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Patients Win About Half the Time They Challenge Denied Health Care Services

Andrew Nixon / Capital Public Radio

Andrew Nixon / Capital Public Radio

California data show about half the time a patient challenges a denied health care service through a third party, the patient wins and gets the health service.

The Affordable Care Act has made the right to appeal denied health care uniform and universal for every insured person in the United States. 

For Tony Simek of El Mirage, Arizona, the ability to appeal a denied health care service allowed him to get back on track to a normal, healthy life.

Simek has sleep apnea, a common condition that can cause serious complications. His condition requires him to use a night-time breathing machine. But when the device stopped working for him, daytime sleepiness made it hard to concentrate at his software engineering job.

“I had actually gotten to a place where in December or late November, I actually fell asleep while driving a vehicle and that’s something that would normally have never happened to me," says Simek.

Simek’s doctor recommended an in-lab sleep study so he could adjust the pressure of his apnea machine and get a better nights’ rest. But getting the test wasn’t as simple as following the doctor’s orders.

“The test was actually I was rather surprised by that so I reached out to my doctor to find out why," he says. "And apparently my doctor had been told that it was “not medically necessary” in their judgment of my health condition.”

Simek says he had had this test before – and he thought his job-based coverage through a California employer was solid. He spent hours on the phone with the health plan trying to get the service. The insurance company sent him four denial letters.

“I have never had a problem with health insurance prior to this," he says.

So Simek filed an appeal with the California Department of Insurance, which regulates his health plan. The insurer’s denial was overturned and he got the test.

“I have been sleeping well ever since,” he says.

Click here to see an interactive graphic on patient success rate

*The California Department of Managed Health Care is one of two agencies regulating insurance companies. It deals mainly with managed care plans. These rates combine DMHC decisions made in the patients favor and the cases where insurers reversed their own denials voluntarily. 

Cheryl Fish Parcham of Families USA says the Affordable Care Act provides that every insured person has the right to appeal a denial to the health plan and to an expert, outside reviewer.

“It’s often very worthwhile for a consumer to appeal," says Parcham. "It’s a really important protection for people.

Previously there was no uniform national process for appealing a denial by an insurer.

"Insurers get it wrong the first time," says Parcham. "So if you’ve been denied a health care service, it might be because the plan didn’t understand why that service was needed and why it fit their guidelines.

Learn more about how to appeal a denial of service through either the Department of Insurance or the Department of Managed Health Care.

Peter Kongstvedt used to manage health plans, now he’s at George Mason University. He says most health care denials involve administrative errors or mechanical problems.

He says patients are often just as successful challenging denials directly to the insurer as they would be through a third party.

"It can be an error on the health plan side," says Kongstvedt. "Maybe they put somebody in the system wrong and they don’t know that they’re eligible yet. Or it gets a data entry error that occurs, so it doesn’t appear that it makes any sense to the system. The computer says 'Oh, we don’t pay for this service on that diagnosis,' -- that type of thing."

Under the Affordable Care Act people with pre-existing conditions can't be denied a health policy because of a pre-existing health condition. But insurers can deny medical care if they consider it to be "medically unnecessary." Under the ACA, all patients have the right to appeal denials.

Other denials are usually based on medical necessity – for instance, evaluating whether a procedure or device is experimental or investigational. Kongstvedt says such decisions require human judgment.

"The computer doesn’t – it usually doesn’t make that decision," says Kongstvedt. "It simply flags it and then it gets reviewed, first by a nurse reviewer who then presents it usually to a medical director.

Insurers say only about three percent of claims are denied.  Robert Zirkelbach is from America’s Health Insurance Plans.

"Coverage decisions are based on medical evidence," says Zirkelbach. "It’s the medical evidence that drives coverage decisions, and the more evidence that’s available about the appropriateness and effectiveness of a particular drug or treatment or technology, that’s what drives what’s covered.

Click here to see an interactive graphic of IMR figures from the California Department of Insurance

Source: California Department of Insurance

*The California Department of Insurance is one of two agencies regulating insurance companies in the state. CDI mostly deals with Preferred Provider Organizations (PPOs).

Zirkelbach says health insurers support the Affordable Care Act’s expansion and standardarization of the appeals process.

"Health plans are committed to getting it right," says Zirkelbach.

Families USA says health insurers are doing a good job notifying consumers of their right to appeal denials. An opportunity it says, people are not using as much as they could.

Click here to see an interactive graphic on patient success rate

 Source: California Department of Managed Healthcare

Private Insurance Screenshot 

Digital Production: Marnette Federis


Pauline Bartolone


Pauline Bartolone has been a journalist for more than 15 years, during which she was Capital Public Radio’s healthcare reporter from 2011-2015. Her work has aired frequently on National Public Radio.  Read Full Bio 

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