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ODI appeal process recovers millions on health insurance claims


Source: Health Policy Institute of Ohio

More than $21 million in previously denied health care benefits and services to Ohioans has been recovered through an appeals process started by the Ohio Department of Insurance (ODI) nearly two decades ago (Source: “Patients Denied Benefits, Services by Health Insurers are Using Appeal Process to Recover Millions,” The Columbus Dispatch, August 26, 2019).

Patients can initiate an appeal by contacting the health insurance company. If the company doesn’t agree to overturn the decision, the patient can start the external review process.

If the provider’s decision doesn’t involve a medical judgment, the request is sent to the ODI. If the decision involves a medical judgment, the request goes to an independent review organization for consideration by a medical professional.

In Ohio in 2017, 514 cases involving over $6.3 million in health care benefits and services were submitted for independent review. The insurance companies’ original decisions were reversed in 36% of the cases, saving consumers $1.17 million, according to the ODI.

The ODI has created a document titled How to Appeal a Decision by Your Health Plan Issuer to explain the process.

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