Seeking an External Review for Your Health Plan Dispute

(Page 2 of 2 of Health Plan Disputes: An Overview)

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Most states have an external review program that lets a consumer appeal a health plan's negative decision after an internal review. In a few states, these programs are available only for disputes with managed care plans (like HMOs and PPOs). 

Do You Have a Right to External Review?

The type of health plan you have dictates whether you are entitled to an external review (also called an independent review) of your dispute. You can usually get an external review if you are:

  • self-insured (you enrolled in the plan and pay for the premiums yourself), or
  • covered by an insured employer-sponsored plan (you have health insurance through your job and your employer buys coverage from an insurance company, such as Blue Cross).

You are not entitled to external review if you are enrolled in a self-funded employer-sponsored plan. This means you have health insurance through your job and your employer pays for the health care costs of its employees directly, rather than purchasing insurance from an insurance company. (To determine which type of plan you have, see Nolo's article Understanding Your Health Insurance Coverage.)

Procedures for External Review

The procedures in an external review of a health dispute vary by state. That means you'll have to review your policy to find out what types of disputes are eligible for review, the time limits for bringing a complaint, and how to proceed with your appeal. In most cases, you must complete the internal review process before you can ask for an external review. The external review is usually available for free or a small charge. Most states allow the consumer to give written authorization to let a third party (for example, a medical provider) file the appeal.

Limited Issues on External Appeal

Unlike the internal review, an external review is usually limited to determinations of what is a "medical necessity." That means the dispute must involve a procedure, treatment, or prescription drug that you and your doctor believe is essential for your health, but your health plan disagrees. For example, your doctor believes that a new prescription drug is essential to treat your asthma, but your insurance plan's position is that the drug is experimental and hasn't been shown to help asthma patients.

For the most part, you cannot obtain an external review of a coverage issue (like whether your fertility treatment falls within your plan's definition of covered procedures).

Preparing Your External Appeal

In most states, the review panel does not conduct a hearing. Instead, you must submit all your evidence and arguments in writing. Be sure to read the external review requirements carefully and submit everything that is requested.

According to the Health Care Marketplace Project, many external appeals are denied because:

  • the consumer does not have a right to an external appeal (for example, the consumer participates in a self-funded employer-sponsored health plan)
  • the consumer did not complete the internal review process before seeking external review
  • the issue does not involve a determination of medical necessity, and
  • the consumer did not provide all requested information (for example, the patient failed to submit consent forms).

If you want the panel to consider your appeal, make sure you have met all preconditions and that your issue is appropriate for external review.

Go to Court

If an internal or external review of your health plan dispute doesn't give you the results you were looking for, you may be able to sue your health plan in court. Whether you're allowed to go to court often depends on the type of plan you have and the state where you live. Determining whether you can sue an insurance company can be complicated -- and the lawsuit itself is sure to be complex as well -- so it's wise to seek the advice of an attorney who specializes in insurance cases.

For help in choosing a good attorney, read Nolo's article How to Find an Excellent Lawyer. For help in choosing a good attorney, use Nolo's Lawyer Directory for a list of insurance attorneys near you (click the "Types of Cases" and "Work History" tabs to find out about the lawyer's experience, if any, with medical insurance cases).

File a Complaint With the HMO Accrediting Organization

The following applies only to patients who have a dispute with an HMO. Many HMOs are accredited by an independent organization such as the National Committee for Quality Assurance (www.ncqa.org), the American Accreditation HealthCare Commission/URAC (www.urac.org), or the Joint Commission on Accreditation of Health Care Organizations (www.jcaho.org). Because HMOs want to remain in good standing with these groups, filing a complaint with an accrediting organization might spur the HMO into resolving the issue to your satisfaction.

File a Complaint With the State Insurance Department

Also for HMO patients: Most HMOs are licensed by a state insurance department. So filing a complaint with your state's insurance department may spur the HMO into action or might even prompt the department to intervene in your dispute.

To learn about managing health care expenses and dealing with other pressing financial issues, get The Busy Family's Guide to Money, by John Waggoner, Kathy Chu, and Sandra Block (Nolo with USA Today).

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