N.Y. Report: More Medical Patients Winning Coverage Appeals

April 6, 2006

A new report shows that more New Yorkers are challenging and winning reversals of decisions that deny them insurance coverage for certain medical conditions.

A new report chronicles the increased utilization of New York State’s external appeal law, which allows New Yorkers to potentially overturn their insurer or health maintenance organization’s denial of coverage.

The process allows consumers to challenge denials of coverage on the grounds that a procedure, treatment or piece of medical equipment is deemed experimental, investigational, or not medically necessary.

“More New Yorkers are learning about the state’s External Appeal mechanism and about 45 percent of the cases are being resolved in the consumer’s favor, giving more residents access to health care services that they might not have otherwise received,” said Superintendent of Insurance Howard Mills.

The 45-page New York State External Appeal Program report looks at activities occurring between January 2004 and December 2004 and also assesses program trends dating back to the law’s inception in July 1999.

“The report’s findings demonstrate that the external appeals process for New Yorkers enrolled in health plans is working. The process empowers New Yorkers to take a more active role in their own health care decisions and further protects their rights as a patient,” said State Health Commissioner Antonia C. Novello.

Highlights from the report include:

— The External Appeal Program received in 2004 a record number of consumer applications (2,321), a 29 percent increase over the previous high (1,803), which was set in 2003.

— The overwhelming majority of external appeal applications are related to insurer or HMO denials based on medical necessity and deal with coverage for substance abuse treatment, diagnostic testing, surgical, mental health and inpatient services and coverage for durable medical equipment (e.g., a wheelchair, a neck brace).

— The External Appeal Program ruled in favor of the consumer in 45 percent of the cases involving medical necessity denials in 2004, and in 51 percent of the instances in which consumers were denied coverage by an insurer or HMO on the grounds that a treatment was deemed either experimental or investigational.

— The Insurance Department’s toll-free External Appeal Hotline, 1-800-400-8882, now receives on average about 5,000 calls annually.
Governor George Pataki signed the External Appeal Law in 1999. Under the Law, a consumer must complete the first-level internal appeals process with his or her health insurer or HMO in the event coverage is denied because a product or service is considered experimental, investigational or not medically necessary. The consumer may directly access the Insurance Department’s External Appeal Program for information, either through the aforementioned toll-free hotline or online on its Web site at www.ins.state.ny.us/extappqa.htm.

External appeals must be submitted to the New York State Insurance Department within 45 days of a consumer’s receipt of a final adverse determination from their insurer or HMO’s internal appeals division, or when an insurer or HMO waives the internal appeal process. Health insurers and HMOs are allowed to charge consumers $50 for each external appeal. But the $50 fee is waived for those who receive health care coverage through Medicaid, Child Health Plus, or Family Health Plus and refunded completely to an external appeal applicant if the decision is rendered in the consumer’s favor.

The Insurance Department reviews external appeal applications for eligibility and completeness and then randomly assigns appeals to one of three certified external appeal agents that have networks of medical experts available to review the appeal. External appeal agents, all of whom are state-certified, customarily assign one clinical peer reviewer to assess medical necessity cases whereas three clinical peers are asked to review appeals of treatments considered to be experimental or investigational. Decisions in traditional external appeal cases are rendered within 30 days.

If a consumer’s attending physician attests that a delay would pose an imminent or serious threat to a patient’s health, an expedited appeal can be arranged in which an application is reviewed and decided within three days. Anyone needing to file an expedited appeal can do so 24 hours a day, including weekends and holidays, by faxing the appeal to 1-800-332-2729.

The New York State External Appeal Program report is available online at www.ins.state.ny.us/acrobat/extapp04.pdf.

Source: NYSID

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