Navigation Links
Patients' Must Know Rights When Health Plans Deny Claims
Date:8/25/2009

WESTERVILLE, Ohio, Aug. 25 /PRNewswire/ -- Newspapers report daily that our healthcare system is broken, express concern about healthcare denials and mention that the system shifts costs to consumers. Commonly denied treatments include cosmetic surgeries, experimental/investigational drug therapies, pain management and chiropractic treatments according to NAIRO (www.nairo.org), a trade organization of independent review organizations (IROs). Health plans claim they deny such cases based on whether the treatment is medically necessary, in network, covered by the medical policy or experimental/investigational.

"State laws give patients denied payment of treatment or services recourse for appeal," said Seana Ferris, President of NAIRO. "Unfortunately many healthcare consumers don't understand the process, don't know their right to appeal or quit too soon." Presently 44 states and the District of Columbia have external review legislation. NAIRO provides frequently asked questions about patients' rights on its Website at www.nairo.org/patients-faq.php.

Steps for Patient Appeal

By learning the steps in their health plan's and state's appeal processes, patients can escalate their appeal to appropriate agencies when necessary. "Patients denied payment of treatment must first exhaust the internal appeal process offered through their health plan," Ferris said. "Following the denial of an internal appeal, they can request an external review using a qualified and unbiased third-party, like a URAC-accredited IRO." Generally, the health plan, not the patient, bears the cost of an external review.

Ask Questions

To start the process, patients need to ask questions, like these:

  • What is the reason for the denial?
  • Did the health plan seek an independent medical review determination from an IRO before denying coverage?
  • What are the timeframes to make an appeal and what information is required?

States Decide the Process

IROs assist many leading health plans in making medical necessity determinations as a part of the plan's internal appeal process. Typically, this is a best practice among health insurers. However not all health plans conduct these arm's length reviews. When a health plan denies a benefit, consumers should inquire whether the plan conducted an objective review using an unbiased third party, like an IRO.

Once patients exhaust the internal review process outlined by their health plan, their rights hang on the type of claim denied and the state they live in. Their next step is to request an external review appeal following the process established by their state insurance commissioner.

Role of the IRO

IROs employ independent, credentialed and licensed healthcare practitioners with specialist credentials needed to perform an evidence-based review a case based on its medical necessity. The expert is board-certified, in active practice and has the knowledge and experience to perform an unbiased and thorough medical review of the case.

"Consumers today have many rights when it comes to healthcare denials," Ferris said. "They just need to learn the ins and outs of the appeal process and then see the process through to the end."

About NAIRO

NAIRO works to promote the value and integrity of the independent medical review process, as an integral part of improving U.S. health care. Its members embrace an evidence-based approach to medical review for resolving coverage disputes between enrollees and their health plans. For more information, visit www.nairo.org.

NAIRO officers are available for press interviews.


'/>"/>
SOURCE NAIRO
Copyright©2009 PR Newswire.
All rights reserved

Related medicine news :

1. First Swedish Patients Receive MitraClip(R) Therapy
2. Prostate Net Announces: Major Medical Education Initiative for Patients, Caregivers and Healthcare Professionals
3. Cancer patients who are separated when diagnosed have worse survival rates
4. Young leukemia and lymphoma patients live longer today than in years past
5. U-M researchers discover therapeutic target that could help patients with pulmonary fibrosis
6. Distressed Patients Suffer Panic Attacks as UK Medicine Stocks Hit by Shortages, Chemist+Druggist Reveals
7. Newer Drug Beats Tamoxifen for Older Breast Cancer Patients
8. Roche and InterMune Initiate Phase 2b Clinical Trial of RG7227/ ITMN-191 in Patients With Chronic Hepatitis C
9. Tumor size and level of visceral pleura invasion can impact survival of NSCLC patients
10. Study shows carvedilol is effective in preventing variceal bleeding in cirrhotic patients
11. Laurence Barsh, DMD, Founder of Snoring Isn't Sexy, LLC Emphasizes Need to Evaluate and Treat Sleep Patients
Post Your Comments:
*Name:
*Comment:
*Email:
(Date:6/26/2016)... ... ... On June 10-11, 2016, A Forever Recovery, a holistic treatment center for ... Table in Battle Creek, MI, where the rehabilitation facility is located. This annual celebration ... world’s leading providers of cereal and other breakfast foods. Its residents often refer to ...
(Date:6/26/2016)... ... June 26, 2016 , ... Many women are ... with endometriosis. These women need a treatment plan to not only alleviate symptoms ... can help for preservation of fertility and ultimately achieving a pregnancy. The specialists ...
(Date:6/25/2016)... ... June 25, 2016 , ... "With 30 hand-drawn hand ... project," said Christina Austin - CEO of Pixel Film Studios. , ProHand Cartoon’s ... within Final Cut Pro X . Simply select a ProHand generator and drag ...
(Date:6/25/2016)... ... ... On Friday, June 10, Van Mitchell, Secretary of the Maryland Department of Health ... of their exemplary accomplishments in worksite health promotion. , The Wellness at Work Awards ... at the BWI Marriott in Linthicum Heights. iHire was one of 42 businesses to ...
(Date:6/24/2016)... ... ... June 19, 2016 is World Sickle Cell Observance Day. In an effort to ... treatments, Serenity Recovery Center of Marne, Michigan, has issued a pain management ... (SCD) is a disorder of the red blood cells, which can cause episodes of ...
Breaking Medicine News(10 mins):
(Date:6/23/2016)... -- Research and Markets has announced the addition ... 2022" report to their offering. ... with kidney failure, it replaces the function of kidneys by ... and thus the treatment helps to keep the patient body,s ... Increasing number of ESRD patients & substantial healthcare ...
(Date:6/23/2016)... -- Roche (SIX: RO, ROG; OTCQX: RHHBY) announced that ... PCT (procalcitonin) assay as a dedicated testing solution for ... clearance, Roche is the first IVD company in the ... risk assessment and management. PCT is a ... in blood can aid clinicians in assessing the risk ...
(Date:6/23/2016)... Bracket , a leading clinical trial technology and specialty ... Bracket eCOA (SM) 6.0, at the 52 nd ... in Philadelphia , Pennsylvania.  A demonstration of ... its kind to fully integrate with RTSM, will be held ... a flexible platform for electronic clinical outcomes assessments that is ...
Breaking Medicine Technology: