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Thursday, January 26, 2012

Holding Insurance Companies Accountable: The Importance of a Good Appeals Process

By Erinn Ackley - Red Lodge, Montana

Inclusion of a fair and expeditious appeals process that holds health insurance plans accountable is a very important component of the Affordable Care Act. In 2006, my father struggled through his insurer's appeal process in order to receive his prescribed treatment, a potentially lifesaving bone marrow transplant. Up until his doctor requested approval for the transplant, my father's insurer had freely covered all of his pre-treatment tests (including those to find his donor) and treatments.

After the denial of two different transplant protocols submitted by my father's physician, my dad journeyed through his insurance provider's expedited independent review process...twice. His insurer stated that my father would be notified of the reviewing foundation's decision within 48 hours of receiving his request for expedited review. My father received notice nine days after the first review and 13 days after the second review (which ultimately overturned the original denial). However, that the entire appeals process took 60 days from start to finish - not exactly how my family wanted to be spending this critical and precious time.

The two time-consuming denial processes also resulted in my father having to go through an additional round of intensive chemo (covered by the insurance plan) to keep his cancer "in check" and his body receptive to a transplant.

Eventually, as the result of the efforts of countless people working on my father's behalf to reverse the unjust, bureaucratic actions of his health insurance policy, my dad received his prescribed bone marrow transplant-126 days after his physician originally submitted the transplant request.

Unfortunately, my father passed away, at the age of 59, four and a half months after his transplant. We will never know if the outcome would have been different if his transplant had not been delayed for four months while he appealed for his prescribed treatment, but we do know that, if the Affordable Care Act had been law at the time, some key parts of our experience would have been different:

  1. In my father's case, the appeal decisions were not made in the promised time frames. We lost valuable time that my dad should have been able to spend fighting his illness. Health reform would have made an emergency decision available within days instead of months, both through a more accountable internal appeal and through an external appeal overseen by a third party.
  2. The state commission working on my father's case did not have the legal authority to hold health insurance providers accountable for non-compliances. The Affordable Care Act gives the states such authority.
  3. The "independent" external reviewer was not truly independent. It was a "foundation" compensated directly by his insurance company The Affordable Care Act does not allow such conflicts of interest in the new external appeals process.

Would the time saved through a better appeals process been enough to save my father? We will never know for sure. But I do know that it’s important that everyone has the right to appeal denials generated by health insurance providers through a process that will proceed in a fair and timely manner and hold those making appeal-related decisions accountable. It is my hope that, through these improvements, no family will have to endure what mine endured ever again.

During the fight to pass the Affordable Care Act, Erinn Ackley spoke before Congress on behalf of her father. View her testimony by clicking here. She also appeared in numerous outlets, including ABC News, the Washington Post, and local papers in Colorado, Michigan, Minnesota, Missouri, and Ohio. She gave a voice, not only to her father, but to the consumers across the country who have died because of insurance company abuses. Don’t let opponents of reform take us back to the status quo. Share your story of past insurance abuse (or your experience going through the new process) with us.

Additional resources:

  • Learn more about your new rights to external appeal by clicking here.
  • Find a Consumer Assistance Program to help you navigate your rights by clicking here.
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