by Duaa Eldeib

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When a health insurance company refuses to pay for treatment, most people begrudgingly accept the decision.

Few patients appeal; some don’t trust the insurer to reverse its own decision.

But a little-known process that requires insurers and plans to seek an independent opinion outside their walls can force insurers to pay for what can be lifesaving treatment. External reviews are one of the industry’s best-kept secrets, and only a tiny fraction of those eligible actually use them.

ProPublica recently reported the story of a North Carolina couple, Teressa Sutton-Schulman and her husband, who we identified in the story by his middle initial, L, to protect his privacy. Last year, L suffered escalating mental health issues and needed intensive psychiatric care. Highmark Blue Cross Blue Shield issued the couple multiple denials in their case, even after Sutton-Schulman’s husband attempted suicide twice in the span of 11 days.

The instructions for an external review were buried on page seven of one of the denial letters.

“You can now request that your case be reviewed by a health care provider who is totally independent of your health plan or insurance carrier,” read the letter from the state insurance department in Texas, where the treatment occurred.

Skeptical but hopeful, Sutton-Schulman submitted the request for the external review. Their case was assigned to Dr. Neal Goldenberg, an Ohio doctor who works for a third-party review company as a side job. After reading the extensive appeal, Goldenberg overturned Highmark’s denial to cover treatment that had cost Sutton-Schulman and L more than $70,000.

Highmark previously said in a statement that the company was “passionate about providing appropriate and timely care” to its members. It acknowledged that “small errors made by physicians and/or members can lead to delays and initial denials” but said that those are corrected on appeals.

The lesson is simple, explained Kaye Pestaina, a vice president at the nonprofit health policy think tank KFF, who has studied external appeals.

“Appeal, appeal, appeal, appeal,” she said. “That’s all you have.”

External appeals have been around for decades at the state level, but in 2010, the Affordable Care Act expanded access to the reviews for the majority of people who get their health insurance through work. The details around the external review process vary depending on whether an........

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