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Department: independent external reviews overturned just over half of denials; market conduct team to probe trends
Summary
At a budget hearing, the Pennsylvania Insurance Department told lawmakers that independent external reviews overturned 50.6% of appealed adverse coverage decisions in the program's first year, prompting market conduct reviews and the possibility of restitution or penalties for insurers that show patterns of inappropriate denials.
The Pennsylvania Insurance Department reported that, in the first year after shifting external review oversight to the state, independent review organizations overturned just over half of adverse insurer decisions that reached external review. Commissioner Humphreys told legislators the department's data shows a 50.6% overturn rate for cases sent to independent review.
Representative Frio described cases where families and children were denied coverage for…
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