Different Types of External Reviews
If beneficiaries do not succeed with their internal appeals for their medical claims, they could go through an external review process in which another company reviews their denied claims (Berger 2017). They can go through the external review process for cases related to disagreements on medical conditions between them and their provider and the health insurance plan, cases related to denials for treatments considered experimental or investigational by the insurer, and cases related to the “insurer’s claim that [the beneficiaries] gave false or incomplete information when [they] applied for coverage” (“External Review”). Beneficiaries can go through different types of the external review process.
Beneficiaries could have external reviews conducted by independent review organizations (IROs). They could usually turn to IROs, which are typically contracted with the beneficiaries’ health insurer, after the claim went through two internal reviews (“External Review”; “More Consumers Could Benefit from Independent External Review” 2017). IROs can “offer unbiased decisions and eliminate conflicts of interest” as they review all documentation, policy language, interview physicians on the patient’s case, etc. (Advanced Medical Reviews 2018). These IROs employ physician advisors, who review many cases, ranging “from hospital claims to other more specialized medical services” (BHM Marketing 2017; “More Consumers Could Benefit from Independent External Review” 2017). IROs have fees that could be at most $25 per external review (“External Review”). IROs would review cases if the IROs are contacted within 180 days after the internal appeal denial, and then they must either reverse or uphold the insurer’s decision within 30 days (BHM Marketing 2017). Depending on the severity of the patient’s medical condition, IROs can complete the external review within seven days (BHM Marketing 2017).
Beneficiaries could also have an external review process conducted by the federal government’s Department of Health and Human Services (HHS). People must go through this process, which can have no fees, when their states do not “have an external review process that meets the minimum consumer protection standards…” (“External Review”). MAXIMUS Federal Services Inc., a federal contractor, oversees the federal process (“HHS-Administered Federal External Review Process for Health Insurance Coverage”). Patients must ask for a federal external review within four months after their claim is denied the first time or denied in an internal review (“HHS-Administered Federal Review Process for Health Insurance Coverage”). Then, once MAXIMUS reviews the health plan’s information and additional information from the patient, it must decide in the patient’s or insurer’s favor within 45 days, but could finish this process sooner for patients with dire and severe medical conditions usually within 72 hours (“HHS-Administered Federal External Review Process for Health Insurance Coverage”).
In these external reviews, the third-parties, such as IROs and MAXIMUS, could overturn the denial or agree with the insurer’s decision (Berger 2017). Patients and insurance companies must abide by these decisions (Berger 2017). The external reviews give patients another chance to get their claim approved in order to get coverage.