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Health Coverage Denied? Appeals Process Unappealing, Say Advocates

PHOTO: If you’ve had health care denied by your insurer, you know the process of appealing can be, well, unappealing. Massachusetts advocates are hoping for reform soon. Courtesy CDC
PHOTO: If you’ve had health care denied by your insurer, you know the process of appealing can be, well, unappealing. Massachusetts advocates are hoping for reform soon. Courtesy CDC
August 22, 2013

BOSTON - When Massachusetts health insurance policy holders are denied coverage, they have a right to appeal. However, according to consumer advocates, the appeals process is often downright unappealing. It's bad enough when the health insurer refuses to cover a procedure or medication, but then it can get downright confusing, warned Clare McGorrian of Health Law Advocates.

"They don't give enough information about the reasons for denial of coverage," McGorrian said. "Sometimes they give conflicting information, and they don't always give people the information that they are entitled to."

The state's Office of Patient Protection (OPP) is revising its rules on health plan appeals. At a mid-summer public forum, the agency heard suggestions for changes. When the new rules are announced, advocates said, they hope any unfair processes end.

Alyssa Vangeli, a policy analyst at the non-profit group Health Care For All, said she hopes the OPP will make significant changes.

"In general, this is a great opportunity for OPP to play an active role in increasing consumer protections in the appeals processes," Vangeli said. "We did provide detailed recommendations to them."

It is also important that regulations exist to prevent insurance coverage from lapsing while the policy holder is in the midst of appealing, a process that can take a long time, McGorrian said.

"We want OPP to improve the rules and the protections that allow coverage to continue while the insured is arguing with their insurance company whether something will be paid for," she added.

Advocates also said health plans must be prevented from using unqualified clinicians to review consumer appeals. And they urged insurers to do a better job of letting non-English speaking members know they have a right to interpreter and translation services.

Mark Scheerer, Public News Service - MA