What Patients Need to Know About Appealing Insurance Denials

Triage Cancer's CEO explains how patients can appeal insurance denials, highlighting the often-overlooked external appeal process that offers binding decisions.

Navigating insurance denials is the most common issue faced by Triage Cancer, a nonprofit organization dedicated to educating patients and caregivers about legal and practical aspects of a cancer journey, as its CEO told CURE.

“Certainly, the lack of understanding about people’s options and the steps that they can take contributes to not only lack of access to care but also [is] contributing to financial burden because if patients aren’t getting insurance to cover their care, they’re faced with the decision of either not getting access to that care or paying for it out of pocket,” said Joanna Fawzy Doran, who is also a member of the CURE advisory board.

Being faced with such denials, Doran said, is common for patients. “When someone is going through cancer treatment, they are very likely at some point during their continuum of care to face a denial for something, whether it’s surgery or a prescription drug or some type of treatment regimen; insurance denials are very common,” Doran said.

However, she noted that data on insurance denials are scarce because, in most cases, insurance companies are not required to share that information. “The data that we do have on insurance denials is based on laws … that require certain types of plans to provide that data, like marketplace plans,” she said, “but we do know certainly from anecdotal experience that people are experiencing denials. And that could be denials before care, so with preauthorizations for care, but it could also be after care is received, where the insurance company is denying coverage for that care.”

Patients with private insurance plans have two appeal levels available, as Doran explained. They can go through an internal appeals process conducted within the insurance company — and if the denial still stands, they have the option of an external appeal.

When a patient receives an internal denial, their insurance company is supposed to provide them with instructions on how to file an external appeal, Doran said. But, a patient can also start the process by reaching out to their state department of insurance. Depending on the state, someone may then be sent to the Department of Health and Human Services (HHS). Information on which states use a state-run process and which states’ processes are HHS-run can be found on Triage Cancer’s website.

“You get to go outside the insurance company to an independent entity, and they decide whether or not [something is] medically necessary, and that decision is binding on the insurance company,” Doran said. “So, this is what I refer to as the best-kept secret of our health care system because even though the advocacy community fought hard for this protection that was made federal law by the Affordable Care Act, no one knows about it. And when I say no one, I mean, actually, no one. I speak to providers all the time; I speak to patients; everybody is surprised that this exists.

“And a lot of times, people think that the peer-review process where the insurance company speaks to your health care provider and has a conversation is the external appeal, and it’s not — the peer review process is just an internal process for the insurance company. So even if the peer review is denied, you still get to go outside the insurance company to the external review.”

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