Current Events > The American Health Care System is at it again

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https://www.washingtonpost.com/opinions/2023/05/17/health-insurance-denial-claims-reasons/

Millions of Americans in the past few years have run into this experience: filing a health-care insurance claim that once might have been paid immediately but instead is just as quickly denied. If the experience and the insurers explanation often seem arbitrary and absurd, that might be because companies appear increasingly likely to employ computer algorithms or people with little relevant experience to issue rapid-fire denials of claims sometimes bundles at a time without even reviewing the patients medical chart; a job title at one company was denial nurse.

Its a handy way for insurers to keep revenue high and just the sort of thing that provisions of the Affordable Care Act were meant to prevent. Because the law prohibited insurers from deploying a number of previously profit-protecting measures such as refusing to cover patients with preexisting conditions, the authors worried that insurers would compensate by increasing the number of denials.

And so, the law tasked the Department of Health and Human Services with monitoring denials in both plans on the Obamacare marketplace as well as those offered by employers and insurers. It hasnt fulfilled that assignment. Thus, denials have become yet another predictable, miserable part of the patient experience, with countless Americans unjustly being forced to pay out of pocket or, faced with that prospect, forgoing needed medical help.

A recent study by the Kaiser Family Foundation (KFF) of plans on the Affordable Care Act marketplace found that even when patients received care from in-network physicians doctors and hospitals approved by these same insurers the companies in 2021 nonetheless denied, on average, 17 percent of claims. One insurer denied 49 percent of claims in 2021; anothers turndowns hit an astonishing 80 percent in 2020. Despite the potentially dire impact that denials have on patients health or finances, data shows that people appeal only once in every 500 cases.

Sometimes, the insurers denials defy not just medical standards of care but also plain old human logic. Here is a sampling collected for the Bill of the Month joint project of KFF Health News, where I work, and NPR.

Dean Peterson of Los Angeles said he was shocked when payment was denied for a heart procedure to treat an arrhythmia, which had caused him to faint with a heart rate of 300 beats per minute. After all, he had the insurers preapproval for the expensive ($143,206) intervention. More confusing still, the denial letter said the claim had been rejected because he had asked for coverage for injections into nerves in your spine (he hadnt) that were not medically needed. Months later, after dozens of calls and a patient advocates assistance, the situation is still not resolved.

An insurers letter was sent directly to a newborn child denying coverage for his fourth day in a neonatal intensive-care unit. You are drinking from a bottle, the denial notification said, and you are breathing on your own. If only the baby could read.

Deirdre OReillys college-age son, suffering a life-threatening anaphylactic allergic reaction, was saved by epinephrine shots and steroids administered intravenously in a hospital emergency room. His mother, utterly relieved by that news, was less pleased to be informed by the familys insurer that the treatment was not medically necessary.

As it happens, OReilly is an intensive-care physician at the University of Vermont. The worst part was not the money we owed, she said of the $4,792 bill. The worst part was that the denial letters made no sense mostly pages of gobbledygook. She has filed two appeals, so far without success.

Insurance that you fucking pay for should not be able to deny anything

paying for the Charlie Brown experience

If a system regularly forces people to decide if saving their own life is worth the high cost, it's a fucked system

I worked in a doc office once and part of my job was dealing with insurance

United was particularly bad at denying shit that from what we could tell should have been fine. It then takes fucking forever trying to get them to reverse it

"Has the patient tried this first? Did they also try that? Did they try the first thing again? Did they try, like, not having a medical condition anymore?"

The average prior authorization attempt

This is one reason there should be a public option even in a system that includes private insurance. There's a greater incentive for private insurers to keep their members happy if they know they can always cancel and get the government-run plan instead.

Aren't these them death panels I heard so much about in 2008-2010?

This is why we should have an actual healthcare system and not insurance through private companies where the government has "oversight" to try to replicate an actual healthcare system.

DarthAragorn posted...

Insurance that you fucking pay for should not be able to deny anything

Imagine if you were hit by a car that blew a red light and Allstate was like "Can you prove to us that you actually need a car to get around?"