Health Insurance Appeals and Complaints: Who to Talk to, How to Handle Problems

It’s no secret that people and their insurance companies sometimes clash over which medical services will be covered.

Many WebMD readers have posted questions about consumer rights under the new health reform law -- especially when it comes to fighting against an insurance company decision that seems unjust.

Here are answers to some of the most frequently asked questions about health reform and filing grievances with insurers.

Q: If you feel your health insurance company is not following the new laws, who do you contact?

A: If you have reason to believe your insurance company is not complying with provisions under the Accountable Care Act you can contact your state’s department of insurance to file a complaint.

If you get your health insurance through your job, it’s also a good idea to discuss your concerns with your human resources department. Or you can contact the U.S. Department of Labor’s Employee Benefits Advisors for help by calling 866-444-EBSA (3272).

Q: How long will the appeal process take or how soon should I expect the matter to be settled?

A: You’re entitled to appeal directly to your insurer if it:

• denied payment for your care
• ruled that your care was not medically necessary
• said that you’re not eligible for the benefit in question
• claimed that your treatment is experimental
• claimed that you have a pre-existing condition

The new law sets the following timelines for insurance companies to review and decide on an appeal:

• 72 hours for denials of urgent care
• 30 days for denials of nonurgent care you have not yet received
• 60 days for denials of service you have already received

Q: What if my appeal with my insurance company is denied?

A: If your appeal is denied, you are entitled to an explanation from your insurer. The plan is also required to explain how you can go about filing an external appeal, in which your case is reviewed by an independent third party.

Keep in mind that if your case is urgent and you or a loved one are in danger of becoming increasingly ill without treatment, you can ask to have both the internal review and external review conducted at the same time.

Q: Is that appeal process already available? If not, when does it take effect?

A: For many people, internal and external appeals processes are already available. If your health plan went into effect on or after March 23, 2010, your insurer must comply with these laws as of Sept. 23, 2010.

If you have a plan that was in place prior to March 23, 2010, however, it may qualify for grandfathered status and the new guidelines for appeals may not apply. You can learn more about grandfathered health plans and what it means for you at the web site of Families USA, a nonprofit advocacy organization.

However, even if you have a grandfathered health plan, you should check with your insurer and/or state department of insurance about your right to appeal. Most states -- 44 -- already offer an external appeal process, although the laws vary greatly. All health plans are encouraged to adopt the new regulations prior to July 1, 2011.

Q: If I have a grievance and I'm appealing my insurance company's decision, what do I do in the meantime?

A: Ask your insurance company to continue paying for your treatment until a determination on your appeal has been made.

If your request is refused, it’s a good idea to speak with the doctor or hospital treating you. Ask to arrange a payment plan or if collections can be put on hold until your appeals process is complete.

Q: If I don't pay a contested medical bill, will it ding my credit?

A: Yes. It’s important that you don’t ignore medical bills. Instead, work with your health care provider to arrange a payment plan so your bills are not sent to a collection agency, which providers can be quick do. That can damage your credit rating.

If your bill has already been sent to collections, speak with the collections agency and ask to pay the bill right away. But don’t send a penny until you get the agency to agree to remove the bill from your credit report.