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ACA: Power to Appeal When Insurance Companies Deny Claims

By Dr. Linda Burke-Galloway
. 1 Comment(s)

One of the most disheartening things I’ve witnessed as a physician is insurance denials of needed medical services in the name of saving costs or the desire not to pay for services. Well, all of that has now changed based on the Affordable Care Act. If you purchase a health plan on or after March 23, 2010, you have the right to appeal a health insurance plan’s decision. According to HealthCare.Gov, if your plan denies payment after considering your appeal, the new health law permits you to have an independent review organization decide whether to uphold or overturn the plan’s decision. If your plan denies a claim, it’s obligated to: 

-Provide the reason for the denial

-Inform you of your right to appeal

-Provide appeal information in your native language (if it's not English) if the plan begins on or after January 1, 2012

-Give you their decision within 72 hours after receiving your request when you're appealing the denial of a claim for urgent care

-Give you their decision within 30 days for denials of non-urgent care that you have not yet received

-Make a decision within 60 days for denials of services you have already received

-If, after an internal appeal the plan still denies your request for payment or services, you can ask for an independent external review. If your state has a Consumer Assistance Program, that program can help you with this request

-If the external reviewer overturns your insurer's denial, your insurer must give you the payments or services you requested in your claim 

Although there are many benefits associated with the Affordable Care Act, the right to appeal a decision made by an insurer is empowering. You are no longer alone. You no longer feel helpless as I did when my insurer denied reimbursement for medical equipment that was mandated by my surgeon. I had attempted to complain to my Insurance Commissioner for assistance to no avail. Martin Luther King once said "Of all forms of inequality, injustice in healthcare is the most shocking and inhumane." The Affordable Care Act strives to bring these injustices to an end. 

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  1. Valerie Rose

    I have "Obamacare", Blue Anthem coverage (thru covered California). I've been amazed that an average of 2 out of 3 of drug RX's are DENIED when I try to get them filled, once because not on "list" and 3 times needing pre-approval--drugs i NEVER had trouble getting filled in past. But NOW the worst has happened. In January 2014--when my ACA insurance had just gone into effect--and when there was no policy to read, no phone help to be found, etc... I had a Rubber Band Ligation treatment for hemorroids that had been bleeding and painful. I'm sure the colorectal doctor had no idea that such a simple procedure was going to be DENIED by obamacare because no PRE-APPROVAL was acquired! It's not standard in insurance industry to require pre-approval for such--there was no way to know that, and as we all know, no phone help available at the time! I make $9/hr and now I'm liable for over a thousand dollar doctor bill? Seriously? And advice please...

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