When insurance companies refuse to pay for lifesaving medical treatment, many Americans give up, not realizing the law provides a powerful tool to challenge those decisions — the external appeal.
The Centers for Medicare & Medicaid Services (CMS) and consumer protection offices in Washington, D.C., Maryland, and Virginia confirm that thousands of patients remain unaware of their rights under federal and state law.
A ProPublica investigation detailed how one North Carolina couple, Teressa Sutton-Schulman and her husband, known in court filings as “L,” faced repeated denials from Highmark Blue Cross Blue Shield for psychiatric treatment that followed two suicide attempts in just 11 days. The insurer’s instructions for an external appeal were buried deep in the paperwork.
Once Sutton-Schulman requested the review, an independent doctor overturned the denial, forcing the company to cover more than $70,000 in treatment costs, ProPublica reported.
“Appeal, appeal, appeal, appeal,” said Kaye Pestaina, a vice president at the nonprofit health policy group KFF, who has studied external appeals. “That’s all you have,” she told ProPublica.
External review rights were strengthened by the Affordable Care Act in 2010, expanding state-level programs and requiring insurers to submit to independent review in certain cases. Yet as Karen Pollitz, who helped draft those federal rules under the Obama administration, explained, lobbying from insurance companies weakened the original protections, leaving many patients unaware or ineligible for the process, she told ProPublica.
Even so, Maryland and the District of Columbia have maintained consumer programs that help residents navigate appeals and force accountability from insurers. The Maryland Office of the Attorney General’s Health Education and Advocacy Unit continues to handle complaints and disputes, offering free assistance to residents dealing with denied claims, billing issues, or policy cancellations, according to CMS.
“The numbers are low because some people just give up. They’re frustrated. They’re tired. They’re battling cancer,” Kimberly Cammarata, director of Maryland’s Health Education and Advocacy Unit, the state’s consumer assistance program, told ProPublica.
“And sometimes the information about why the claim was denied or about how to appeal is terribly unclear. A lot of these outcome letters will say you have a right to an external appeal, but they don’t exactly tell you where to go.”
Maryland’s new law now forces insurers to print appeal information prominently at the top of denial letters in bold type, ensuring patients are told they can contact the state’s consumer assistance program. Similar changes in Connecticut led to a 40% increase in appeals filed after patients were better informed of their rights, ProPublica reported.
The D.C. Office of the Health Care Ombudsman and Bill of Rights performs the same role in the nation’s capital, providing direct assistance to residents denied coverage or facing unresolved insurance disputes, according to CMS. Residents can also contact the Department of Health Care Finance for Medicaid concerns or DC Healthy Families for children’s coverage. Both programs help guide consumers through internal and external appeal procedures.
Virginia, which no longer participates in the federal Consumer Assistance Program, directs residents to the State Corporation Commission’s Bureau of Insurance in Richmond for complaints or appeals involving private insurance plans. Those with Medicaid or children’s health coverage can contact the Department of Medical Assistance Services or the FAMIS program, while Medicare recipients can reach out to the Virginia Insurance Counseling and Assistance Program, CMS records show.
“Here at CMS,” Dr. Mehmet Oz, 17th CMS administrator, wrote on X, formerly known as Twitter, “we’ve got the info, tools, and answers!”
What to Do When Denied Coverage
Experts recommend that patients denied coverage take several immediate steps: keep all paperwork, request copies of their claim files, contact a consumer assistance office for free guidance, and appeal every denial. Many disputes, they note, stem from clerical errors or coding mistakes — problems that can be quickly fixed once identified.
For urgent or complex cases, federal rules allow expedited reviews, which must be decided within 72 hours. If the reviewer rules in favor of the patient, insurers are legally obligated to pay for treatment.
“We can help people write their appeals,” Elisabeth Benjamin, vice president of health initiatives at the Community Service Society, told ProPublica. “We write appeals for them, sometimes going through thousands of pages of medical records and writing 15- to 20-page appeals.”
Health advocates say that broader awareness and enforcement are the only ways to counter insurers’ growing use of denials as cost-control tactics.
“Every state needs one of these programs,” Cheryl Fish-Parcham, director of private coverage at Families USA, told ProPublica. “Health care is so complicated, and people really need experts to turn to.”
