Affordable Care Act: expands consumers' rights for claims appeals

August 2, 2010 — One of the most frustrating parts of healthcare for both the doctor and patient is the denial of a claim. To add to the confusion, the appeals process for denied claims varies from state to state and plan to plan.

On July 22, the Obama Administration issued new rules under the Affordable Care Act to expand consumers’ rights and standardize the process for internal and external appeals. The rules will apply to plans beginning with a start date of Sept. 23, 2010 and existing health plans that make significant changes, such as large increases in co-pays or employee contributions.

It is estimated that 31 million people will benefit from these new rules, which may increase to 78 million by 2013. 

The rules would allow patients to seek an external review by a third party assigned by the state after the claim is denied a second time via internal review by the insurer.

According to the Department of Health and Human Services, by July 1, 2011, states are required to make changes to their external appeals processes to ensure that their laws include, at a minimum, the consumer protections of the National Association of Insurance Commissioners (NAIC) Uniform Model Act.

The NAIC’s Model Act includes a number of requirements including the need for clear information for consumers regarding their rights to internal and external appeals, emergency processes for urgent claims, and access to a third party reviewer assigned by the state. 

Should the state laws not meet the required standards, consumers will be protected by similar Federal external appeals standards. Additional information regarding these provisions of the Affordable Care Act can be found here. 

Source: American Chiropractic Association, www.acatoday.org