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4 PPACA claim fight secrets

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Long before Congress sent the Patient Protection and Affordable Care Act (PPACA) bill to President Obama in 2010, Congress was working on controversial bills to establish a “patients’ bill of rights.”

Most of the work focused on efforts to establish minimum standards for internal reviews, and external appeals, for patients who wanted to object to managed care plan benefits decisions.

In 1998, for example, National Underwriter Life & Health, one of the publications that backs, covered a doomed attempt by Sen. James Jeffords, R-Vt., to organize support for a bill that would set up national standards for appeals.

PPACA included a section establishing the long-sought standards for appeals, but the U.S. Department of Health and Human Services (HHS) has been using interim final regulations issued in 2010 to implement the provisions, and its Center for Consumer Information & Insurance Oversight (CCIIO) PPACA implementation division has not made significant changes to the external appeals section of its website in more than a year.

See also: What if a health plan member hates a coverage decision?

CCIIO, HHS, and the Centers for Medicare & Medicaid Services — the HHS agency in charge of CCIIO — seem to have published little information about state or federal health plan decision appeals efforts elsewhere.

But CMS has let some of the appeal and review data it has quietly been collecting over the years surface in a routine paperwork review packet. CMS sent the packet to the federal Office of Management and Budget (OMB) to get permission to continue collecting the information needed to implement the PPACA appeals and review standards.

For a peek at some of the information in the packet, read on.


1. The CMS grievance process data is a good source of data on PPACA grandfathering.

To analyze trends in the number of claims, officials need to have numbers for the number of the non-grandfathered health plan enrollees who are subject to the PPACA grievance requirements and the number of grandfathered plan enrollees who are not subject to the requirements.

In the paperwork review packet, CMS gives numbers for the individual market and the government group plan market.

In the individual market, the percentage of enrollees who still had grandfathered coverage dropped to 22 percent in 2013, from 40 percent in 2011.

In the government group plan market, the percentage in grandfathered plans dropped to 56 percent, from 82 percent.

See also: Sticker shock often follows insurance cancellation

Little ripples in water

2. Claim denial rates stayed about the same.

CMS reports several two sets of approval, denial and review period extension data for claim decisions. One is for claims submitted before services have been delivered, and the other is for claims submitted after services have been delivered.

The claim denial rates seem to have been about the same in 2013 as they were in 2011.

In the government plan market, for example, post-service claim denial rates held steady at 18 percent.

In the individual market, post-service claim denial rates held steady at 20 percent.

See also: Ted Cruz’s PPACA alternative: 3 things to know

A sailboat on calm water

3. The ratio of internal appeals upholding decisions to appeals denying decisions has stayed about the same.

Internal review times may be trying to keep the ratios steady to avoid triggering regulator scrutiny, but internal review programs in both the government plan and individual markets upheld two decisions appealed for every three decisions they denied, both in 2011 and in 2013.

See also: PPACA: Feds Unveil Appeal Rule Draft

A fence separates one stick figure from many stick figures

4. The number of patients who file new requests for external appeals appears to be small.

The number seems to be growing along with the number of enrollees in plans subject to PPACA external review standards.

CMS officials said the number of new government plan external appeals filed increased to 1,500 in 2013, from 600 in 2011.

In the individual market, the number increased to 400, from 200.

See also: PPACA: Feds Give States More Time to Meet External Review Standards

Correction: Trends in claim denial rates were described incorrectly in an earlier version of this article. Claim denial rates seem to have held steady from 2011 to 2013.


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