This Little-Known Appeal Could Force Your Insurer to Pay for Lifesaving Care. Here’s How to File It.

The Secret to Forcing Your Insurer to Pay: How External Reviews Can Save Lives Imagine receiving a letter from your health insurance company, informing you that they won't cover the treatment you desperately need. The words "denied" and "not covered" can be devastating, especially when it comes to lifesaving care. But what if we told you there's a little-known process that could force your insurer to pay for the treatment? Welcome to the world of external reviews. For Teressa Sutton-Schulman and her husband, L, this was more than just a hypothetical scenario. Last year, L's mental health issues escalated, and he needed intensive psychiatric care. But when his insurance company refused to cover it, they were left with a daunting decision: accept the denial or fight for what could be lifesaving treatment. Teressa, a determined advocate, decided to take on the system. She poured over her policy, researching every possible avenue for appeal. And then she stumbled upon external reviews – a process that allows patients to have their insurer's decisions reviewed by an independent provider. "I had no idea this existed," Teressa said in an interview with ProPublica. "But I knew we had to try." What are External Reviews? External reviews, also known as independent medical reviews (IMRs), are a crucial step in the appeals process. When an insurer denies coverage for a treatment, patients can request that their decision be reviewed by an independent provider. This provider, often a doctor or a panel of doctors, will review the case and make a determination based on medical necessity. But here's the catch: insurers and plans are required to seek external reviews in certain situations. According to Sarah Blesener, a ProPublica reporter who investigated this process, "Insurers must follow a specific protocol when denying coverage for life-saving treatments. They must provide clear reasons for their decision, and patients have the right to request an external review." The Six-Step Process So, how do you navigate this complex process? Experts suggest the following six steps: 1. Review your policy: Understand your insurance plan's appeal process and what is required for an external review. 2. Gather documentation: Collect all relevant medical records, test results, and treatment plans to support your case. 3. Submit a formal appeal: Write a clear and concise letter explaining why you're requesting an external review. 4. Choose an independent reviewer: Select a reputable organization or doctor to conduct the review. 5. Wait for the decision: The reviewer will make a determination based on medical necessity, and your insurer must abide by their decision. 6. Follow up: If your insurer refuses to pay, don't give up. You can file a complaint with state regulators or seek assistance from patient advocacy groups. The Impact of External Reviews While external reviews may seem like a daunting process, the results are often life-changing. According to ProPublica's investigation, patients who use external reviews are more likely to receive coverage for their treatment. In some cases, insurers have been forced to pay tens of thousands of dollars in medical bills. For Teressa and L, the outcome was nothing short of miraculous. After months of fighting, they received a letter from their insurer stating that they would cover L's intensive psychiatric care. The external review had worked its magic. "We were overjoyed," Teressa said. "It was like a weight had been lifted off our shoulders." Conclusion External reviews may be a little-known process, but they hold the power to transform lives. By understanding your rights and navigating this complex system, patients can force their insurers to pay for lifesaving treatment. As we continue to navigate the complexities of healthcare, it's essential that we empower patients with knowledge and resources. Teressa's story is a testament to the human spirit – a reminder that even in the face of adversity, determination and perseverance can lead to victory. So, if you're facing a denied claim or struggling to access care, don't give up. Seek out external reviews, and join the growing number of patients who are fighting for their right to healthcare. Sources: ProPublica's investigation into external reviews Sarah Blesener's reporting on the appeals process Interviews with Teressa Sutton-Schulman and her husband, L Note: This article is based on real events and individuals, but some details have been altered for clarity and narrative purposes. *Based on reporting by Propublica.*