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HHS shrinks consumer right to appeal coverage denial

New rules issued by the Department of Health & Human Services (HHS) downgrade consumers' rights to appeal insurers' denials of coverage, providing them less time to prepare appeals, less information about claim denials, and fewer types of denials that can be challenged.

The amendment to the interim final rules, which replaces a patchwork of state policies, guarantees all patients nationwide have the same rights to appeal if their insurers do not cover care that they consider necessary. Patients can protest a claim denial to their health plans and then, if necessary, to an outside arbiter, reports the Washington Post

HHS also delayed the start of the external review process until Jan. 1, instead of the original July 1 implementation date, according to the Wall Street Journal. States and insurance companies needed more time to adhere to the requirements, said Steve Larsen, director of the HHS Center for Consumer Information and Insurance Oversight.

Health plans can now take up to 60 days, compared with 45 days under the earlier guidelines, to review consumers' appeals. And consumers only have two months to file a complaint instead of four months as in previous guidelines, reports the WSJ.

The new rules also narrow the grounds for a patient to protest an insurer's decision. For instance, patients can appeal if an insurer declines to pay for care based on a medical judgment, but not if the dispute is based on diagnosis coding mistakes, the Post notes.

However, some consumer protections remain intact. For example, decisions by external review panels are binding, patients can still appeal if their insurers cancel their coverage, and self-insured employer-sponsored plans must use at least two independent review organizations, notes Kaiser Health News.

To learn more:
- read the HHS interim final rule
- view the Washington Post piece
- check out the Wall Street Journal article
- see the Kaiser Health News story

Related Articles:
Internal and external appeals: Health plans face quick turnaround in urgent cases
Rules for claims appeals on hold; California may increase insurers' required coverage;
Insurers increased denials by 49 percent because of pre-existing conditions
Insurers often reverse claims denial, GAO says

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