How Health Insurers Have Made Appealing Denials So Complicated — ProPublica

Have you ever had a medical claim denied by an insurance company? Have you tried to sue it? Did you end up feeling confused, frustrated, exhausted or defeated?

I have been a healthcare reporter for over 40 years. And when I tried to find a way to contest the insurance denial, I ended up on the same road. And I didn’t actually try to appeal.

ProPublica approached me earlier this year with a proposal that might have seemed simple. They wanted us to create an interactive Dispute Guide to help readers navigate the maze of insurance companies. (ProPublica and the Capitol Forum team of reporters are investigating all the ways insurers refuse to pay for medical bills. If you have a story you’d like to share, let the insurer know here.)

Over the next several weeks, I spoke with more than 50 insurance professionals, patients, lawyers, doctors and consumer advocates. Almost everyone said the same thing. “It’s a great idea.” But it’s nearly impossible to do. The insurance industry and its regulators have made complaints so complex that only a minority of patients actually file complaints. for example, Fewer than two-tenths of the 1% of patients participating in the Obamacare plan bothered to appeal The claim was denied in 2021.

Core Issue: There are many types of insurance in the United States, and each has a different process for challenging denials. Also, state and federal lawmakers and regulators are not forcing all insurers to follow one simple standard.

I have attempted to create a spreadsheet that guides readers through the process of appealing for different types of insurance and situations. For example, if a patient needs urgent care, the appeal follows a different route. However, with each daily report and interview with each expert, the situation became more and more confusing. There was a time when I thought I was drowning in exceptions and caveats. One night, I was filled with the feeling that I was trapped in an impossible maze, and the signs pointing the way kept me going further.

Here are some of the very confusing issues:

First, people need to know exactly what kind of insurance they have. UnitedHealthcare is the name on your insurance card, so you might think it’s an insurance company, but that policy doesn’t tell you what plans they have. Your real insurance company may be your employer. According to the KFF, formerly the Kaiser Family Foundation, about 65% of workers who are insured through their employer are on a so-called “self-funding plan.” That means your employer will pay for your medical bills, but you may hire an insurance company like UnitedHealthcare to manage your claims.

Another major type of insurance that companies offer to their employees is known as a “complete insurance plan.” Employers hire insurance companies to bear all the risks and pay the claims. With this kind of plan, the name on the card becomes the actual insurance company. Why is this difference important? Because the route you take to contest an insurance denial can be different depending on whether it’s a fully-insured plan or a self-funded plan.

But a lot of the time people don’t know what their plans are and don’t know how to find out. I’ve heard that some employers’ HR departments don’t either, but they should.

“It’s a little scary because people honestly don’t know what they have,” said Karen Politz, a senior researcher at KFF who specializes in health insurance research. “I want to warn you that if you set up a decision tree where A: Yes, B: No, C: Don’t know, many people will click I don’t know.”

Government insurance is a complex issue in itself. I am a Medicare beneficiary and have an Supplemental and Part D plan for drug coverage. The appeals process for drug refusal is different than it is for my other medical treatments. And it’s a different process than people with Medicare Advantage plans have to follow.

A spokeswoman for the Centers for Medicare and Medicaid Services, the federal agency that oversees Medicare, said in an email that the agency “is actively working to identify ways to simplify and streamline the appeals process, and to help stakeholders and How we can work with focus groups to better communicate information relevant to the appeals process with the beneficiaries we serve.”

And let’s not forget Medicaid and children’s health insurance programs. Covering a total of 94 million subscribers as of April, more than a quarter of the US population. The federal government sets minimum standards for each state’s Medicaid program to follow, but each state can further complicate things by requiring different application pathways for different types of care. Therefore, the process may vary depending on the type of care denied and may vary from state to state.

And if you’re one of the 12.5 million people covered by both Medicare and Medicaid, don’t let me tell you how mysterious it is. “Medicare for some, Medicaid for others,” explains Avi Coursol, senior attorney for the National Health Act program, as to what appeals paths need to be taken.

I turned to Jack Daly, a San Diego attorney and coordinator for the California Health Consumers Alliance, which works on statewide legal aid programs. On the Zoom call, he looked at an Excel spreadsheet I had created for California Medical’s Medicaid program based on what I had already learned. Then he shook his head. A few days later he came back with a new guide and stayed up all night fixing what I had put together and adding tons of caveats.

It was single-spaced and seven pages long. The document details his five stages of the Medi-Cal appeal process, with some cases going to state superior courts. There were so many abbreviations and acronyms that I had to create a glossary. (DMC-ODS is Pharmaceutical Medi-Cal Organized Delivery System?) And this was only for one state.

Christian Heck, Ph.D., an epilepsy specialist neurologist at the University of Southern California Keck Medicine, said her health care system has a team of experts dedicated to challenging denials and applying for pre-approval, and that insurance companies He said he would have to call and get approval. for advance procedures.

“That’s a big problem,” Heck said. “Usually multiple attempts are required. We have to play this terrifying, terrifying game, and the patient is somewhere in between.”

Oncology is particularly complex, said Dr. Barbara McEnany, former president of the American Medical Association and who runs a 6,000-patient oncology clinic in Albuquerque, New Mexico.

“My practice is built on the theory that all the patient should do is come to the hospital and we should manage everything else. Because you can’t, it’s impossible,” she said.

Mr. McEnany asked me to join a designated denial struggle team for a year whose only job was to request preapproval for cancer treatments (average of 67 applications per day) and challenge denials. He said he spent $350,000 on it.

First, she candidly said, “I know everything will be denied.” It’s almost a given that insurers lose their first record, she said. “Often the records have to be sent by her two or three times before she finally acknowledges that they actually received them. …They play all these delay games.”

McEnany believes money is what really matters to insurance companies.

Her theory is that insurers save money by delaying payments as long as possible, especially when patients or doctors give up on complaints, or when patients’ conditions deteriorate rapidly without treatment. .

For insurance companies, “death is cheaper than chemotherapy,” she said.

I asked James Swan, a spokesperson for AHIP, the industry group formerly known as America’s Health Insurance Plans, what his organization thinks about such comments. He refused to address it directly, nor did he answer my question why the industry made appeal denials so complicated. In a written statement, Swann said doctors and insurers “must work together to provide evidence-based care and to avoid inappropriate, unnecessary and more expensive treatments.” In most cases, claims that are not immediately approved simply require the provider to submit additional information, such as diagnosis and other details, to properly document the request. If a claim is not approved after accurate and complete information has been submitted, patients and providers have several levels of appeal. “

Swann outlined some of the appeals procedures available, including review by physicians not involved in the original dismissal of the claim, the opportunity to submit additional clinical evidence, and review by bodies independent of the insurer. did. He also noted that the Medicare Advantage and Part D programs go through multiple stages of appeals before going to court, including stages that require review by an outside, independent body.

Domna Antoniadis is a New York City medical attorney who co-runs Access to Care, a non-profit organization that educates patients and providers about their health insurance rights. She spent hours helping me navigate the various appeal systems.

She offered one important tip for people using commercial insurance. That is to obtain and read the complete policy plan. About 100 pages detail what medical services are covered and all the steps necessary to appeal a denial. Don’t rely on a four-page synopsis, she said. It probably won’t help.

Similarly, Medicare, Medicare Advantage, and Medicaid refusal letters should explain how to appeal a decision.

Seek help from your healthcare provider if possible. In some cases, the insurance company will deny the claim because the clinic submitted the claim based on the wrong code, but that can be fixed quickly.

Antoniadis recognizes the challenge, but believes consumers have far more power than they think. They can rebel to defend themselves.

“The appeals process is not always properly handled by the plan, so consumers should report and file a complaint with the relevant government regulator if they believe they have been unfairly denied. There is,” she said. “It’s essential to change the system.”