Delay, Deny, Make Money
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A Good Day To Advocate for Better Healthcare
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Prior Authorization - Nightmare
Demanding prior authorizations for healthcare treatment is a way that insurance companies hold on to money longer. Denying to pay for care is a quick way to increase profits.
Here is a federal Office of the Inspector General report on such denials in the Medicaid realm. They looked at seven Managed Care Organizations (MCO) parent companies with the largest number of people enrolled in comprehensive, risk-based Medicaid. These 7 parent companies operated 115 MCOs in 37 States, which enrolled a total of 29.8 million people in 2019. One in 8 requests for prior authorization were denied.
Recall that some companies use automated software to deny prior authorizations. I seem to recall one company nixing about 100,000 claims per month. I believe they are being sued for this malfeasance by the state of California.
Wendell Potter went from Healthcare executive to Universal Healthcare advocate when he was forced to defend his company’s denial of treatment. By the time the insurance company, Cigna, reversed themselves (3 days) she was dead. You can read about Wendell Potter here. You can read about her, Nataline Sarkisian, the woman, who died as a result of Cigna’s denial, here. And of course, Wendell Potter has a substack newsletter.
The Biden administration has issued a new rule regarding prior authorizations for many but not all policies. It is CMS Advancing Interoperability and Improving Prior Authorization Processes Final Rule (CMS-0057-F). At the end of this week it will be published and I promise you we will have an action to provide comments on this rule.
The administration’s newly finalized rules will require insurance companies who work in federal programs to speed up the approval process and make decisions within 72 hours for urgent requests. The regulations will also require companies to give a specific reason as to why a request was denied and publicly report denial metrics. The regulations will primarily go into effect in 2026.
The Biden administration’s new rules will cover companies who work with Medicare, Medicaid and individual insurance exchanges – that means the rules will impact about 105 million people. That still leaves out the largest pool of privately insured Americans – the 158 million who rely on insurance from their employer.
Remember that woman that Wendell Potter’s insurance company, Cigna, denied to cover and later agreed to cover. That three day delay resulted in death. This rule would not help
The new rules also exclude prior authorizations for medications, though the federal government has said it intends to work on a rule for medications in the future.
Here is a link to a Guardian news story on the item.
You know what the answer is - Universal Healthcare.
ACTION
Let’s let our elected representatives in Washington DC know about this new rule. It is a start, but a very small one. Universal Healthcare like HR 3421 is really the answer. Their contact info is in the Resources section.
Or use RESISTBOT to send the message below by texting SIGN PDOMJN to 50409.
“I am your constituent and I just found out that the a new rule (CMS Advancing Interoperability and Improving Prior Authorization Processes Final Rule (CMS-0057-F)) will reduce the time insurance companies have to respond to requests for prior authorization for insurance companies that deal with the federal government. Insurance companies make more money by denying services.
It is a small baby step and leaves out 158 million people who get insurance through their employer. The real answer is Universal Healthcare. Please work to get that passed. HR 3421 is an exceptional bill that covers everyone, cradle to grave for hundreds of millions less than we spend now. Thank you”
Abortion Updates - What No Exception Means
Here is a link to a recent story in the Guardian about a woman, K. Monica Kelly, whose fetus had trisomy 13. It is a genetic condition that causes severe deformation, pain and 90% of the time death within a year of birth. Her doctor told her the fetus’ brain had not split into separate lobes and that abortion was not an option in her state, Tennessee.
She managed to obtain the abortion she needed in Florida, just in time, since Florida has a 15 week limit. She is suing her state.
EXTRA CREDIT ACTION
Tell Representatives in Congress to pass the Women;s Health Protection ACT and the Protecting Access to Medication Abortion Act. Their contact info is in the Resources section below or Use RESISTBOT on your cell phone by texting SIGN PTMEWG to 50409 to send this message.
“I am your constituent and I just learned about a woman, K. Monica Kelly who was pregnant with a severely malformed fetus and her state, Tennessee, refused to let her have an abortion. The story is in the Guardian. She was lucky enough to have sufficient money to get the abortion in Florida.
Women are being made to suffer by a minority that seeks to control women at any cost. I want you to pass the Women’s Health Protection Act to legalize abortion and the Protecting Access to Medication Abortion Act to make sure they can get the medicine they need. Lives are at stake.”
RESOURCES
Healthcare Advocacy (Us)
Website
Our Newsletter resources including reproductive healthcare
Healthcare Advocacy Reading List
Find My Elected Officials
Contact the White House https://www.whitehouse.gov/contact/
Contact State and Federal Representatives
By phone: (202) 224-3121
By email: democracy.io
Important Healthcare Resources
League of Women Voters Healthcare Reform Toolkit
Organizations to Contact
National Nurses United Medicare4All
Physicians for a National Health Program
One Payer States
Healthcare Now
Reproductive Health
NARAL - Pro Choice America
Charley. chatbot abortion resource - make sure to use a secure incognito browser if you live in a state that has banned abortion
Planned Parenthood
Miscarriage and Abortion Hotline has references about where to procure abortion medications. They also assist women in the process of self managed abortion or miscarriage by phone or text and will respond in an hour. Details and hours of operation at their website.
United State of Women Reproductive health page (bottom of the page) has important resources such as medical support, access to Telehealth, prescriptions by mail, and legal support references.
Practice careful communications - The Digital Defense Fund has a number of tips to keep texts, calls, and internet use private. Here is their site.
If you need financial help with an abortion try abortionfunds.org
Claims Denials and Appeals & What to Do
Appeal a Healthcare Decision
Appeal/Negotiate a Hospital Bill
Disinformation Management
Cybersecurity Infrastructure Security Agency
Save Democracy
Chop Wood, Carry Water by Jessica Cravens
RESISTBOT
Link to the RESISTBOT site to learn more
Link to Chop Wood, Carry Water RESISTBOT write up
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It is recent and I am reporting it to Medicare as fraud. Her receptionist agreed with me when I told her I wouldn’t pay for a phone call of 5 minutes for results of a test I was entitled to. My mammogram results were mailed to me as expected.
Alan,
When an insurance company rejects pre-authorization and the patient experiences a calamity because treatment was delayed, can the insurance company be sued? Are there instances where such lawsuits have succeeded?