Washington, D.C. – July 28, 2011 – The American Cancer Society Cancer Action Network (ACS CAN) has joined 14 other patient and consumer groups and individuals in filing comments on the administration’s amendment to the interim final rule regarding the rights of patients to appeal denials of claims under the Affordable Care Act.
The comments commend the administration for working with patient and consumer representatives to develop a workable appeal process that ensures that consumers have a meaningful opportunity to contest denials of health insurance coverage.
But the comments also list improvements to the rule that are necessary to fulfill the new law’s promise to significantly strengthen the rights of patients to appeal denials of claims. When the rule was released in June, ACS CAN reacted with deep concern that it inadequately fulfills the intent of the law and denies consumers the tools they need to launch appeals for access to lifesaving care.
For example, the rule enables insurers to provide minimal explanation for denying a claim, permitting vague explanations such as that the claim is “not medically necessary” or “experimental/investigational.” The groups’ comments suggest that insurers should be required to include a narrative statement of the reason for the denial of coverage. For example, insurers should have to explain that the service is not medically necessary because the patient does not meet the clinical criteria for the service, and a copy of the clinical criteria should be sent to the patient without the patient having to request it.
The rule also narrows the scope of issues that can be appealed to an external reviewer to those involving “medical judgment.” The term is new and not well-defined. More importantly, it excludes appeals of denials based on questions of what services were covered under the contract with the patient, and on provider coding errors. Given the importance of an external appeal in resolving disputes in an equitable manner, the comments argue that all disputes should be appealable to an external review group.
The comments also discuss other important issues to consumers, including who chooses the review panel, whether consumers can be charged for appeals, and issues of translation of plan materials into foreign languages.
The comments can be found here.
FOR MORE INFORMATION, CONTACT:
Steven Weiss or Alissa Havens
American Cancer Society Cancer Action Network
Phone: (202) 661-5711 or (202) 661-5772
Email: [email protected] or [email protected]
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