By Consumers For Quality Care, on August 28, 2019
When consumers receive a bill from a hospital or doctor visit that they do not understand or disagree with, they have a right to appeal the charges. While the Affordable Care Act codified this right into federal law, it has been Ohio law since 1999, The Columbus Dispatch explains.
“The consumer receives a denial or a reduced benefit from their carrier that they disagree with, so they have the right to file an appeal with their carrier,” said Jana Jarrett, the Ohio Department of Insurance’s assistant director of consumer affairs.
Between 1999 and 2017, 7,012 appeal cases were reviewed by the Ohio Department of Insurance or an independent review organization. During that time, the state recovered more than $21.6 million in previously denied health care services and benefits.
In 2017, Ohio reviewed 514 cases, which included $6.3 million worth of services and benefits. Insurers’ decisions were reversed in 36 percent of the cases, saving consumers $1.17 million in payments.
Patients start the appeals process by contacting their insurance company. If the insurer once again denies the appeal, consumers can then turn to the external review process.
“(Independent review organizations) contract with medical providers that have expertise in these various things, so they make those decisions about whether or not they are medically appropriate or medically necessary because we at the department are not clinicians, we can’t make those decisions,” [Carrie Haughawout, the Ohio Department of Insurance’s deputy director] said.
Either the Department of Insurance or the external review organization makes the final determination on the case. If the entity does not agree with the consumer, their last resort is to file a lawsuit.
These steps help consumers stand up for their health care and fight against decisions that they do not agree with.
“I think (the external review process) helps consumers greatly, because at the end of the day, they really didn’t have a voice and this gives them a voice to feel that their claim was adjudicated correctly,” said Meredith Merlini, vice president of National Medical Review. “If the claim is denied, they’re not happy, but at least they were given an opportunity to have their claim looked at by someone who’s not the insurance company.” …
“This gives the consumer almost like a level playing field,” Merlini said. “Treatment is between a patient and the doctor. Our process is really deciding who’s paying for it.”
The findings from the Ohio Department of Insurance highlight consumers’ success in having their denials overturned. Consumers for Quality Care has previously highlighted evidence that shows consumers often win out when they fight insurance denials.