The latest Commonwealth Fund research finds that 20 percent of adult Americans under 65 report that, in the last year, a health insurer denied them or their family members coverage for care their doctors deemed medically necessary. Many of these people ended up without care and in worse health. Some of them ended up with medical bills they believed their insurers were covering.
Sometimes, insurers denied care before treatment, refusing to approve it through the prior authorization process. Sometimes, insurers denied coverage after treatment, meaning that patients were stuck with the bill. Either way, insurers left Americans without the care and financial protections they needed, in many cases, endangering their health and/or pushing them into medical debt.
Because our state and federal governments allow insurers to operate without revealing denial rates, people can’t avoid the bad actor insurers. They have no clue which insurers have high denial and delay rates. Moreover, neither federal nor state governments have the resources or tools to prevent insurers from inappropriately delaying and denying care.
Insurers claim that they are not denying medically necessary care. They say that they simply are not paying for care that they do not cover or for which the providers do not submit claims correctly. Without good data to verify their claims, insurers can say what they please.
Independent research provides evidence that insurers deny care more often than they admit. Hospitals and physicians say that insurer denials are rising. The data is not available to oversee the insurers effectively and to warn Americans about insurers with high denial rates.
Researchers surveyed 4,600 Americans with private health insurance for this study. About half of them could not or did not appeal their care and coverage denials. Many Americans do not know that: 1. they can appeal; 2. appealing is easy and does not require a lawyer; and, 3. in most cases, patients win. Their insurers end up approving the care they originally denied. Or, their insurers end up paying for some or all of the cost of the care.
Appeal rights differ depending upon the state you live in and the type of insurance you have.
Ideally, Medicare coverage rules would apply across all insurers or, better still, everyone could opt into Medicare if they wanted to avoid inexplicable denials. With traditional Medicare, treating physicians can deliver almost all services without prior authorization, eliminating care delays. Moreover, if the hospital or physician provides a service and Medicare denies payment, the provider is responsible for absorbing the cost, not the patient.
When Medicare denies coverage, providers generally undertake the appeal and patients rarely need to appeal. Given that it is only the providers who can explain why a service is medically necessary, this rule makes enormous sense.
Here’s more from Just Care:
- Medicare Advantage: Denials and more denials, some deadly
- Medicare Advantage inappropriate denials of care abound
- Doctors and hospitals face increasing claims denials
- States address prior authorization denials, while Congress fears to tread
- Government lets Medicare Advantage inappropriate care denials and other abuses go unpunished
