reviews let you discuss poor quality appeal review components
obtained at the lower levels of review.
Unfortunately, on the commercial coverage side (group and individ-
ual health plans), provider appeals are often limited to 1 or, at best, 2
internal appeals with a payer. However, obtaining an authorization
from the patient to pursue external appeal review is often an option
that lets you escalate to an external review process with independent
decision makers.
In an effort to improve what was widely recognized as "ineffective
appeal processes," the ACA sought to standardize healthcare insurance
appeals for group and individual insurance plans and universally extend
access to the gold standard: external/ independent review of denied
healthcare claims. Since the ACA passage in 2010, independent review
organizations have lined up medical dream-team level reviewers to meet
the challenge of reviewing cases.
While the scope and role of independent review has grown signifi-
cantly since passage of the ACA, few consumers — an estimated 1 in
1,000 — use the process. Getting consumers to file even an initial
appeal, much less Level II and External Review requests, remains
daunting.
Fortunately, the treating medical professional has the right to act
on the patient's behalf when you believe an insurer is wrongfully
denying access. The provider is often in the best position to pursue
the process altogether — records collection, drafting and submis-
sion — and may even benefit from the dialogue regarding how
plan/policy language addresses coverage questions.
To insure that the providers can participate, if willing, the ACA
made clear that the patient can assign their right to pursue appeals to
any other party: a willing family member, a training advocate or the
medical organization that provided the treatment. Unfortunately, med-
Coding & Billing
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