Reprinted from the Health District's quarterly publication mailed to district residents (Winter 2002)
TOPIC: What to do if your insurer says 'no'
 
by karin meyer

Colorado consumers who are denied coverage for services they feel are medically necessary and appropriate have an advocate if they wish to further appeal the decision.

In 2000, the state Legislature passed a bill establishing a two-level appeals system through the Colorado Division of Insurance for consumers who have exhausted their own health plan appeals.
The Division of Insurance doesn’t actually hear or decide your case. What it can do is help you record your complaint and assign your case to an outside national entity, which conducts a review of the process by which you were denied coverage. The health insurer, not the consumer, pays for this review. (www.dora.state.co.us/insurance)
Points of contention in appeals cases often center on the issues of cosmetic vs. medical need and the use of experimental procedures, says Susan Gambrill, special assistant to the commissioner at the Division of Insurance.
need help?
For more tips regarding your rights to insurance preauthorization and grievance procedures, visit the Colorado Division of Insurance’s Web site at www.dora.state.co.us/insurance. Click on the “Publications” tab on the left side. Under “Brochures,” click on “What Happens When Your Health Insurer says ‘No’?” Information is also available at (800) 930-3745.

“For bone marrow transplants, sometimes it’s considered experimental if you’re over age 45, but sometimes it’s OK for younger people,” says Gambrill, citing one example.

Even though the state offers help, consumers still need to do their homework throughout the appeals process with their insurance company, even before an appeal through the state process is even considered.

“Consumers should make sure their doctor is totally behind them and isn’t disagreeing with the medical necessity of the procedure,” Gambrill says.

Consumers can and should consider attending the second level of their insurer’s internal appeal, which is conducted by a panel. Providing personal testimony or that of a doctor’s helps strengthen your case, she says. “It is helpful to have legitimate backing, especially at that level,” she says.

Keeping accurate written records helps build a solid case and is crucial if your case goes to the state’s external appeal, since it is a paper review, Gambrill says.

From June to December 2000, the state had 28 requests for appeals assistance. Of those, the insurance carrier’s decision was upheld in 14 cases and reversed in 13 cases. (One case was withdrawn.)

“That’s about what most programs nationwide are seeing. And the (50-50 split) is the way it should be. Those (cases) are the gray areas,” Gambrill says.