The Secret to Forcing Your Insurer to Pay for Lifesaving Care
When Teressa Sutton-Schulman's husband, L, was struggling with escalating mental health issues, she knew he needed intensive psychiatric care. But when the insurance company refused to cover it, she felt like she'd hit a brick wall. "I was told that they wouldn't pay for it because it wasn't 'medically necessary,'" Teressa recalls. "But I knew that L's life depended on it."
Most people in this situation would give up and accept the insurer's decision. But not Teressa. She dug deeper, determined to find a way to get her husband the care he needed. And what she discovered was a little-known process called an external review – a secret that could potentially force insurers to pay for lifesaving treatment.
The External Review Process: A Lifeline in Disguise
An external review is an independent assessment of an insurer's decision to deny coverage. It's like a second opinion, but with teeth. When an external reviewer determines that the insurer was wrong, they can order the company to pay for the treatment. This process is often referred to as "external appeal" or "independent review."
But here's the thing: most people don't know about it. According to ProPublica, only a tiny fraction of those eligible actually use external reviews. And that's a problem.
The Numbers Don't Lie
In 2020, ProPublica analyzed data from the National Association of Insurance Commissioners and found that:
Only 1 in 10 people who had their claims denied used an external review.
Of those who did appeal, only about 30% were successful in getting their insurer to pay for treatment.
How to File an External Review
So, how can you use this little-known process to force your insurer to pay for lifesaving care? Here are six steps experts suggest:
1. Read the fine print: Check your insurance policy or plan documents to see if they offer external reviews.
2. Gather evidence: Collect all relevant medical records and documentation to support your claim.
3. File a complaint: Submit a formal complaint to your state's insurance department or the U.S. Department of Health and Human Services (HHS).
4. Choose an independent reviewer: Select a qualified external reviewer from a list provided by your insurer or plan.
5. Submit your appeal: File your external review request with the chosen reviewer, including all supporting documentation.
6. Follow up: Keep track of the progress of your appeal and be prepared to advocate for yourself.
Real-Life Examples: When External Reviews Made All the Difference
Teressa's story is just one example of how external reviews can make a difference in people's lives. In another case, a woman named Sarah was denied coverage for a life-saving surgery due to her insurer's arbitrary definition of "medically necessary." But after an external review, the reviewer determined that the insurer had erred, and Sarah received the treatment she needed.
The Future of External Reviews: A Brighter Outlook?
As the healthcare landscape continues to evolve, it's clear that external reviews will play a more significant role in ensuring patients receive the care they need. With the passage of the No Surprises Act in 2020, insurers are now required to provide patients with information about external review options.
Conclusion: Don't Give Up
Teressa's story is a testament to the power of perseverance and advocacy. When faced with an insurer's refusal to cover lifesaving treatment, don't give up. Use the external review process to fight for your rights and get the care you need. Remember, it's not just about winning – it's about saving lives.
Note: This article is based on real events and individuals, but some details have been altered for clarity and anonymity purposes.
*Based on reporting by Propublica.*
