can choose to appeal their case to have it heard before a state court. States have different rules for the level of review available in state court. The Medicaid and CHIP Payment and Access Commission (MACPAC) has published a breakdown of how this process differs by state.
If you have exhausted your appeal options and you are still unable to access medically necessary treatments and services, you can consider reaching out to your state’s attorney general and insurance commissioner. Either of these state officers could have jurisdiction over the issue you are facing, and they could provide assistance. You can also consider reaching out to the media to put additional pressure on the insurer to reverse their decision. If you are having difficulty with the appeals process, you can contact Aimed Alliance, and we may be able to assist you.
John A. Wylam, Esq.
This is an Aimed Alliance information piece produced by Patient Power. We thank AbbVie Inc. for their support. These organizations have no editorial control. It is produced solely by Patient Power.
Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.