What to do when your HMO says no to treatment or medication – Pasadena Star News

The challenge of turning down your health plan for a treatment, treatment, or medication may seem like an uphill battle, but here’s the good news: California consumers often succeed.

In the past two years, patients have won nearly 68 percent of independent medical reviews conducted by the state’s Department of Managed Health Care, which regulates the majority of coverage.

However, the two-part appeal process can be time-consuming or taxing for people who already have old age, disabilities or serious illness, says Scott Glovsky, a Pasadena attorney who specializes in insurance cases.

“The inequality of power is so great that a lot of people deny it and think, ‘What, am I going to fight this billion dollar company? “The truth is, you absolutely can,” Glovsky says. “One of the keys is to be persistent and never accept a rejection as final.”

Consumer advocates say consumers need to understand their rights.

“Patients are often unaware of the appeal process in their health plan because health plans are not consumer friendly, and plan documents are often filled with typeface and legal documents, which is frightening to many people,” said Ashira Vantress, an attorney in Washington, DC. The D.C.-based Aimed Alliance, a nonprofit that advances healthcare rights, said in an email.

“For consumers, it is important that they act as their own investigators to carefully review their plan documents and coverage requirements when they receive a rejection letter.”

Reasons for appeal

Expensive care, such as proton beam therapy for cancer, biologic drugs or residential mental health treatment, is often denied, Glovsky says. This is especially true, he says, if the treatments require going out of the network contracted with the insurance company.

“If treatment is medically necessary and your plan can’t provide it, they should provide you out of network treatment,” he says. “I see all the time the treatment the plan can’t provide, but they still deny it even though under the plan it’s considered illegal.”

If the consumer does not agree to the refusal, the first step is to appeal internally with the insurance company.

“Basically, an internal appeal is a request for the health plan to do a full and fair review of the denial decision,” Vantress says.

Consumers should do the following:

Carefully review your rejection letter. The letter should explain why the insurance company rejected the claim and provide instructions on how to appeal the decision internally. Health plans may refer to the process as filing a complaint. “The rejection letter will really define the battle you have to fight,” Glovsky says. This will say exactly what is the basis of the denial.”

Vantress said that if the letter did not include an explanation of how to appeal the decision, patients should call the customer service number and inquire. You may also name a representative or attorney authorized to handle the appeal on your behalf.

Glovsky says to contact the health plan via email to make sure all information about the refusal is in writing.

If you have any phone conversations, take notes of the date, time, name and surname of the person you spoke with, and details about the conversation, according to consumer advice from the U.S. Department of Health and Human Services.

Gather supplemental information. Most often, a health plan’s appeal process requires consumers to provide additional information explaining why a medically required drug or treatment is necessary, Vantres said.

She said the plan documents will provide information on how the plan determines what is medically necessary. From there, work with your healthcare provider to establish medical necessity.

Ideally, Glovsky said, your doctor would cite health plan language regarding the medical necessity to establish the case, and describe what would happen to the patient’s health if treatment was refused. He also suggests that more than one doctor write a letter in support of the appeal.

“Healthcare providers can be patients’ biggest advocates as they pursue health insurance claims,” ​​Vantres says. “They can explain to the insurance company why treatment or medication is necessary for a patient, and often have staff familiar with benefits use policies and appeals processes.”

Send appeal quickly. Many health plans require an appeal within 180 days of a refusal. They have 30 days to process an appeal, excluding emergencies. In most circumstances, consumers should wait that long before pursuing an independent external review.

Glovsky says internal appeals are often unsuccessful because the insurance company applies the same standards that led to the initial denial. But he said the insurance company sometimes initially receives incomplete medical information and can be submitted to reverse the decision.

The health plan must issue a written decision and include the means of external review.

higher gravity

If the appeal is denied by the health plan, patients can request a free external review from any state regulator or federal review program, depending on the insurance plan. (See below for more information on this.)

Before appealing to the DMHC, Glovsky recommends reviewing an online database of past decisions. Information is searchable by keyword, category (medical necessity, experimental/investigative or emergency/urgent care), and whether consumer or health plan is prevalent.

“You can get a good idea of ​​whether your treatment might be approved based on other independent medical reviews,” he says.

The DMHC’s Independent Medical Review form will ask for a description of your medical condition, as well as the treatment, service, or medication you are requesting. Medical records and correspondence from the HMO must also be uploaded.

Reviews, conducted by physicians, are usually decided within 45 days, or within seven days for urgent appeals for urgent cases.

According to the state Department of Insurance, independent physicians review cases by looking at peer-reviewed scientific evidence regarding service effectiveness, nationally recognized professional standards, expert opinions, and potentially effective treatments.

Decisions are considered final, and health plans must provide the service immediately if its refusal is overturned.

“There are a lot of barriers to accessing the care that you are often entitled to under your plan,” Glovsky says. “Consumers who educate themselves and take the time to do the work necessary to challenge rejections are often successful.”

How to file an appeal with your insurance company

You can apply by phone, mail, or online. Health plans are legally required to respond to consumer calls within 30 days, or within three days in the event of an immediate and serious threat to a patient’s health.

If you do not agree with the HMO’s decision, you can file a complaint with the government agency that regulates your plan.

How to request an independent review

If you don’t know the agency that regulates your plan, contact your insurance company to find out.

All HMOs and some PPOs and EPOs are regulated by the Department of Healthcare Management. Consumers can request an independent medical review for denials, delays in requests for treatment, and denial of emergency treatment coverage. Consumers are allowed to bypass the internal health plan appeal process if they are denied on the basis of an experimental/investigative treatment. Detailed information is available online or at 888-466-2219.

For documents regulated by the Insurance Department, an independent medical review is also available. See the information online or at 800-927-4357.

Find information about the Medicare appeal process over here.


The Health Consumer Alliance, a network of consumer assistance programs, offers free insurance refusal assistance. 888-804-3536

The Aimed Alliance has a guide to the California appeals process.

Medicare beneficiaries can get free help through the Health Insurance Counseling and Advocacy Program. Call to find your nearest office: 800-434-0222

Insurance contacts for appeal/grievance:

Etna: 800.445.5299

Blue Cross anthem: 800-365-0609

blue shield: 800-393-6130

Healthnet: 800-522-0088

Kaiser Permanente: 800-464-4000

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