Consumers can challenge rejected medical claims

Carol Scott-Kamlarz of Oakland has been living with a debilitating condition for several years.

"I was in a lot of pain for the last several years, unable to walk properly. My ankle was totally arthritic and I had no cartilage between my ankle bones," said Scott-Kamlarz.

Then a doctor told her about a new ankle replacement surgery that would enable her to walk pain free, but her health insurance company refused to authorize the surgery, calling it investigational and experimental.

"This wasn't investigational and it wasn't experimental. The surgery has been done for several years," said Scott-Kamlarz.

A report by the General Accountability Office released this year found that 1,600 patients appealed their rejected claims to the Department of Managed Health Care in 2009. Fifty-four percent of those patients won their appeals. In fact, the GAO study found nationwide that, "coverage denials, if appealed, were frequently reversed in the consumer's favor."

"I think that health plans do make these initial determinations that sometimes are factored into their bottom line," said Lynn Randolph from the California Department of Managed Health Care.

But the California Association of Health Plans disputes that.

"In most cases, care is provided without any controversy at all. In fact, over $80 billion is paid to doctors and hospitals now in California by Health Plans," said Patrick Johnston, president of the California Association of Health Plans.

Anthony Wright is executive director of Health Access, a health advocacy group.

"The critical thing is for Californians to know their rights and Californians for 10 years have had the right that if they get denied by an HMO and PPO, they have the ability to appeal within the company, but also to get an independent third party," said Wright.

HMOs are regulated by the Department of Managed Health Care. Major health insurance companies are regulated by the Department of Insurance. Patients must first with their insurance company before appealing to the state regulators. Many times, it's doctors who encourage patients to appeal.

"Well insurance companies will have more of a tendency to be conservative about their medical management and their approval of prior authorization or approval of claims and doctors will be pushing for whatever they think is best for their patient," said Andrea Rosen from the Department of Insurance.

"These things are never absolutely certain and in some cases medical science continues to move ahead," said Johnston.

An independent panel of doctors has the final decision on any appeals.

"A lot of times a plan will automatically deny a treatment if it is an experimental treatment, but the Independent Medical Review gives the consumer that chance to have an independent clinician determine it," said Randolph.

Scott-Kamlarz took advantage of the independent medical review and won.

"I'm walking now after five weeks since I've had surgery. I'm walking fine," said Scott-Kamlarz.

Many Bay Area employers self-fund their own insurance plans. If you get your health coverage through an employer like that, any appeals need to go through the U.S. Department of Labor. There is information on how you can appeal a claim denial in the links above.

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