The other category, involving providers outside the insurer's network, would seem more cut-and-dried. But "these disputes can raise extremely serious medical issues," Sara Rosenbaum, JD, professor of health law and policy at the George Washington University School of Public Health, wrote in an accompanying commentary. "For example, [in one case] a health plan member was left permanently paralyzed when the health plan's medical director refused to approve out-of-network neurologic emergency care."
So is the dispute system working? It's hard to say, says Studdert. The fact that patients win about half of all appeals "may tell us that the appeals system works well, that it's not just a rubber stamp process. On the other hand, it raises the [concern] that the initial decision makers are getting it wrong that often. Our suspicion is that one of the reasons they may get it wrong is that it's really hard to make the decision in some of these cases -- it's just not clear."
Clearly, not all disputes are actionable, so trod carefully before considering an appeal. "There are many factors that must get weighed. When a treatment is futile, when it is not going to maintain you or restore you, it no longer has any value. It's not black and white, but that's why you need people with good medical judgment making those kinds of decisions."
She says she believes the evidence suggests that the internal review system is working well, citing the fact that there were 4 million subscribers at the two HMOs over the course of the study and they generated a small number of appeals. "It is rarely used, most of the cases are readily resolvable, and there are a few cases where it turned out to be a really good thing that the process was there," she tells WebMD.