Health Care Reform Expands Consumers' Rights for Claims Appeals

Empower your patients to appeal their denied claims.  

One of the most frustrating parts of health care for both the doctor and patient is the denial of a claim. To add to the confusion, the appeals process for denied claims varies from state to state and plan to plan. On July 22, the Obama administration issued new rules under the Affordable Care Act to expand consumers’ rights and standardize the process for internal and external appeals. The rules will apply to plans beginning with a start date of Sept. 23, 2010, and existing health plans that make significant changes, such as large increases in co-pays or employee contributions. It is estimated that these new rules will affect 31 million people, and the number may increase to 78 million by 2013.

The rules would allow patients to seek an external review by a third party assigned by the state after the claim is denied a second time via the insurer’s internal review. According to the Department of Health and Human Services, by July 1, 2011, states are required to make changes to their external appeals processes to ensure that their laws include, at a minimum, the consumer protections of the National Association of Insurance Commissioners (NAIC) Uniform Model Act, including clear information regarding consumers’ rights to internal and external appeals, emergency processes for urgent claims, and access to a third-party reviewer assigned by the state. Should the state laws not meet the required standards, consumers will be protected by similar federal external appeals standards. For more information, click here.

ACA has seen firsthand the power that patients wield when they can effectively advocate on their own behalf. Regulators will often take particular notice when they receive a complaint or an appeal from an enrollee, rather than the provider, as they are charged with protecting the consumer.

To assist patients through the process of advocating for themselves, ACA’s Insurance Relations department has developed a Web page for patients (www.acatoday.org/patientresource). It includes resources on the benefits of chiropractic care that patients can share with their human resources departments or their primary care physicians. In addition, it helps patients determine whether their plan is governed by ERISA or the state department of insurance.

ACA News Extra...

Help Your Patients Advocate for Their Chiropractic Coverage
ACA has noticed a trend in recent years where self-funded plans have a chiropractic benefit that allows MDs and DOs to provide care, but excludes DCs. While ACA advocates for members’ patients who are affected by this policy, patients should be encouraged to speak to their employers, as well. That’s why we created a resource that will help your patients speak to their human resources department in cases when chiropractic coverage is denied because their medical plan doesn’t allow DCs to perform spinal manipulation. This information may be especially helpful for the patient’s human resources department to have before they begin negotiating benefits for the upcoming year. To download or print the patient education handout, click here.