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Office of Patient Protection reports steady appeal volume and identifies pharmacy and diagnostics as common external reviews
Summary
The Health Policy Commission's Office of Patient Protection reported its 2023 annual numbers: ~303 external reviews for insurance denials (about 44% granted), notable volumes in pharmacy and outpatient diagnostic requests, and roughly 1,500 hotline assists, with modest increases in external reviews in 2024.
The Health Policy Commission’s Office of Patient Protection presented its 2023 annual report, detailing consumer support activities and appeal outcomes including internal appeal volumes reported by plans, external review results and hotline activity.
Director Nancy Ryan said OP’s four core services are open enrollment waivers, regulation of insurer internal appeals, external review facilitation and a public hotline. OP recorded a decline in open enrollment waiver requests in 2023 tied to special enrollment activity after the federal public health emergency, but reported an increase in external reviews in 2024.
On external reviews, staff said plans reported over 15,000 internal appeals in 2023 and OP received 303 eligible external review requests that year; about 44% of external reviews resulted in coverage being granted. Pharmacy and outpatient medical/surgical services were among the most common categories; staff noted many diagnostic requests related to cancer screening and that OP is examining how to better categorize outpatient services for reporting.
OP also described its role in appeals from patients of risk‑bearing provider organizations and ACOs; those RBPO/ACO external review requests remain small in number (six in 2023) and primarily addressed referral restrictions. Nancy Ryan said OP handled roughly 1,500 hotline calls in 2023 and continues to coordinate with the Division of Insurance and plans to improve communications and timely implementation of OP decisions.
Ryan emphasized ongoing collaboration with state agencies and recent guidance to insured health plans clarifying internal reviewer qualifications and plan communications after overturns to ensure decisions are implemented without delay.
