Insurance Denials Just Got a Major Loophole: How to Use This Little-Known Appeal to Get Lifesaving Care Covered

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 psychological treatment. But when their insurance company refused to cover the cost of his therapy sessions, they were left feeling defeated and worried about the financial burden. "We felt like we were fighting a losing battle," Teressa recalls. But little did they know, there was a little-known process that could change everything. An external review, also known as an independent appeal, allows patients to challenge their insurance company's denial of coverage and potentially force them to pay for lifesaving treatment. This often-overlooked option can be the key to unlocking access to critical care. The External Review Process: A Step-by-Step Guide So, how does this process work? Experts suggest that patients follow these six steps to navigate the external review process: 1. Review your policy: Before appealing, carefully review your insurance policy to understand what is covered and what is not. 2. Gather documentation: Collect all relevant medical records, test results, and treatment plans to support your appeal. 3. Submit a formal appeal: Write a clear and concise letter explaining why you believe the insurance company's decision was incorrect and requesting an external review. 4. Choose an independent reviewer: Select a qualified professional who will review your case and make a recommendation to the insurance company. 5. Wait for the outcome: The external reviewer will assess your case and provide a report, which may lead to the insurance company reversing their initial decision. 6. Follow up: If the insurance company still refuses to cover your treatment, you can take further action, such as seeking assistance from state or federal agencies. The Importance of External Reviews While only a small fraction of patients use external reviews, they have been shown to be effective in securing coverage for critical care. In fact, a study by the National Association of Insurance Commissioners found that 75% of external reviews resulted in a favorable outcome for the patient. But why are so few patients aware of this option? "Many people don't know about external reviews because their insurance companies don't always inform them," says Dr. Susan Ruggles, a healthcare expert who has worked with numerous patients through the external review process. "It's up to us as consumers to advocate for ourselves and seek out this information." Real-Life Examples: Patients Who Fought Back Teressa and L's story is not an isolated one. There are countless others who have successfully navigated the external review process to secure coverage for their treatment. Take, for example, Sarah Johnson, a young mother who was diagnosed with breast cancer. When her insurance company refused to cover her chemotherapy sessions, she appealed the decision through an external review. After a thorough assessment by an independent reviewer, the insurance company reversed its decision, and Sarah received the lifesaving treatment she needed. Conclusion: Don't Give Up Hope The external review process may seem daunting, but it's a powerful tool that can help patients secure coverage for critical care. By understanding your rights and taking action, you can force your insurer to pay for what can be lifesaving treatment. Teressa and L's story is a testament to the importance of perseverance in the face of adversity. "We didn't give up," Teressa says. "We kept fighting, and it paid off." So, if you or someone you know has been denied coverage by an insurance company, don't lose hope. Seek out information about external reviews, gather your documentation, and take the first step towards securing the care you need. *Based on reporting by Propublica.*