A quick glance at the AHIP (American Insurance Plan) website helps illustrate why continued reluctance by individuals to pressure their own state leadership can determine their own life or death. So, while we ignorantly resist involvement with government, understand that your government in your state influences your health. And your state government is influenced by lobbyists. It is NOT a REPUBLICAN or DEMOCRATIC issue guys, go through the information. Here we examine EXTERNAL REVIEW, what you can do when you are sick and your insurance company DENIES payment and you seek to go to a government resource (usually your state department of insurance) to get help in getting them to pay.
After a brief review of the EXTERNAL REVIEW process of several states, it seems there is NO pattern of Republican or Democrat, but instead, those states with the WORST external review policies also take the MOST money from insurance lobbyists.
Information regarding external review is cited to the AHIP website (a pro insurance company site) and information about 2008 lobbyist dollars spent by insurance companies to influence state governments is from followthemoney.org. The opinions represented here, are my own, the information is from those sites.
So, get started. You're sick (yes, this is the ONLY scenario that counts when it comes to medical insurance).
You begin treatment (and if possible, though there are those charlatans that require you to show your ability to pay FIRST). BEGIN the treatment if you can because INSURERS AVOID LIABILITY FOR MAKING DECISIONS THAT COST PATIENT LIVES BY ARGUING THAT THEY DON'T DENY TREATMENT, THEY SIMPLY DECLINE PAYMENT FOR THAT TREATMENT.
While battling for your health, your insurance experience begins...bills, explanation of benefits forms, and DENIALS of CLAIMS. (Here's where the importance of a HEALTH CARE PROXY or a HEALTH CARE POWER OF ATTORNEY comes in so that if you are too weak, someone ELSE can take on your new second job...dealing with insurers.)
You get DENIED coverage
You start your health plan's APPEAL PROCESS (which is time sensitive on your part and must be started by you usually a month to three months after the denial)
You receive notification from your insurer that your appeal is denied or less likely, that the insurer has decided to pay your claim (usually occurs within a month or so but BEWARE, insurers stall this process by requiring more information, resubmission of information, blaming the mail...remember, they don't want to pay and by the way, you are still SICK and have to spend time on this)
IF YOUR APPEAL TO THE INSURER IS DENIED we reach the area of the EXTERNAL REVIEW PROCESS This is an appeal to the Insurance Department or some Consumer department within your STATE government. The (American Health Insurance Plan website, often infuriating because it is a spin specialist on pro insurance company propaganda, includes contact information for the various states at http://www.healthclaimappeals.org/state-appeal-process.html) or you can contact your own STATE INSURANCE DEPARTMENT.
Now you find out, often too late, whether your state is pro-life, meaning yours. What do you do after your insurance company has denied a claim? That would be to seek an external review, provided for in every state but vastly different in terms of when appeals are available (grounds)and how long those appeals take (urgent/non-urgent). At that same AHIP website you can see what kinds of appeals will be considered by state governments. In parentheses, I've included information from followthemoney.org regarding the TOP 15 lobbyist industries in a state and where insurance companies are among those top dollar givers, the amount they gave in 2008.
Key provisions to EXTERNAL REVIEW include WHAT GROUNDS ARE USED FOR GETTING A REVIEW, HOW LONG IT TAKES, WHETHER YOU HAVE TO PAY FOR THAT REVIEW. I've rated states as pro-life or not for external review based on these criteria, this is only an OPINION.
Alaska: My conclusion, pro-life regarding external review. If you live in Alaska, for instance, if your claim is denied based on MEDICAL NECESSITY, EXPERIMENTAL OR INVESTIGATIONAL EXCLUSIONS, MEDICAL JUDGMENT, FAILURE TO MEET INTERNAL APPEALS DEADLINES, YOU HAVE THE RIGHT TO PURSUE AN EXTERNAL REVIEW. In this way, Alaska seems pretty pro-life. Further, the government authority in Alaska will respond within 21 WORKING DAYS for cases deemed non-urgent and will respond within 72 hours for cases deemed urgent. (Insurance companies are not among the 15 largest contributors of lobbying dollars in Alaska)
North Carolina: My conclusion NOT PRO-LIFE regarding external review. EXTERNAL REVIEW is only available for health insurance claim denials based on medical necessity. If your claim was denied because you filed your appeal to the insurance company too late, or because you are fighting for your life and your DOCTOR decides it's not worth it, YOU ARE OUT OF LUCK IN NC In the spirit of its pro-insurance company angle, the state of NC allows itself up to 45 DAYS to review "non-urgent" cases (which is sort of ironic since it only hear's appeals that are MEDICALLY NECESSARY) and it allows itself 4 DAYS for URGENT cases. (Insurance Industry 11th largest lobbyist based on $817,608 spent to influence NC government in 2008)
Maine: Leans towards PRO-LIFE in terms of external review in my opinion. Maine allows the option of an external review, without paying a fee for claims that are denied based on medical necessity, on pre-existing condition exclusions, or on experimental or investigational exclusions. Unfortunately, Maine allows itself up to 30 days to review those non-urgent cases. Insurance companies are not among the 15 largest contributors of lobbying dollars in Maine)
Missouri is not pro-life in terms of external review: Their policy is only to review those cases denied based on medical necessity and it takes 20 days What types of disagreement qualify for external review? Missouri specifically authorizes your representative (GET A HEALTH CARE PROXY OR POWER OF ATTORNEY) to file for you. Insurance Industry 12th largest lobbyist based on $1,217,161.00 spent to influence Missouri government
Massachusetts not good. Only medical necessity will get you an EXTERNAL REVIEW and you'll be asked to pay $25 bucks for the privilege supposedly this fee can be waived if necessary. style="font-weight:bold;">Insurance Industry 10th largest lobbyist based on $439,417.00 spent to influence Massachusetts government
Wisconsin is Pro-life for a price in my opinion, you'll pay the government to give you your external review and you have to be requesting the review for amounts of $250 and over. In WISCONSIN, ALL APPEALS are subject to external review but of course, you'll have to pay a $25 fee for the privilege. WISCONSIN IS PRO-Life for the rich. Insurance Industry 11th largest lobbyist based on $483,895.00 spent to influence Wisconsin government
Pennsylvania is NOT PRO-LIFE regarding external review You can only obtain review based on an insurance company denial based on medical necessity and you will pay up to $25 to get that review. Insurance Industry 8th largest lobbyist based on $2,320,150.00 spent to influence Pennsylvania government.
Georgia is not pro-life, in my opinion. External review requires that amounts in issue be over $500 and external review is available for claim denials based on excluded benefits (anything not covered by your plan) and for claims denied that cause the consumer to have concerns related to health care quality, access to services and required disclosure. Notice no appeal for medical necessity or for claims denied based on experimental treatments. There's no fee to file for an external review but the dollar amount at issue must be at least $500. Insurance Industry 5th largest lobbyist based on $1,168,862 spent to influence Georgia government.
Washington DC is GREAT and pro-life. All claims denied are eligible for external review, you or an authorized representative can file, no fee, no minimum amount and though non-urgent cases can take up to 30 days (not good), urgent cases will take up to 72 hours (standard urgent time). (No lobbying)
Louisiana is NOT GOOD. Only denials based on medical necessity are eligible for review. Insurance Industry 7th largest lobbyist based on $54,000.00 spent to influence Louisiana government
Where's AARP when you need them FLORIDA? Florida is NOT pro life when it comes to external review, in my opinion. In Florida you're eligible for an external review if your claim is denied based on experimental or investigational exclusion,on medical necessity, on health care quality,on excluded benefits or unauthorized services, denied for emergency services, or denied based on billing issues BUT you get the Florida angle by who can file...you (of course), your HEALTH CARE PROVIDER can file for YOUR insurance coverage but the review process can take up to 165 days for non-urgent and 65 days for URGENT reviews. Abysmal. Insurance Industry 4th largest lobbyist based on $5,430,260.00 spent to influence Florida government.
Conclusion: Governments have impact on your insurance coverage whether you want to acknowledge that or not. Consumers who retreat to concepts of "free market" omit the fact that government is a partner, for your benefit or for the insurer benefit and that's why insurers spend money on lobbying.
