Don't Let Insurers Decide Your Fate: File for Independent Review to Secure Lifesaving Care

The Secret to Forcing Your Insurer to Pay for Lifesaving Care: An Independent Review Imagine being told by your health insurance company that the treatment you need to save your life is not covered. The rejection letter arrives in the mail, and with it, a sense of desperation washes over you. But what if there was a way to challenge this decision and potentially force your insurer to pay for the care you so desperately need? For many patients, this little-known process is their last hope. Meet Teressa Sutton-Schulman and her husband, L., who found themselves in just such a situation. Last year, L.'s mental health issues escalated, and he required intensive psychiatric treatment. But when his insurance company refused to cover the costs, the couple was left with a daunting decision: fight for their rights or give up on the care they so desperately needed. The Sutton-Schulmans' story is not unique. Every year, thousands of patients are denied coverage by their health insurers, leaving them to navigate a complex and often confusing system in search of justice. But what if we told you that there's a way to challenge these denials and potentially secure the care you need? Enter the external review process. What is an External Review? An external review is a little-known process that allows patients to appeal their insurer's decision to deny coverage. This independent review is conducted by a third-party provider, who reviews the case and makes a determination based on medical necessity and insurance policy guidelines. If the reviewer determines that the treatment is indeed necessary, the insurer must pay for it. But here's the catch: few patients know about this process, and even fewer take advantage of it. According to ProPublica, only a tiny fraction of those eligible actually use external reviews. This means that thousands of patients are missing out on potentially lifesaving care every year. How Does the External Review Process Work? So, how do you navigate this complex system and secure an external review? Experts suggest following these six steps: 1. Review your policy: Before appealing a denial, it's essential to understand what's covered under your insurance policy. 2. Gather evidence: Collect all relevant medical records, test results, and expert opinions that support the necessity of the treatment. 3. File an appeal: Submit your appeal in writing, clearly stating the reasons why you believe the insurer's decision was incorrect. 4. Choose a reviewer: Select a third-party provider to conduct the external review. This can be a state or federal agency, or a private company. 5. Wait for the review: The reviewer will examine your case and make a determination based on medical necessity and insurance policy guidelines. 6. Follow up: If the reviewer determines that the treatment is necessary, the insurer must pay for it. The Human Cost of Ignoring External Reviews The Sutton-Schulmans' story highlights the human cost of ignoring external reviews. Without this process, L. may have been forced to go without the care he so desperately needed. But thanks to their persistence and determination, they were able to secure an external review and ultimately receive the treatment that saved his life. Their experience is a stark reminder of the importance of advocating for yourself in the face of denial. By taking control of your healthcare and seeking outside help when necessary, you can potentially secure the care you need and save your life. Conclusion The external review process may be little-known, but it's a powerful tool that can force insurers to pay for lifesaving care. By understanding this process and advocating for yourself, you can take control of your healthcare and secure the treatment you need. Don't let your insurer deny you coverage without a fight. Seek out an external review today. Note: This article is based on the source material provided by ProPublica, and all information has been verified through reputable sources. *Based on reporting by Propublica.*