How are default denials not criminal?
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It may be more useful to look up the study being referenced:
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The answer is in the study posted by UCB:
“…the aggregated approval statistics do not allow for further analysis into which services are being denied.”
Without more details, aggregate numbers are nearly meaningless. Perhaps the “12-14%” denials are appropriate Standard of Care. For example, try physical therapy before back surgery? Or, PT instead of meniscal surgery for degeneration? (Research shows that PT + hylaronic injections are similarly effective to surgery.). Or lifestyle changes instead of cardiac stents?
Protip: not everything your personal doc recommends meets Standard of Care.
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Doesn’t the fact that over half of denials are overturned indicate that the majority of the initial denials were NOT warranted?
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Someone I know works for a company that (among other things) assists hospitals in writing letters to insurance companies supporting patient procedures, tests and hospitalizations. Each insurance company has different criteria it is looking for, so support must be tailored to what that company requires - including specific phrasing - or the claim will be automatically denied. Appealing will likely result in coverage, but resolution requires manpower, which costs money. The way things work is convoluted and expensive, and it hurts everyone but the insurance company’s profits. IMO, anyway.
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I don’t think you can generalize.
Neighbor of mine- 50-ish years old. Dying of advanced colon cancer. Wife is told “we are at the end of the line”. She does “her research” and finds a doc halfway across the country with a “new and innovative therapy” for advanced colon cancer. She sends H’s medical records; doc agrees to take him on as a patient. Insurance company refuses-- their stance is basically “if you want to charter a plane, take a man hooked up in five different places, to be treated by a doctor whose “therapy” has not been peer reviewed- then go ahead. But we will not pay for it”. He dies a few days later. Family is ballistic- suing the hospital, insurance company, original oncologist who said “we are at the end of the line”. I understand their pain- truly I do. And having watched parents and in-laws die, I think the day they tell you “we are at the end of the line” is likely worse than the day a parent dies. So clinging to something- anything- is only human.
But so many of these “innovative therapies” have ALREADY been tried, failed, proven to be even worse than the placebo. And they are expensive. So blame the insurer? Sure. But are you really advocating that a man near death should be moved 1500 miles for a “wish and a prayer” procedure?
Or even worse- the number of end of life patients whose families are furious at the insurance companies for denying a hip replacement (a fall, unrelated to the disease) or other invasive surgical procedure? I was told “it’s time for a feeding tube so you can take her home and maker her comfortable” a few hours before my end-stage Alzheimer’s parent died. Really? A patient is actively dying and the answer is MORE intervention (NB- not more pain relief, which of course I am behind 100%).
So these “Never” proclamations could be more nuanced. Occasionally sound medicine and cost containment go hand in hand.
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Sure, but “not warranted” doesn’t equate to “criminal”. For example, how many of those original requests were missing paperwork and/or lab results and once the proper paperwork was presented, the procedure was approved? Without details, gross numbers are not “criminal”.
That said, your heading is correct: always appeal, if for no other reason, to better understand their rationale.
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To be clear, I !understand many treatments mds want are explicitly not covered by insurance. While I think that in itself is a huge problem, that is not the problem being discussed here.
My mom was an office manager for a medical clinic for 20 years. She and my dad had cadillac insurance through his union job. There were many years that every procedure, treatment, test, etc was automatically denied by their insurance company. Every one. It was so bad, even their PCP was aware that their insurance company would deny everything he ordered. It was all routine stuff…neither of them ever had any serious or chronic health conditions. She was adept at reading the certificates of coverage and always knew that what was denied was supposed to be covered, so she always got on the phone and got the denials reversed…which given her career was a relativelyneasy task. She filed a couple long complaints with the MO State Insurance Commissioner and got some traction on one of the complaints and things improved a bit after that.
In another example, a close friend has been undergoing cancer treatment for over a year. More than half her claims have been denied. Her providers have a concierge service that runs interference between patients and insurance companies. The concierge has gotten every denial (but one for a new drug she could not have until the standard of care drugs caused an adverse reaction-which they did and insurance company got to then pay for 3 days of ICU treatment) reversed with only a phone call.
THAT operating procedure is the issue here. Given that many folks would not challenge the original denials, I find the overturned denial rates alarming.
Medicare Advantage is supposed to cover all the same stuff that regular medicare covers, so why the higher rates of denials? What about United Healthcare? Are their patients/providers significantly worse at attaching all the right paperwork to claims than insurance companies with lower overturned denial rates? Hmmm…I dont think so.
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