If you saw your physician for a medical problem and they recommended a test or a treatment but you were denied authorization for the treatment by your health insurance company, you may be wondering what rights you have.
Get informed about the Los Angeles medical necessity denial appeals process for ERISA policies here. A knowledgeable attorney can inform you of your rights and assist you in filing an appeal. If you are unsure if you have an ERISA plan, a general rule of thumb is that ERISA policies are health insurance policies from employers. That said, an employer plan is not governed by ERISA if the employer is a government or a religious institution. Other plans not governed by ERISA, or “non-ERISA” plans, include individual and family plans as well as plans purchased directly from insurance companies or from state Affordable Care Act insurance exchanges like Covered California. Note that this article is focused on ERISA policies. If you have a non-ERISA policy, learn more about the appeals process here.
Reasons to Appeal a Medical Necessity Denial for an ERISA Policy
Some patients do not want to deal with the hassle that an appeal can cause. In fact, in 2020, only one-tenth of one percent of Affordable Care Act plan denials were appealed. However, even if they think they have no reason to appeal or that their appeal will be denied, they should still appeal. This is a formal way of telling the health insurance carrier they are challenging their decision to decline benefits. Other times a denial is simply due to an oversight or a clerical error and can be easily resolved. And 37% of claim denials in 2020 across all ACA plans were overturned.
According to a study completed in 2011 by the Government Accountability Office, many denials are related to bureaucratic issues, such as missing forms or the wrong billing code. An appeal will help get treatment records considered and pack a claim file with support for the medical necessity of a treatment or test. Finally, if the policyholder decides they want to pursue a lawsuit against their insurance carrier with the help of an attorney, they must have already followed the Los Angeles Medical necessity denial appeals process for ERISA policies. All available appeals must be exhausted prior to the commencement of a lawsuit.
Information to Include in a File
One benefit of an appeal is that the patient has the opportunity to fill their own file with pertinent medical information to support medical necessity. It is important to note that cases have been won and lost simply on what information was or was not provided in the file.
If the individual needs to move to the next step of filing a lawsuit, already having this information in their file can be extremely helpful. An attorney can help the policyholder understand what types of information will be helpful and can also work with their medical team to get the necessary records.
The Rights of Los Angeles Policyholders
If the patient’s medical necessity request and appeals are denied, they may feel like they are lacking rights. However, they do still have several options. Any denied policyholder has the right to request information about who reviewed the claim for the insurance company. Anyone who is denied a claim should ask for the medical reviewers’ credentials.
With an ERISA policy, all medical professionals who reviewed an appeal should be identified upon request. Even if their advice was not used in deciding a claim, under 29 C.F.R. 2560.503-1 (h)(3)(iv) they must reveal this information.
How an Attorney Can Help with the Medical Necessity Denial Appeals Process for ERISA Policies
If you lack the time or the knowledge to follow the Los Angeles Medical necessity denial appeals process for ERISA policies, it is time to get an experienced attorney on your side. A practiced Los Angeles lawyer knows the requirements and steps to follow so that your chances of an overturned denial increase.
They are also familiar with your rights as a patient and as a consumer and can fight to have them upheld. If you received a medical necessity denial letter, call today to learn more about how an attorney can help.