The Employee Benefits Security Administration (EBSA) has published a little information about patients’ efforts to fight group plan benefits decisions in a routine paperwork review notice.

EBSA estimates that the United States now has about 96 million workers in group health plans subject to the internal health plan decision appeals standards and external review standards set by the Patient Protection and Affordable Care Act (PPACA) in 2010.

See also: 4 PPACA claim fight secrets

EBSA estimates that, in a typical year, U.S. group plan enrollees will:

  • File 983 million claims.

  • Receive some kind of denial or extension notice for 183 million claims.

  • File 337,200 internal appeals, or one appeal per 2,900 claims.

  • File just 8,400 formal requests for external reviews.

EBSA, an arm of the U.S. Department of Labor, developed the first set of procedures implementing the appeal and external review standards in 2010.

To comply with the requirements, plans that deny requests for benefits have to send denial notices that meet EBSA requirements. Federal law requires EBSA to put the denial notice requirement through a review by the federal Office of Management and Budget (OMB) every three years.

The new approval for the denial notice will expire in 2019.

See also:

What if a health plan member hates a coverage decision?

PPACA: Agencies Postpone Claims and Appeals Enforcement

     

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