In an interview with American Managed Care JournalⓇ (AJMCⓇ), Jeffrey Sippel, M.D., MPH, associate director of inpatient clinical services and associate professor of clinical medicine in the Department of Pulmonary Sciences and Critical Care Medicine at the University of Colorado School of Medicine, discusses the pattern of denials of insurance claims for non-infected individuals. We discussed. Learn about invasive ventilation (NIV) in Medicare Advantage plans and how these denials affect patients with amyotrophic lateral sclerosis (ALS).
transcript
From your perspective, are there any solutions to fix these medical denial issues?
I think there are many things you can do to fix this problem. The first is to assume that if a patient is diagnosed with a neuromuscular disease, they will need clinician-directed support. And the insurance company can follow up and audit it, but if the first bid is rejected, that really sets us back a few steps. So I think the first bid for these patients should be approval, not denial, and we can approve and validate rather than deny and appeal.
What actually happens is that the time pressure is completely placed on the patient, as opposed to the insurance company owning the time portion. By the way, the patient’s performance is poor, and the patient does not have time. I think this humane aspect is completely underestimated by insurance companies. I made several verbal appeals and was able to speak to someone on the phone. Although this is just my opinion, and I have had relatively unprofessional discussions, I think this speaks to the lack of evaluation in the insurance industry. It doesn’t matter if I talked to the pulmonologist or any other doctor in that appellate channel. Relatively speaking, it’s a backhand. And it’s very frustrating. If it takes you 15 minutes to an hour to complain about something, you call, you wait, you’re put on hold, and you’re finally going to talk to someone, I expect professional behavior, but it’s just that it’s always there. It’s not like I’m in it.
This is an important topic. Because I feel that this vulnerable patient population, her ALS patients, are at risk purely for economic reasons. And I think there’s a great opportunity for people with very short schedules to improve their quality of life even a little bit. Their time with loved ones, family and friends is short, so we should do what we can to improve their quality of life. And while this is a tool in the toolbox, it is immediately denied.
