The United States is respected around the world as a leader in the development of medical breakthroughs in life-saving drugs and vaccines, surgical procedures such as transplants, cutting-edge medical equipment, diagnostics and molecular medicine. These advancements, among others, have transformed the global health care system. However, the U.S. does not garner the same respect for its health insurance system. Despite this, some elements of how the U.S. offers insurance coverage, including wellness or population health techniques, are studied internationally. Many U.S. developed interventions and innovations have optimized clinical outcomes where the health care dollar is often limited. 

Despite medical advances, a primary area of frustration for many Americans enrolled in private or public sponsored health insurance arrangements is how insurers make coverage determinations for medical and pharmaceutical care. Often, coverage is denied using esoteric terms such as the care is not “medically necessary” or the care is considered “experimental or investigational.” What makes the situation even worse is the complex and fragmented appeals system that Americans and their attending providers must use when asking an insurer, payer, or other entity to reconsider the denial or adverse determination.  Patients, their families and caregivers are often not aware of their appeal rights or knowledgeable about other due process protections afforded them by law. 

Individuals with behavioral health conditions are often some of the most vulnerable and dependent upon how and when health plans decide to cover their care.  Historically, mental health and substance use disorder treatments were subject to more restrictive limits than medical and surgical services, resulting in frequent care denials and other adverse determinations. Prior to 2008, these unequal medical management practices were legal in many states.  Thus, individuals typically could not use the appeals process to question unfair and harmful decisions based on inequities between how an insurer was covering medical/surgical care versus behavioral health care. However, under the Federal Parity Law, health insurers must treat behavioral health benefits the same as physical health benefits, giving new and increased protections to consumers accessing care.

In 2017, The Kennedy Forum published an issue brief entitled “Filing An Appeal Based On A Parity Violation.” The 16-page policy brief describes different types of potential parity violations to illustrate one’s right to file an appeal based on how health plans treat physical health services differently than mental health and substance use disorder (behavioral health) treatments. The analysis focuses on how protections founded within the Federal Parity Law can be used as a vehicle to increase access to the appeals process.

In addition, the issue brief provides a concise overview of how the appeal systems works (or does not work for that matter) for individuals with behavioral health disorders.  The appeals process, especially for parity violations, remains a complex and confusing system for stakeholders.

It is time to rethink and improve on the existing health insurance appeal system with an eye towards making the appeals process more efficient, transparent and meaningful. A robust appeal system also will create a deterrent effect if those who inappropriately deny care are held accountable.

The Kennedy Forum recommends 10 action steps to help improve the health insurance appeal system:

1. Increase awareness of the appeal process
2. Promote more due process and transparency
3. Allow attending providers and other advocates to file appeals
4. Simplify the appeals process
5. Standardize the appeal across market segments and state lines
6. Upgrade the external review process
7. File more appeals
8. Leverage technology to improve efficiency
9. Update oversight regulations
10.   Promote advocacy and education programs

While this report focuses on behavioral health disorders, these recommendations apply to all types of health insurance appeals, and would benefit everyone who is seeking a reconsideration for care that has been denied by a health plan.  

There is an old saying that a rising tide lifts all boats.  The assumption is a better run appeals system would help all stakeholders, including not only patients but health plans.  Stay tuned for future blogs that provide more insights into this issue.