Tuesday, August 26, 2008

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How Crafty Health Insurers Are Denying Care

You can fight back when your health plan says no

By Bernadine=20 Healy M.D.

Posted August 25, 2008

Britain's government-run health system is under siege for restricting = new=20 therapies. The outcries became especially sharp this summer after = patients and=20 doctors got wind of plans to deny several new cancer=20 drugs that are widely available in Europe and the United States, = including=20 Avastin=20 and Sutent,=20 because they aren't "cost-effective." In an op-ed in the Daily=20 Mail, one of Britain's leading oncologists, = Jonathan=20 Waxman of Imperial College London, decried a "misguided and = barbaric=20 decision to ban four kidney=20 cancer drugs" that double life expectancy. And that means years of = life in=20 some cases. You may think this is just a British battle over care denial = in a=20 country with rigid caps on its health purse and a penchant for = rationing. Not=20 so. In the United States, it's private insurance companies, which make = hefty=20 profits managing half of America's medical expenditures for the = non-Medicare=20 population, that in ways often hidden and arbitrary have the authority = to deny=20 coverage=E2=80=94and therefore, in all too many instances, care.

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Outrage tends to bubble up when denials become human drama, = triggering media=20 interest. There's the 17-year-old girl who died before her liver=20 transplant was approved. Or the people in California whose insurers = canceled=20 their policies retroactively after they got sick. What's often missed is = that=20 these cases are the tip of an opaque iceberg. An estimated 10 to 15 = percent of=20 claims are denied for various reasons, some of them technical, such as = not=20 meeting filing deadlines or failing to get pretreatment authorizations. = Denials=20 that produce the most disputes are those where insurers judge the care = to be=20 unnecessary or unproven, pitting a proverbial sick David against a=20 multibillion-dollar Goliath. What few Davids know is that insurance = contracts by=20 law grant companies the legal right to manage a patient's care, = including=20 denying it, sight unseen, and give them the final say, if challenged. = Unless the=20 state steps in.

Many denials are iffy calls and can appear distinctly arbitrary, with = one=20 insurer saying no to a particular therapy or procedure=20 while others reimburse for it. An FDA-approved drug might be denied = because it's=20 used off-label, even if it is shown to work in peer-reviewed reports. In = cancer=20 care, the generally expensive intravenous chemotherapy drugs given in a = doctor's=20 office are typically covered, while an equivalent, if not better, = therapy taken=20 at home orally is not. When insurance authorization is required for each = new=20 service or each hospital stay for the same serious illness, who's best = to say=20 what's medically necessary? Doctors and their staff will spend hours = trying to=20 get the approvals, but patients should be warned that if the company = ultimately=20 denies payment, for whatever reason, it's the patients who are = responsible=E2=80=94with=20 bill collectors ready at their door.

The problem is bound to grow as insurers make use of sophisticated = data tools=20 dubbed "denial engines," which are touted to reduce reimbursements by 3 = to 10=20 percent. Bearing brand names like Ingenix Detection Software and = Bloodhound=20 Technologies' ClaimsGuard, they search patient records for any signs = that claims=20 have strayed outside company parameters. Weeding out fraud or speeding = up=20 processing is one thing; serving up excuses to deny legitimate coverage = is=20 another.

More than ever, people must study the details of their health plans. = A few=20 insurers, like Aetna, offer on their website a useful list of all = services they=20 won't cover=E2=80=94and why. And know that = every insurance=20 company is mandated to have an internal appeals process, though there is = little=20 openness to help those seeking reconsideration, such as information on = similar=20 appeals and their outcome or the data used for denial. Nor do insurers = provide=20 much detail about the professionals making decisions. Who are they? = What's their=20 experience? Are they moonlighters denying care from New Delhi? (Yes, = many large=20 insurers are now outsourcing claims adjudication to India.)

But those with the stamina to endure the many exhausting steps of = internal=20 review sometimes win. Even if you lose, completing the formal written = internal=20 appeal makes you eligible for an independent external review in 43 = states and=20 the District of Columbia. State reviews overturn about half of insurers' = decisions, and in most states that's final. Nancy Nielsen, president of = the=20 America Medical Association and a former chief medical officer of a = nonprofit=20 insurance plan, says, "If health insurers are making coverage decisions = that are=20 fair and compassionate, very few will be overturned by the state's = external=20 appeal process." The numbers speak for themselves.

The lack of transparency in the face of such mighty discretionary = authority=20 is drawing the attention of state attorneys general. Andrew Cuomo of New = York=20 has launched a nationwide investigation into schemes that low-ball = reimbursement=20 and stick patients with bills insurance companies should have paid. "All = too=20 often," Cuomo says, "insurers play a game of deny, delay, and deceive." = His=20 pursuit is in full throttle and has the advantages of his bully pulpit = and his=20 power of subpoena to pierce the opaque veil that patients never = can.

Tags: health=20 insurance | = insurance=20 | Attorney=20 General | Cuomo,=20 Andrew

<= A=20 name=3DComments>

Reader Comments

life=20 or death

Who do they think they are? If it was them or their loved ones I bet = the care=20 would be approved. We need to put into effect a national law mandating = poolicy=20 that insurance companies can make no decisions that would or could = effect the=20 quality of a persons care. The only people with that authority would be = the=20 patient or their family and their doctor.

JOHN of=20 ND
Aug = 26, 2008=20 18:02:35 PM [permalink]=20 [report=20 comment]=20

Govt.=20 Health Care

CA has deep wisdom & insight!

How can Govt., with all of its bureaucracy do anything better?! We = need to=20 outsource the PO, the Military, the railroads, water, etc. it all needs = to be=20 privitized(eg. different gauge tracks)

For example, most healthcare in Europe is Govt. sponsored, or run -- = the fact=20 that they have for a long time had a longer, & better quality of = life has=20 nothing to do with that -- they have different diseases & lives -- = we need=20 to be AMERICANS!, & die younger, worse off, & poorer -- but = secure in=20 our ideology & logic.

of NY
Aug 26, = 2008 17:44:06=20 PM [permalink]=20 [report=20 comment]=20

For=20 Profit Or Else

Insurance companies are in the business to make a tidy profit for = their=20 stockholders. They also make a bundle in the stock market investing all = those=20 premiums. When the stock market tanks as it currently is, you see denial = rates=20 skyrocket and a drastic cutback of approved procedures. They are in the = business=20 of making the hurdles so high and so numerous that one just gives up in = disgust=20 or in despair. They count on very few people actually appealing denials. = That is=20 the racket. And without strict regulation and some strong armed = Insurance=20 Commissioners who will enforce the laws, they will do what they do = best--prevent=20 utilization of services.

The argument about "you have to draw the line somewhere..." is bogus. = You are=20 not qualified to determined what constitutes "quality of life"--that job = is=20 taken already. " We'll spend all this money..." you go on to argue. And = what=20 happens to the money that you don't spend??? It goes directly into the = pockets=20 of the CEOs and the stockholders--FOR PROFIT. If you take the profit = motive out=20 of healthcare, it eliminates a whole host of evils and people get much = better=20 care.

And just for the record while we are on the topic of healthcare--ANY = provider=20 who refuses to take TRICARE PRIME (the military insurance policy) = because it=20 does does reimburse you well enough is UNPATRIOTIC. It is your duty as = an=20 American to treat our soldiers and their families. Yes, I am well aware = of what=20 it pays. We must lobby the Feds hard to raise the reimbursement = rate--but in the=20 meantime treat the soldiers for God's sake! It is your duty. Nobody has = asked=20 Americans to do squat in these two concurrent wars. Well, I am asking. = See these=20 soldiers and their families. They need help and the VA cannot keep up.IT = IS YOUR=20 DUTY.

DEFuning of=20 NC
Aug = 26, 2008=20 14:35:53 PM [permalink]=20 [report=20 comment]=20

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Health

How Crafty Health Insurers Are Denying Care

You can fight back when your health plan says no

Related News

Reader Comments

life=20 or death

Govt.=20 Health Care

For=20 Profit Or Else

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