Health Care Appeals Are No Snap
Imagine that you're sick and your health plan turns you down for treatment you consider essential. For some people, this scene is all too real.

In 42 states and the District of Columbia, you can appeal your health plan's decision to an independent reviewer that will evaluate the evidence in your case and make a ruling. Last month, the Supreme Court gave its official stamp of approval to state laws governing that appeal process, ending longstanding uncertainty about its legality.

For consumers, having access to an independent review is certainly better than nothing — especially when the patients' bill of rights, which would mandate such reviews, is still stuck in Congress. But the situation is hardly ideal. State laws vary widely, and even the most consumer-friendly ones force people to navigate a thicket of regulations, a daunting process for patients who are already sick and scared.

Most states require consumers to first exhaust the internal appeals process of their plan. That can mean going through two or more levels of review, which can take months.

There are other stumbling blocks. About a dozen states limit who can use the process, excluding, for example, people who are part of preferred provider organizations or have individual health plans. California, Texas and Connecticut refuse to review after-the-fact denials. This means that if you get the treatment you think you need and then try to reverse a denial retroactively, your case won't be considered. In some states, you have just 20 days or less to file an appeal after a denial. The list goes on.

Many cases are not pursued all the way through the system. In New York, for example, consumers appealed 25,527 denials to their health plans in 2000, but only 910 made it through external review, said Joanna Rose, spokeswoman for the New York State Insurance Department.

Karen Ignagni, chief executive of the American Association of Health Plans, a trade group based in Washington that supports independent review, said the low numbers showed the positive effect of health plans' internal appeals processes, which resolve disputes that might otherwise have gone to external review.

But Karen Pollitz, project director at Georgetown University's Institute for Health Care Research and Policy, isn't so sure. Pennsylvania's experience illustrates how many people drop out of the process before the independent review stage. From January 1999 to September 2000, consumers filed nearly 8,200 appeals with their health plans. At the first level of internal appeals, the health plans upheld their own decisions 55 percent of the time, said Ms. Pollitz, who recently wrote a report assessing state external review programs.

But despite losing their appeal, only 1,062 consumers, or 24 percent, went on to the second level of internal appeals. At the second appeals level, health plans upheld their own decisions 58 percent of the time, but an even smaller proportion of consumers, 124 people, or 20 percent of the 618 who had been denied, went on to file an external appeal.

"It seems people just get worn out, and they don't go on," Ms. Pollitz said.
http://www.nytimes.com/2002/07/21/business/yourmoney/21HEAL.html