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Denied an Insurance Claim? Consumers Get Federal Help Under ACA

Patty Wight
/
MPBN

RAYMOND, Maine - When it comes to having claims denied, consumers who buy insurance on the Affordable Care Act's online marketplace have to be savvy.

They have to understand things like premiums, deductibles, and co-pays - essentially become their own HR department. But the federal health law does provide help, making the complicated process of insurance appeals a little bit easier.

In 2013, Brian and Leigh Walker's teenage daughter required hospitalization for an ongoing medical problem. A week went by, and her doctors felt she needed further care. But the Walkers, of Raymond, received a phone call from their insurance company: They were told no further hospitalization would be covered.

"And I looked at my wife and said, 'So now what do we do?' At the time the decision was simple - we needed to make sure she was cared for," Brian Walker says.

About a week later, their daughter was discharged - and the Walkers' faced an $8,000 bill. Brian spent hours on the phone with the insurance company trying to resolve the denied claim.

"There were calls where I would literally be on hold for a long time, and then I'd end up in Georgia," he says. "And the people would say, 'What are you calling us for?' and I'd say, 'Well, I got forwarded here.' It was a really difficult situation."

"I don't think we could have done this on our own," says Brian's wife, Leigh Walker. "I mean, we would have had to at least get a lawyer directly to deal with it. I don't think as an independent person, unless you have medical knowledge and have the ability to go through your entire policy and pull out the relevant pieces that show that it is medically necessary, it's pretty difficult."

The Walkers contactedConsumers for Affordable Health Care. Since 2010, the organization has received funding under the Affordable Care Act to provide free help for insurance appeals. They'll make phone calls, get medical records, and provide representation. Legal and Policy Director Andrea Irwin says consumers used to be essentially on their own when it came to appeals.

"Unfortunately, there aren't a lot of members of the private bar that pursue these cases because it does take a lot of time," Irwin says. "And there isn't really a financial incentive for private attorneys to pursue these cases. There aren't attorney's fees at the end. You're really just getting the person coverage for the service they're supposed to get."

But Irwin says consumers shouldn't shy away from appeals. "Probably at least 70 percent are worth pursuing an appeal that get denied."

There are three steps to an appeal:  First, there's a written appeal. If that's denied, the next step is a hearing with the insurance company. If the claim is still denied, the final option is an external hearing, where an independent physician listens to the case and makes the final decision.

Maine's Bureau of Insurance oversees the external reviews. Superintendent Eric Cioppa says the Bureau also helps consumers with complaints that don't fall under the appeals process.

"You know, 'I think I've paid my deductible and I don't owe anymore,' " he says. "Or, 'This network provider is listed like it was in-network, and then I went and it turns out they weren't in-network.' I mean, those are the sort of complaints that wouldn't be subject to external review, but we would certainly help a consumer with."

Last year, the Bureau got more than $2 million in restitution for consumers. It behooves consumers, says Cioppa, to scrutinize claims and ask questions.

Brian Walker says he's glad he did. He's currently awaiting an external hearing on his daughter's uncovered hospital stay. No matter what the outcome, he says the appeals process has been worth it. "We got our day in court. We got our day where we have independent people saying, 'I've heard your side of the story, and here's our decision.' "

And the experience has helped the Walkers with subsequent insurance denials. Leigh Walker was denied coverage for some lab work she had done. After nearly a dozen phone calls to her insurance company, she says they discovered the lab made a mistake when it filed the claim. It was corrected, and the Walkers saved a couple hundred dollars.