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If an insurer closes a door, the state may open a window p2

We are talking about health insurance claim denials and appeals of those decisions. Consumers may not realize that they can appeal a claim denial. The insurance company has a process in place that generally starts with a call to the customer service line. There is a form that the consumer or the physician must complete and send to the insurer with as much supporting documentation as possible. The consumer can challenge the decision, and the consumer can contact the Minnesota Department of Commerce for help.

There are a lot of people and organizations involved in coverage appeals. The doctor, the insurance company's initial claims processing team and the committees that review the decisions … we mentioned in our last post that appeals may go to an external review committee, adding another layer of complexity. On top of that, if the dispute involves a prescription drug, many health plans contract their pharmacy services out to a third party vendor. With each handoff, of course, comes another opportunity to mess up.

In the case we touched on, the insured's physician had prescribed a medication that sent up a red flag for the insurer. The problem was that the insurance company believed the physician wanted to use the drug in a treatment regimen that the Food & Drug Administration had not approved. Insurance companies do not favor off-label uses chiefly because of the risk to the patient. There is also a liability question if something goes awry.

The claim was denied, and the insured appealed. Finally, the insurer was convinced that the prescription was medically necessary. The pharmacy vendor, however, denied the claim. According to a BCBSM spokesman, the insurer failed to communicate its decision to the pharmacy company.

The Commerce Department fined BCBSM $20,000 for the mistake. The commissioner characterized the error as a troubling, even unprecedented unfair claim practice and a clear violation of consumer protection laws.

The state can help consumers unwind this type of claim denial, and that help can result in the insurance company paying the claim. No part of that $20,000, though, will go to the patient who was denied the medication. That is why we urge people who have experienced this type of foul up to contact an insurance attorney as soon as possible.

Source: Star Tribune, "Blue Cross penalized for denying Minnesota patient's claim," Christopher Snowbeck, Jan. 7, 2016

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