Insurers Forced to Pay for Lifesaving Care: Uncovering a Crucial Appeal Process

The Secret to Forcing Your Insurer to Pay for Lifesaving Care: An Unlikely Appeal Process As she watched her husband's mental health deteriorate, Teressa Sutton-Schulman felt like she was running out of options. His escalating anxiety and depression had become a daily struggle, but their insurance company refused to cover the intensive therapy he needed. Desperate for answers, Teressa turned to an unlikely lifeline: an external appeal process that could force her insurer to pay for what might be lifesaving treatment. This little-known process, known as an "external review," is one of the healthcare industry's best-kept secrets. Despite its potential to turn the tables on insurance companies and secure vital care for patients, only a tiny fraction of those eligible actually use it. But for Teressa and her husband, L, this obscure appeal proved to be their last hope. What is an External Review? In most cases, when an insurer denies coverage for treatment, patients are left with few options but to accept the decision or seek expensive out-of-pocket care. However, under federal law, insurers must provide a process for external reviews, where an independent third-party organization evaluates the initial denial and makes a binding decision. This review is typically free of charge to the patient and can be initiated by either the patient or their healthcare provider. The Six-Step Process Experts recommend that patients follow these six steps when navigating the external appeal process: 1. Review your policy: Understand your insurance plan's coverage and any limitations on external reviews. 2. Gather evidence: Collect all relevant medical records, test results, and expert opinions to support your case. 3. Choose a review organization: Select one of the three independent review organizations approved by your state or federal government. 4. Submit your appeal: File your request for an external review with the chosen organization, providing all required documentation. 5. Wait for the decision: The review organization will evaluate your case and make a binding decision within 30-60 days. 6. Enforce the decision: If the review is in your favor, contact your insurer to ensure they implement the recommended treatment. The Human Impact Teressa's story is not an isolated incident. Millions of Americans face similar struggles with their insurance companies every year. By exploring this little-known appeal process, patients and healthcare providers can gain a powerful tool to advocate for necessary care. As Teressa reflects on her experience, "It's like having a safety net – you never know when you'll need it, but it's there to catch you." The Future of Healthcare As the healthcare landscape continues to evolve, the external review process offers a beacon of hope for patients and families navigating complex insurance systems. By shedding light on this often-overlooked mechanism, we can empower individuals to take control of their care and advocate for what they need. For those facing similar struggles with their insurers, Teressa's story serves as a testament to the power of perseverance and advocacy. As she puts it, "Don't give up – there are people who care, and there is help available." *Based on reporting by Propublica.*