Regulations on Appeals

Well, I have read the new set of regulations and I am very excited. Although, based on our experience submitting insurance appeals both to insurance companies and through independent reviews, we will be writing substantial, detailed comments on some things that we think can be improved, the biggest news is that all plans (other than grandfathered plans) will have to provide independent reviews. These are external appeals through the state insurance departments, which contract with independent review organizations to review insurance company decisions. When an independent review organization overturns an insurer's decision, the independent review decision is binding.

Independent reviews already exist in most states for individual and small group plans, but for the first time, self-funded plans will be subject to independent reviews. No more self-funded plans doing essentially whatever they like without anybody looking over their shoulders. This will be a huge benefit to patients.

Other things besides coverage and claims decisions can be appealed. If, for example, your insurer retroactively cancels your policy, you will, for the first time, have a right to appeal.

For states that don't have strong external appeal processes, in a phased-in transition, you will be able to use a federal external appeal process instead. Indeed, insurers are expected to comply strictly with the internal appeal requirement -- and if they don't, consumers will have a right to go directly to external appeal through an independent review organization. Insurers will not be allowed to fail to comply with their own procedures and get away with it.

In my opinion, external appeals to independent review organizations are the most important consumer protection to have been developed over the past 10 years. The extension of external appeals to all plans will revolutionize the balance of power between insurers and consumers.

As I said, we will be writing comments, and will post them here for your review. But you will see that they largely are picky and technical, based on all of the experiences we have had with insurers over the years. For the most part, the regulations are a watershed in health insurance consumer protection. The balance of power will change. And that is nothing short of thrilling. Jennifer