Over the past few years, millions of Americans have faced this experience. submitting a health insurance claim that once might have been paid immediately but instead was just as quickly denied. If experience and the insurer’s explanation often seem arbitrary and nonsensical, this may be because companies are increasingly likely to use computer algorithms or people with little relevant experience to issue quick (sometimes instantaneous) denials of claims. packages) without patient review. medical chart. At one company, the job title was “denial nurse.”
It’s a convenient way for insurers to keep revenue high, and exactly the kind of thing the provisions of the Affordable Care Act were designed to prevent. Because the law prohibited insurers from using previously profit-protecting measures, such as refusing to insure patients with pre-existing conditions, the authors worried that insurers would compensate by increasing the number of denials.
And so the law tasked the Department of Health and Human Services with overseeing denials both in the Obamacare marketplace and by employers and insurers who offer them. He did not fulfill that assignment. Thus, denials have become another predictable, miserable part of the patient experience, with countless Americans unfairly forced to pay out-of-pocket or, faced with the prospect, turned away from needed medical care.
A recent KFF study of ACA plans found that even when patients received care from in-network doctors — doctors and hospitals approved by these same insurers — the companies still denied an average of 17% of claims in 2021. : One insurer denied 49% of claims in 2021. In 2020, the other’s rejections reached an astonishing 80%. Despite the potentially dire impact that denials can have on patients’ health or finances, data shows that people only appeal once in 500 cases.
Sometimes insurers’ denials go against not only the standards of medical care, but also plain old human logic. Here’s a sample put together for the KFF Health News-NPR joint Bill of the Month program.
- Dean Peterson, of Los Angeles, said he was “shocked” when he was denied payment to treat a heart rhythm disorder that caused him to pass out with a heart rate of 300 beats per minute. After all, she had the insurer’s pre-approval for the expensive ($143,206) intervention. More confusing still, the denial letter said the claim was denied because he “asked for coverage for your spinal nerve injections” (he didn’t) that were “not medically necessary.” Months later, after dozens of calls and the help of a patient advocate, the situation is still unresolved.
- A letter from the insurer was sent directly to the newborn denying coverage on his fourth day in the neonatal intensive care unit. “You drink from a bottle,” the disclaimer says, and “you breathe on your own.” If only a child could read.
- Deirdre O’Reilly’s college-age son, who suffered a life-threatening anaphylactic allergic reaction, was saved with epinephrine shots and intravenous steroids in the hospital emergency room. Her mother, who was completely relieved by the news, was not pleased to be informed by the family’s insurer that the treatment was “not medically necessary”.
As it happens, O’Reilly is an intensive care physician at the University of Vermont. “The worst part wasn’t the money we owed,” he said of the $4,792 bill. “Worst of all, the rejection letters were meaningless, mostly pages of denial.” He filed two appeals, but so far unsuccessfully.
Some denials are, of course, well looked after, with some insurers denying only 2% of claims, the KFF study found. But the spike in denials and often outlandish justifications offered may be explained in part by a ProPublica investigation into Cigna, the insurance giant with 170 million customers worldwide.
A ProPublica investigation published in March found that an automated system called PXDX allowed Cigna’s medical reviewers to sign off 50 charts in 10 seconds, presumably without examining patient records.
Decades ago, insurer reviews were reserved for a small fraction of expensive treatments to ensure providers weren’t ordering profits with an eye on patients’ needs.
These reviews, and disclaimers, are now down to the most mundane medical interventions and necessities, including things like asthma inhalers or heart medication that a patient has been on for months or years. What is approved or denied may be based on changes in the insurer’s contracts with drug and device manufacturers, rather than optimal patient treatment.
Automation makes reviews cheap and easy. A 2020 study estimated that automated claims processing saves US insurers more than $11 billion annually.
But challenging a denial can take hours of patients’ and doctors’ time. Most people don’t have the knowledge or stamina to take on the job, unless the bill is particularly large or the treatment is clearly life-saving. And the process for larger claims is often fabulously complicated.
The Affordable Care Act specifically stated that HHS “shall” collect data on denials from private health insurers and group health plans and must make that information publicly available. (Who would choose a program that denies half of the patients’ claims?) The data is also supposed to be available to state insurance commissioners, who share oversight and abuse prevention responsibilities with HHS.
To date, the collection of such information has been haphazard and limited to a small subset of plans, and the data is not audited to ensure it is complete, according to Karen Politz, senior research fellow at KFF and one of KFF’s authors. study. Therefore, data-driven federal oversight and enforcement is more or less non-existent.
HHS did not respond to requests for comment for this article.
The government has the power and responsibility to end reckless denials that harm patients financially and medically. Thirteen years after the passage of the ACA, perhaps it is time for mandated investigation and enforcement to begin.
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