For example, let me refer you to a recent report on private health insurance denials, a study that was required after the Patient Protection and Affordable Care Act was enacted. That’s the health-care legislation that has been pejoratively nicknamed Obamacare. Nonetheless, it’s because of this law and the resulting GAO follow-up that we received a great piece of advice for people covered by private health insurance.
If you are denied coverage, file an appeal.
The GAO said the data it reviewed indicated that health insurance denials are frequently reversed on appeal. In looking at data from four states, the GAO found that 39 percent to 59 percent of appeals filed with insurers in those states resulted in the insurer reversing its coverage denial. Additionally, data from a national study on appeals conducted by a trade association for insurance companies showed that coverage denials were reversed about 40 percent of the time. Now, with such limited data, this doesn’t mean you have a double-digit chance that your denial will be overturned. In fact, in a letter responding to the denial report, the Department of Health and Human Services said the GAO findings underline a great deficiency in information on insurance denials.
Still, the GAO report provides helpful information for the nearly 64 percent — as of 2009 — who rely on private health insurance, most through employer-sponsored group coverage. A number of provisions under the Affordable Care Act protect people against the denial of coverage, but until the law is fully implemented, rejections can continue.
When President Obama signed the health-care legislation a year ago, he said: “Today, I’m signing this reform bill into law on behalf of my mother, who argued with insurance companies even as she battled cancer in her final days.”
More than 10,000 people annually have their coverage dropped because they become sick or make a mistake on their application, according to the administration.
The GAO said coverage denials occur for a variety of reasons. Frequently it happens because of billing errors and eligibility issues and “less often for judgments about the appropriateness of a service.” When it comes to billing errors, often the denial is because of duplicate claims or missing information. Data from Maryland showed that duplicate claim submissions accounted for 32 percent of all denials in 2007.
In its report, the GAO pointed out that consumers have several avenues to dispute denials. They can file an appeal with their insurer. In most states, consumers can have their appeal reviewed by an external party, such as an independent medical review panel established by the state. And they can file complaints with the state, generally through the department of insurance. For those with group health plans, appeals can be filed with the U.S. Labor Department. By the way, in fiscal 2010, more than 9,600 complaints related to coverage denials by group health plans resulted in payments totaling nearly $7 million, according to data from the Labor Department.
Here are a few resources you need to check out. For help in dealing with your insurer, try contacting the nonprofit Patient Advocate Foundation (www.patientadvocate.org). For information about the health-care law, go to www.healthcare.gov. If you have a preexisting medical condition and you are having trouble finding coverage, go to www.PCIP.gov. On that site you will find information about the new Pre-Existing Condition Insurance Plan, which was created as part of the Affordable Care Act.
The federal government plans to collect additional information about the extent of insurance enrollment denials, denials of coverage for medical services and the reasons for those denials. Good. Such information should make it easier for people to shop for insurance.
Readers can write to Michelle Singletary c/o The Washington Post, 1150 15th St. NW, Washington, D.C. 20071. Her e-mail address is email@example.com. Comments and questions are welcome, but because of the volume of mail, personal responses may not be possible.
(c) 2011, Washington Post Writers Group