How are default denials not criminal?
2 Likes
It may be more useful to look up the study being referenced:
3 Likes
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.
2 Likes
Doesn’t the fact that over half of denials are overturned indicate that the majority of the initial denials were NOT warranted?
7 Likes
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.
8 Likes
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want to charter a plane, take a man hooked up in five different places, to be treated by a doctor whose “therapy” has not been peer reviewed- then go ahead.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.
2 Likes
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.
3 Likes
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.
8 Likes
There are insurers who routinely deny coverage with the notion that a certain percentage of insured will not pursue it. They routinely approve the coverage during an appeal. It is an effective strategy for profit maximization (unless they lose subscribers as a result but I don’t think that is the case). It feels unethical but I’m not sure that what would make it a crime. I suspect that there could be grounds for a class action lawsuit, but that would be civil and not criminal.
Medicare Advantage providers are, I suspect, charging less and require referrals to specialists. Their business model may well be banking on their practice of routinely denying a certain percentage or all of the claims and is probably part of what enables them to charge less.
When my mother and father were both hospitalized at the same time – he had a stroke and died from an unrelated cancer a year later and she developed Guillane-Barre syndrom – I hired a woman whose job was to manage the insurance companies. She submitted claims and then dealt with denials. Like the concierge service @scubasue describes, she was able to get virtually everything covered eventually.
Incidentally, I found the same thing to be the case in dealing with The College Board and ACT about accommodations and especially extra time on SAT and ACT tests. It appear that they routinely deny certain kinds of requests that they later accommodate. But to get get accommodations, you need to be articulate and spend time and probably money. It skewed the granting of accommodations to kids with active, educated parents and not to the kids who needed the accomodatoins the most.
2 Likes
When they knowingly deny claims for services that are clearly covered, that must cross the line from unethical to criminal.
1 Like
IANAL (I am not a lawyer) but get involved in many things that involve lawyers. If a company arbitrarily denies claims without making a judgment about them, my guess is that they are open to a civil lawsuit but not criminal prosecution. If they pick claims with certain characteristics to deny but don’t evaluate the quality of the claim, my guess is that is civil also. The only think that could possibly be criminal is if they evaluate the claim, decide they would have to pay it, and choose to deny, my guess is that that act in one case is a civil law violation but maybe aggregating many such cases, a state attorney general might consider a case of criminal fraud. But there are plenty of lawyers on here whose knowledge/judgment is going to be better than mine.
1 Like
I recently had some blood work done as prescribed by my doctor. They were around $20 for each test, then there was a line item for general health panel for 175. I have no idea what that was for, but I certainly am not going to pay for i.
1 Like
How do you find such a person?
This was quite a while ago so my memory is a bit hazy. I searched on the web for a medical billing advocate or health insurance advocate. I picked her because she charged a monthly fee rather than a fee per claim or hourly fee. She was terrific and a really wonderful person. Sadly, she died quite young (age 48) a few years later. Her company was listed as a benefits consultant. A number of the folks who did this at the time worked primarily for doctor’s offices.
My Googly friends say,
You can find a medical claims or billing advocate through professional directories like the Alliance of Claims Assistance Professionals or by checking employee benefits and non-profit resources. [1]
Professional Directories & Organizations
- Alliance of Claims Assistance Professionals (ACAP): A professional group of specialists who help consumers sort out medical bills, insurance claims, and denials.
- National Association of Healthcare Advocacy: Runs a national directory to help patients locate independent, private advocates.
- Patient Advocate Foundation (PAF): Offers free case management and support for insurance denials and medical debt crises. [1, 2]
Alternative Options to Check First
- Employer Benefits: Ask your human resources department if your health plan or workplace offers free or discounted health advocacy services as an employee benefit. [1]
- Hospital or Clinic: Contact the financial assistance or billing department of the facility where you received care to ask for local recommendations. [1]
- State Resources: Look into your state’s Consumer Assistance Program or State Health Insurance Assistance Program (SHIP) if your issue involves Medicare. [1]
2 Likes