Attorney Examines External Appeals Landscape

If self-insured health plans across New York decided to offer the external appeals procedures already available to enrollees in traditional plans, the result would be at least a 40% jump in the number of consumers eligible to use the state’s system. That’s according to a white paper just published by an expert attorney with New Yorkers for Accessible Health Coverage, a statewide coalition. Author Mark Scherzer notes that under the Affordable Care Act, ERISA exempt self-insured plans must begin offering independent external appeals effective July 1, 2011. That would make external appeals available to most of the 4,000,000 New Yorkers who are not now entitled to such appeals. Scherzer thinks most large, self-insured plans won’t want to use state-based systems, however, for fear of having to cope with conflicting coverage determinations made in different states. In any event, to comply with the new federal law, New York State must change its existing external appeals program in a few ways, including permitting immediate external review in urgent situations, allowing filings requests made up to four months after initial adverse determinations, and permitting review only by accredited organizations. IPRO is one of three organizations certified to conduct independent external appeals in New York. Recent data suggest that appeals filed by New Yorkers account for approximately 20% of all appeals filed nationwide. For a copy of Implementing Health Care Reform: External Review of Health Plan Decisions, visit