Health insurance appeal wins are up, report says
The number of consumers filing internal appeals with their health insurer to challenge denied coverage has risen "substantially" since 2014, and the percentage receiving a favorable outcome from those appeals has also jumped up, according to a new analysis by a state agency.
A total of 6,338 internal appeals were filed with health insurers in 2017, and 57 percent, or 3,628 of those were resolved in favor of the consumer, while the remaining 43 percent were denied, according to the report from the Health Policy Commission.
In 2014, 44 percent of the 3,906 internal appeals were resolved in favor of the consumer, and 56 percent were denied.
An internal appeal is the first step for consumers to challenge a denial of coverage, and if the health plan upholds its original decision to deny coverage for a treatment the patient may request an independent external review through the Office of Patient Protection.
The Health Policy Commission's examination of four years of Office of Patient Protection data found that despite the increase in the total number of internal appeals between 2014 and 2016, the number and percentage of appeals related to behavioral health treatment declined over the same period.
The commission said the decrease "could suggest that policy changes promoting access" to behavioral health care "may be favorably affecting consumers' access" to such services.
The review found that the percentage of external reviews of behavioral health coverage denials that ended favorably for consumers dropped from 2014 to 2016, but hit 59 percent in 2017, the highest percentage in the past four years.
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