Managed Care: The Appeals Process

As managed care becomes an overwhelming force in the face of our evolving health care system, the horror stories associated with procedures that have been denied continue to grow. Almost every week, there is a new story of an ill individual who was denied proper treatment, resulting in much more serious injury. This site provides links to sites that give information about patients’ rights in appealing denials by managed care organizations. In addition, there is information on the legal aspect as well as ongoing legislative action that concerns this issue. Finally, accounts of other patients’ struggles and advocacy groups that can help patients in similar situations have been included.

The links have been grouped into sites and documents. In addition, they have been ranked on a scale of (*) to (*****) based on the relevancy of the information and ease of navigation of the site.

Related Web Sites:

  1. "How to Fight Your HMO" *****
  This site provides information about a woman’s personal struggle with her insurance company for a surgery that she needed. She also provides great helpful links to other sites that have relevant information about others who may be in the same situation. Other links within the site include legislative action in the area and HMO reform.
  1. National Patient Advocate Foundation ***
  This site provides information about two organizations: the Patient Advocate Foundation and the National Patient Advocate Foundation. The former organization provides education and legal counseling while the latter concentrates on national legislation to ensure adequate funding for patients. This group was first formed to help cancer patients but provides links for illnesses as well via Patient Resources.
  1. Center for Patient Advocacy ****
  The Center for Patient Advocacy is an organization that was formed to ensure high quality health care. This group has achieved a significant presence in Washington to advocate the rights of patients. There are many resources that are provided in this site as well as information on how to fight back when patients have a problem with their insurance company. They also provide up-to-date legislative action on the subject.
  1. Health Administration Responsibility Project *****
  HARP provides resources for many parties involved in the battle against insurance companies for adequate coverage for patients. It offers information that patients can use to learn more about their rights as patients, the appeals process, who to turn to for help, etc. It also provides relevant information for attorneys who are involved in such cases. The links are conveniently organized in outline form for easy access. The legal information is very educational for patients who are not as familiar with legal proceedings in this area. Finally, there is a link to dozens of anecdotes about patients’ misfortunes as a result of denials of treatment by insurance companies. In all, this site is very comprehensive and specific to this topic.
  1. Truman Law ****
  This site concentrates more specifically on the legal aspect of appealing a denial by one’s insurance company. The list of topics is very straightforward and immediately leads readers to their area of interest. This site provides an overview of how patients might approach the legal battle with their insurance companies. It also delineates two different types of appeals.
 
 

Related Topic Documents:

  1. "Protecting Your Healthcare" ****
  This New York Times Op-Ed article written by the former Lieutenant Governor of New York relates the personal struggle of a patient trying the receive coverage for experimental treatment. Included are proposed changes that should be made in New York.
  1. "California levies fines against 43 health plans for failing to tell members of appeal rights" ***
  This article in Nurseweek describes legal action taken by a state to make sure that appeals processes are better known by the enrollees of health plans.
  1. External Appeal Consumer Guide - CT Insurance Department ***
  This document provides specific information on exactly what a patient needs to do before being eligible for an external appeal. Once eligible, it describes in detail how to go through the filing process and exactly what the process entails. It also provides a glossary of terms at the end. However, its usefulness is limited by being specific for Connecticut.
  1. "In Pursuit of Health" *****
  This document is quite lengthy but provides detailed factual as well as anecdotal information about the legal aspects of fighting health plans for treatment. It also provides valuable information on ERISA and other legal tools that lawyers are currently using. This document was written from the perspective of lawyers who have helped patients appeal their denials.

5. Medicaid Grievances Fact Sheet ****

  This fact sheet provides very useful guidelines for resolving complaints, grievances, and hearings in Medicaid managed care. The subtitles are clear and the material is very easy to read. The material is somewhat limited, however, as it relates primarily to Medicaid issues.
 
Note: The information below may contain additional relevant materials and documents. Some of the information may be duplicate. The evaluations depend on both the student doing the review and the information contained at the time of the review. Sites are subject to change!