Since the new healthcare law was so hard to understand, I have kept a close eye on the implementation.  I will post as key implementation things that impact consumers come down the pike. This is one and generally liked thus far.

I posted a summary, Q&A and consumer group reaction below.


Rules to ease consumer appeals in health coverage (USA Today, 7/23/10)

By Alison Young, USA TODAY

The rules, part of the nation's new health care law, will make it easier for consumers to dispute an insurer's decision within the plan and require coverage to continue during the appeal, said Phyllis Borzi, an assistant secretary in the Department of Labor.

Consumers will have the right to an independent, third-party review of insurers' decisions.

Although 44 states allow some form of external appeal, the level of consumer protection varies greatly, and in some states, the outside reviewer is hired by the insurer that denied the claim, Borzi said.

More at USAToday.com

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Questions and answers about new rules on appealing rejections of health insurance claims (LA Times, 7/22/10)

Many do, but rules differ depending on whether you get insurance from an employer or buy it on your own. Consumer protections also vary dramatically from state to state.

Existing federal rules require most employer-provided plans tohave an internal process for appealing a rejected claim. But if you lose, there is no guarantee that you can take your appeal to an independent third-party reviewer.

You currently have no right to an external review of your denied claim if you work for a company that self-insures, as many large employers do. And if you buy insurance on your own, you may not get an external review either.

Thirteen states guarantee an external review for only some kinds of health plans. Six states do not require any independent review process.

So what happens now?

The new rules essentially standardize the process for internal and external appeals. Next year, if you qualify for the new protections, you will be guaranteed an internal review if your claim is denied, whether you get insurance from a private employer, a government employer or directly from a commercial carrier.

These internal reviews will have to conform to new standards that require health plans to explain denials more clearly, to speed decisions in urgent cases and to prevent conflicts of interest by arbiters reviewing denied claims.

In addition, people who qualify will be guaranteed an external review by someone not employed by their health plan.

States have until July 1, 2011, to put these external review regulations in place, or the federal government will do it.

More at LATimes.com including how to find out whether you can get the new protections (Not everyone is eligible; you can also read about that in the link).

Consumers groups are cheering the arrival of new rules making it easier for patients to appeal health insurance denials.

Ron Pollack, head of Families USA, a health consumer group, said the changes are “essential so that consumers are not improperly denied needed care or forced to spend unaffordable amounts for such care.”

“For many years, America’s consumers wanted the right to appeal adverse health plan decisions to an objective and unbiased decision-maker,” Pollack said in a statement. “With the new rules issued today, consumers throughout the nation, irrespective of the health plan they are in, will be empowered to contest wrongful decisions.”

The new guidelines — unveiled Thursday by leaders of the Labor and Health and Human Services departments — will create a national standard by which Americans can contest claims denials passed down by their health insurance companies. Although many states already have an appeals process in place, "there's no guarantee that this process will be swift or objective," Phyllis Borzi, an assistant secretary at the Labor Department, told reporters Thursday.

More at TheHill.com

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Let's discuss the specific positives and shortcomings of this particular implementation.. What do you like, not like about this particular implementation. Then we can call our reps on this. Thanks.

I like the following thus far.
- More states have this appeal process now,
- The appeal process is standard. So, your family member/friend in CA who does it can help you with it if you need some support sitting in NY. The country is not so fragmented anymore in that regard and the consumer left without being able to leverage their support structure.
- you are not so alone in going against the insurance company. The process helps you to a great degree.
-  the coverage continues when there is an appeal.

What I do not like:
- Existing plans/grandfathered plans are not subject to the rule. This may leave out a vast majority of people from the benefits of this implementation legislation.  Insurance companies will drive a mammoth truck thru this; just you watch.


I hope actual implementation - forms, etc.. -- are simple enough... and it can be done online if needed backed with an 1-800 number. That would really simplify the process.


-- Edited by Sanders on Friday 23rd of July 2010 10:47:13 AM