Over the past few years, millions of Americans have experienced immediate denial of medical claims that were once expected to be paid immediately. Where experience and insurer explanations often appear arbitrary and unreasonable, it is often the case that companies employ computer algorithms and personnel with little relevant experience to process claims in rapid succession without checking patient opinions. It may be due to the increased likelihood of issuing denials (sometimes all at once). medical chart. One company’s job title was “denial nurse.”
It’s a convenient way for insurance companies to keep profits high, just as the Affordable Care Act provisions were intended to prevent. Since the law prohibited insurance companies from taking steps to protect their interests, such as denying coverage to patients with pre-existing medical conditions, the authors suggest that insurance companies should not compensate by increasing the number of denials. I was worried about it.
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The law then tasked the Department of Health and Human Services with monitoring denials by both the Obamacare market medical plans and those offered through employers and insurance companies. It doesn’t live up to its mission. Denial has thus become another predictable and distressing part of the patient experience, with countless Americans unfairly co-paying or, in the face of the prospect, depriving the medical help they need. I am abandoning it.
A recent KFF study on the ACA plan found that companies could reduce an average of 17% of claims in 2021, even if patients were treated by in-network doctors (doctors and hospitals approved by the same insurer). turned out to be rejected. One insurer denied 49% of claims in 2021. In 2020, another patient refusal rate reached a staggering 80%. Despite the dire health and economic impact of denials on patients, data show that people only appeal one in 500 cases.
Insurance company denials not only go against medical standards, but they can also go against old-fashioned human logic. This is a sample collected for KFF Health News and NPR’s “Bill of the Month” joint project.
- Los Angeles Dean Peterson said he was “shocked” when he was refused payment for heart surgery to treat an arrhythmia that left him fainting at a heart rate of 300 beats per minute. After all, he had pre-approval from his insurance company for a large ($143,206) intervention. To make things even more confusing, the denial letter said the claim was denied because it was “not medically necessary” and “he asked for compensation for injections into the nerves in his spine” (which he did not do). That’s what I was doing. Months later, despite dozens of phone calls and the support of patient advocates, the situation is still unresolved.
- A letter from the insurance company refusing coverage for the fourth day in the neonatal intensive care unit was sent directly to the newborn. The denial letter read, “You are drinking from a bottle” and “breathing on your own.” I wish my baby could read
- Deirdre O’Reilly’s college-aged son suffered a life-threatening anaphylactic allergic reaction but was saved in a hospital emergency room by epinephrine injections and intravenous steroids. His mother was very relieved to hear the news, but less than happy to be told by her family’s insurance company that treatment was “not medically necessary.”
Coincidentally, O’Reilly is an intensivist at the University of Vermont. “The worst part was not the money we owed,” she said of her $4,792 bill. “The worst part was that the refusal letters didn’t make sense. Most of them were gibberish.” She has filed two appeals, but she has so far been successful. not
Of course, some denials are well considered, and KFF’s research found that some insurers deny only 2% of claims. But the rise in denials, and many of the oddities presented, may be partially explained by a ProPublica investigation into insurance giant Cigna, which has 170 million customers worldwide.
A ProPublica study published in March found that an automated system called PXDX enabled Cigna medical reviewers to sign 50 medical records in less than 10 seconds, presumably without consulting patient records. It has been found.
Decades ago, insurance company scrutiny was limited to a small subset of high-priced treatments to ensure that providers weren’t ordering based on benefits rather than patient needs.
These reviews and their denials now extend to the most mundane medical interventions and needs, such as inhalers for asthma and heart medications patients have been taking for months or even years. What is approved or denied may be based on changes in contracts between insurance companies and drug and device manufacturers rather than on optimal patient care.
Automation makes reviews cheaper and easier. A 2020 study estimated that automated claims processing could save U.S. insurers more than $11 billion annually.
However, it can take hours of patient and physician time to challenge a denial. Many people do not have the knowledge or fitness to take on the job unless the bill is particularly high or the treatment is clearly life-saving. And the procedures for larger claims are often very complicated.
The Affordable Care Act clearly states that HHS is “obliged” to collect data on denials from private health insurance companies and groups’ plans and to publicly disclose that information. I’m here. (Who would choose a plan to deny half of patient claims?) This data will also be provided to state health commissioners who share oversight and abuse control duties with HHS.
According to Karen Politz, a senior research fellow at the KFF and one of the authors of the KFF, so far, such information gathering has been haphazard, limited to parts of the program, and the data is incomplete. It has not been audited to ensure that it is study. Therefore, data-based federal oversight and enforcement is nearly non-existent.
HHS did not respond to a request for comment for this article.
Governments have the power and duty to turn off the fire hydrant of reckless denial that harms patients financially and medically. Thirteen years after the ACA was passed, it may be time for the mandated investigation and enforcement to begin.
KFF Health News, a national news agency that produces in-depth journalism on health issues, is one of the KFF’s core operating programs and an independent source of health policy research, polls and journalism. is. Learn more about KFF here.