Virginia Appeals Reported to Save $2 Million

June 23, 2004

For the past four years, the Virginia Bureau of Insurance has been assisting Virginians whose health benefits or services were denied by their managed care providers. During that time, the bureau reports it has saved consumers more than $2 million through its external appeals program.

Since the program began in May 2000, some 558 cases have been submitted for the review, according to Kim Naoroz, manager of external appeals. Of these cases, 243 were deemed eligible for external appeal. So far, 137 cases have been resolved in favor of the patient, resulting in a combined cost savings of $1,844,000.

Patients who have been denied coverage because their managed care plan determined that the medical services they received were not medically necessary or involved experimental or investigative procedures may be eligible to file an external review appeal through the Bureau of Insurance. However, they must first exhaust all internal appeals with their insurance company.

To date, the bureau has overturned 120 denials of insurance coverage and, in 17 cases, the managed care provider reversed itself. It has upheld 95 denials of coverage, and 11 cases are currently pending.

The bureau determined that 315 of the cases it has reviewed so far were ineligible for external appeal. In 28 of these cases, the review uncovered improper bills totaling more than $174,500 that were sent to patients by their health care providers. Doctors and hospitals are often required by their contracts with managed care companies not to bill patients even if the managed care company does not pay the doctor or hospital. When the bureau discovers that patients have been billed erroneously, it can assist in stopping collection efforts.

Virginia is one of more than 40 states that have an external review process. To appeal in Virginia, consumers must be covered under an eligible insurance plan. They must file an appeal within 30 days of their insurance company’s final decision to deny coverage. The fee for filing an appeal is $50, and the minimum appealable claim must exceed $300.

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