Navigating Insurance Coverage Appeals Under the Patient Protection Act

Under the 2010 Patient Protection and Affordable Care Act (often referred to as health care reform), patients have been given greater ability to appeal the unfavorable coverage decisions made by their health insurance providers.

While this is undoubtedly an important change, it is nearly impossible for an individual patient to make sense of all the provisions and rules. This article is intended to give you a place to start and point you to additional resources you can turn to if you need more information.

One of the biggest changes under the Patient Protection and Affordable Care Act relating to appeals deals with self-funded insurance plans. These are plans that are typically administered by a third party, but funded completely by the employer itself rather than an outside insurance company. Before the enactment of the new law denial decisions made by self-funded insurance plans were not subject to any kind of external review (review made by a party outside the employer itself). The decision of the employer was the final word regardless of whether the appropriate decision was made. Under the new law employees are entitled to external review just like people covered by the traditional kind of health insurance, often called fully funded.

According to the rules issued by the three federal agencies responsible for implementing the provisions of the Patient Protection and Affordable Care Act, health insurance providers must provide patients with information about the appeals process in every denial notice they issue. They are also required to provide the contact information for each state's consumer assistance program, which are programs that field insurance-related questions from consumers and provide answers for free.

Additionally, plans are required to:

  • Strictly adhere to claims procedures. A plan's failure to do so may entitle a patient to skip the rest of the internal review process and proceed directly to the external review process.
  • Provide appropriate notices based on culture and language.
  • Avoid conflicts of interest. Plans may not tie benefits decisions to decisions regarding hiring, compensation, termination, etc.
  • Continue the patient's benefits coverage during the appeals process.
  • Follow new protections that provide employees a full and fair review. The plan must make the claimant aware of any evidence uncovered that is being relied upon as the basis for their decision. Plans must also provide the claimant with the rationale for a denial decision before the internal review denial decision is issued to provide the claimant with an opportunity to address that rationale in advance.

By providing your email address, you are agreeing to our privacy policy.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

Join the conversation

or create an account to comment.

Community Poll

When was your last migraine check-up?