It is your right to know who denied your insurance claim.
Unfortunately, insurance companies often do not explain who is making the decision to your claim. For example, Anthem Blue Cross of California's denial letters reference a "medical reviewer" although the letter is signed by an Anthem Medical Director. It can be unclear whether it was the medical reviewer or the Anthem Medical Director who denied the claim.
Insurers may also hire independent review organizations to arrange medical reviews when a claim is denied based on medical necessity. Some commonly used independent review organizations (sometimes called "IROs") include Focus Health Management, Advanced Medical Reviews ("AMR"), Maximus, Prest & Associates, and MCMC.
These IROs hire physicians to conduct medical reviews and determine whether treatment is medically necessary. These multiple layers of claims handling – from the insurance company, to the independent review organization, to the physician – are not evident from denial letters.
We advise sending a letter to the insurance company and requesting the name of the person who denied your claim, and, if a physician, their specialty. Federal law regulating health benefits (ERISA) requires that health plans identify medical reviewers. 29 C.F.R. §2560.503-1(h)(3)(iv).
Additionally, ERISA requires that medical reviewers must have "appropriate training and experience in the field of medicine involved in the medical judgment." 29 C.F.R. §2560.503-1(h)(3)(iii).
If you would like further information on how to request information regarding your claim, contact our law firm today!