American Speech-Language-Hearing Association

Patients Have New Health Claim Appeal Rights Under the Affordable Care Act

(April 16, 2014)

The Affordable Care Act (ACA) ensures a patient's right to appeal health insurance plan decisions. Appeals are important because figures show that patients are successful 39%–59% of the time when they appeal claims decisions. Under the ACA, patients can ask a health plan to reconsider its decision to deny payment for a service or treatment. New rules spell out how plans must handle internal appeals, but the rules also allow for an independent review organization to decide whether to uphold or overturn the plan's decision.

Background

Under the ACA, consumers have the right to appeal decisions made by health plans created after March 23, 2010. The law governs how insurance companies handle initial appeals and how consumers can request reconsideration of decisions to deny payment. Under the law, if an insurance company upholds its decision to deny payment, the consumer has the right to appeal the decision to an outside, independent decision maker, regardless of the type of insurance or state an individual lives in. This final check is often referred to as an "external review."

Regulations issued by the Departments of Health and Human Services (HHS), Labor, and Treasury standardize both internal and external processes that patients can use to appeal decisions made by their health plans. Under new ACA rules, plans and issuers must comply with the state's external review process or the federal external review process.

Until a few years ago, the rules regarding such appeals varied by state and employer. These new rules will more closely align the appeals process across all types of plans.

Note: The parts of the ACA that concern internal appeals and external reviews only apply to health plans or policies that were created or purchased after March 23, 2010. Plans created on or before March 23, 2010, may be "grandfathered health plans." The ACA imposed appeals and review rights do not apply to them.

Appeals are worthwhile. A recent Kaiser Health News article (Pauline Bartolone, Capital Public Radio, April 14, 2014) reported that data review from California found that about half of the time a patient appeals a denied health claim to the state's regulators, the patient wins.

Resources

For more information, please e-mail reimbursement@asha.org. For questions about appeals, contact Janet McCarty at jmccarty@asha.org or Laurie Alban Havens at lalbanhavens@asha.org.

 


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