Appeals Process in Health Care

There are many instances where insurance providers refuse to pay for patient
healthcare services billed to them or pay less than the billed amount. When insurance
companies make this decision, they usually provide reasons for their decision as well as a
procedure of appealing the decision if the provider is not satisfied with it. Thus, an appeals
process is designed for entities or persons that are unsatisfied with a decision of insurance
providers to contest the decision. According to UHC Community Plan (n.d.), it is a process in
which dissatisfied healthcare providers seek a reconsideration of a decision made by
insurance companies regarding a given service or the amount paid for the service. Even
though they are sometimes used interchangeably, appeals are different from grievances. The
latter are official complaints filed to the insurance provider expressing dissatisfaction with the
actions or behaviors of one’s plans (Medicare Rights Center, 2014).

An appeals process is deemed to be effective if it results in the insurance provider
reconsidering their initial decision in a manner that satisfies the claimant who files the appeal.
The effectiveness of the appeal usually depends on many factors. They include the procedure
followed in the appeals process and the seriousness of the reasons for denying the payment or
making a lower payment. With regards to procedure, an appeal that is made after the time for
appealing has elapsed is not going to be considered. For instance, some plans require that
appeals be filed within 60 days of receiving the determination of the insurance provider
(UHC Community Plan, n.d.). Thus, the appeal process is certain to fail if it is filed after 60
days of receiving the insurance provider’s determination.

Apart from procedural issues, the seriousness of the reasons for insurance provider’s
decision also impacts the effectiveness of the appeals process. For instance, it is relatively

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easy to get a reconsideration of an unfavorable decision from the insurance provider if the
provider’s decision was due to patient registration mistakes or coding errors. However, it is
difficult to get a reconsideration if the provider’s decision was based on factors such as
providing services that the insurance provider deemed to be medically unnecessary.

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References

UHC Community Plan. (n.d.). Retrieved from https://www.uhccommunityplan.com/learn-
about-medicare/appeals-grievances-process
Medicare Rights Center. (2014). Dear Marci. Retrieved
from https://www.aft.org/sites/default/files/wysiwyg/dearmarcie022315.pdf.