A Couple Thought They Were Stuck With a $70,000 Medical Bill. Then They Found a Little-Known Tool Hidden Deep in Their Health Plan Documents.

When a health insurance company refuses to pay for your treatment, most people do exactly what the company is counting on: they give up. They don’t trust the insurer to reverse its own decision, so they swallow the bill or go without the care. But there is a little-known process that can take the decision out of the insurer’s hands entirely…  and force the company to pay for what can be lifesaving treatment.

A North Carolina woman named Teressa Sutton-Schulman found it the hard way. Her husband was in a severe mental health crisis and needed intensive psychiatric care, and their insurer, Highmark Blue Cross Blue Shield, kept denying the claims…  even after he attempted suicide twice in the span of 11 days, according to ProPublica, which followed the couple’s fight. The instructions for the tool that would finally win their case were buried on page seven of one of those denial letters.

“Appeal, appeal, appeal, appeal,” Kaye Pestaina, a vice president at the health policy nonprofit KFF who has studied the process, told ProPublica. “That’s all you have.”

The ‘Best-Kept Secret’ That Can Overturn a Denial

The tool is called an external review. When an insurer says no, you can (in many cases) demand that the denial be re-examined by a medical provider who has no connection to your health plan. If that independent reviewer sides with you, the decision is binding: your insurer is required by law to accept it and pay.

ProPublica described external reviews as “one of the industry’s best-kept secrets,” noting that only a tiny fraction of the people eligible to use them actually do. That gap is the whole story. The protection exists. Most patients never hear about it.

Sutton-Schulman almost didn’t either. She had been fighting the denials and recording every phone call with the company when she came across the language on page seven. “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, sent by the state insurance department in Texas, where her husband’s treatment had taken place.

Skeptical but hopeful, she filed the request. The case landed with Dr. Neal Goldenberg, an Ohio physician who reviews disputed claims for a third-party company as a side job. After reading the couple’s appeal, he overturned Highmark’s denial…  covering treatment that had cost the family more than $70,000.

Highmark has said it is “passionate about providing appropriate and timely care” to its members, and acknowledged that “small errors made by physicians and/or members can lead to delays and initial denials,” but said those are corrected on appeal.

Why Insurers Don’t Advertise External Reviews

The reason so few people use external reviews isn’t an accident, according to the advocates and those familiar with the matter. It’s partly that the denial letters themselves are confusing, and partly that insurers benefit when patients walk away.

“The numbers are low because some people just give up. They’re frustrated. They’re tired. They’re battling cancer,” said Kimberly Cammarata, who directs Maryland’s consumer assistance program. “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.”

Kathleen Holt, Connecticut’s state health care advocate, put the incentive more bluntly. “The insurance companies know that people don’t appeal, and in some ways I think they can be more aggressive with their denials,” she said. “They don’t expect people to come back, and when they do that very small percentage of the time, it’s the cost of doing business for them.”

The numbers back her up. After Connecticut began printing appeal information in a box on the front page of denial letters in 2023, more than 40% of the referrals to her office over the next two years came from people who’d received the new language. And when patients do push back, they win a lot: Connecticut’s healthcare advocate office has been able to resolve or overturn denials in the patient’s favor about 80% of the time, Holt said.

External appeals have existed at the state level for decades, and the Affordable Care Act expanded them in 2010 to most people who get insurance through work. But Karen Pollitz, who helped draft the federal rules under former President Barack Obama, said heavy lobbying by insurers and employers weakened the protections — so today only a fraction of denials qualify, and the health plan itself gets to hire the reviewers. “There are all kinds of ways they could strengthen the laws and the regulations to hold health plans more accountable,” she said.

What to Do Before You Pay a Denied Bill

You don’t have to navigate it alone, and you shouldn’t pay a denied bill before checking your options. Some general information that might be relevant includes: 

1. Save everything: Keep every denial notice, explanation of benefits, plan document and letter. You can also request your full claim file, which most people have a right to under federal regulations.
2. Check for a free consumer assistance program in your state: Many states have them, and their job is to explain your denial and help you appeal (usually for free). Sometimes the problem is as simple as a missing or incorrect billing code.
3. Find out exactly why you were denied and your deadline: Was it ruled “not medically necessary,” or simply not covered? That distinction shapes how you appeal. Most plans give you about 180 days to file an internal appeal, but don’t wait.
4. Ask your doctor for help: Some providers will file the appeal for you or write a letter of support.
5. File the internal appeal first: You usually have to try to resolve it directly with the insurer before you can go external.
6. Then request the external review: Once internal appeals are exhausted, ask your insurer to send your case to an independent reviewer. For a standard federal external review, the plan generally has five days to confirm eligibility, and reviewers typically have 45 to 60 days to decide. If your situation is urgent, you can request an expedited review, which is supposed to be resolved as fast as your condition requires and no later than 72 hours.

Not every denial qualifies. External reviews generally apply to disputes over medical judgment, surprise bills, experimental-treatment rulings or retroactively canceled coverage, not denials based on plan terms or out-of-network care. But for the cases that do qualify, advocates say it is often a patient’s most powerful remaining card.

“Every state needs one of these programs,” said Cheryl Fish-Parcham of the consumer group Families USA. “Health care is so complicated, and people really need experts to turn to.”

 Or, as Pestaina put it: appeal, appeal, appeal, appeal.