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DOI can review, overturn medical insurance decisions By Sherelle Roberts Pierre Frankfort, KY - Kentuckians who disagree with decisions made by their health insurance carrier about the necessity of services, treatments or medication can seek to have an outside expert review that decision, and possibly have it overturned, through a program at the Department of Insurance. Since 2000, Kentucky law gives individuals who are covered by fully insured health benefit plans the right to have an independent, medical review to assess whether the company's denial of a specific claim or requested service or treatment is justified. Reviews through DOI's Independent External Review Program are available when a recommended service or treatment is denied on the basis that it does not meet the insurer's requirements for medical necessity. "Health care is a basic human right and we want to make sure every Kentuckian has access to the quality care and treatment they deserve," said Gov. Andy Beshear. "We are taking steps to make sure every Kentuckian has health insurance and this is one more avenue to better health care outcomes in the commonwealth." "Every Kentuckian should have access to the health services they need," said Public Protection Cabinet Secretary Kerry Harvey. "The external review program provides an opportunity to have denied claims and services reconsidered by additional experts and offers individuals a chance to get the services necessary for good health." DOI Commissioner Sharon Clark says the overall rate of overturned denials by the external review program is 43% or 1,305 cases since the 19-year program began. "This program is a valuable tool to help resolve disputes between patients and their health plans. Besides being cost effective and reducing expensive litigation, the program provides another layer of patient protection, which is the primary mission of DOI." DOI's Policy Utilization Review Branch administers the program, which includes certifying, monitoring and registering the entities and agents who conduct the external reviews. Additionally, through a Memorandum of Agreement with the state's Personnel Cabinet, DOI oversees reviews associated with the Kentucky Employee Health Plan, which is the Commonwealth's self-funded health insurance arrangement administered by Anthem and CVS/Caremark. To be eligible, the following conditions must be met as outlined in state law:
This story was posted on 2020-09-18 09:38:43
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