Healthcare Advocacy - Claims Denial
December 21, 2022
Good Day Healthcare Advocates
Every day that we learn, grow and advocate for better healthcare for all of us is a good day. I have received a number of comments from readers indicating that they like the resources and having a solid action to take. Thank you to all of you. If you have topics you’d like me to cover please let me know via the substack comment button.
Mission
The Healthcare delivery system in the United States is a patchwork that leaves much to be desired. It is the most expensive system among the top 35 industrial countries and covers far fewer participants delivering lower levels of quality care than many of our peer nations. This blog will provide:
· Current problems in healthcare
· Actions you can take
· Background information on healthcare
· References.
Current State of Affairs – Claims Denials
About 90% of the country has some form of health insurance. Health insurance in the US began in the early 1900s. At that time, most doctor bills were paid in cash, and pharmaceuticals were not extraordinarily expensive. Hospitals were expensive, although not like today. Most hospitals were nonprofits and operated a charity as well for those who were unable to pay. Doctors were responsible for running the hospitals, usually a chief of medicine.
Today the situation is drastically different. Colleges teach hospital management as a discipline. Even nonprofit hospitals often outsource less profitable services and pay their administrators in the millions. We will cover this in another session.
For most of us the insurance companies stand between you and your provider and determine what course of treatment they will cover. If your treatment is not covered you may well be out of luck and on your way out. I know that critics of universal healthcare complain about having government death panels determining what will and won’t be covered but in all 900 or so private health insurance companies today, we have death panels and they deny coverage regularly and without any transparency. Universal coverage systems document coverages and coverage levels for everyone to examine.
Another sad truth is that since the insurance company is in the business of turning a profit (unlike the German Bismarck system where insurance companies are non profit) it is in their interest to hold onto funds as long as possible and keep it invested.
They frequently deny claims and let you file a complaint and request a review of the denial. According to the Kaiser family Foundation about 20% of health insurance claims are denied. According to the Healthcare Financial Management Association 65% of those denials are not resubmitted. When claims are resubmitted they are frequently overturned and the claim paid - varies between 60 and 80%.
Let’s recap – Insurance companies denials are money makers for the insurance companies.
So what are the lessons for us?
1. Someone who isn’t your healthcare provider should not determine what treatments are appropriate for you
2. If your claim is denied demand a review and appeal the decision
a. Make sure that if your insurance company requires pre approval that you ensure that your provider seek pre-approval first and notify you – keeps down the denials
3. Insurance companies are not working in our best interest and universal health care is the solution
What You Can Do
See resources below for your senator/representative
You can call or email your Senators and Representative and say
My name is _________, I am a constituent and live in zipcode ________.
We can all agree that we need better healthcare for everyone. Universal healthcare will provide better quality care, at lower cost, make the US more competitive as a country and eliminate medical bankruptcy and provide better care in rural parts of the country.
Please work to pass HR 1976 Representative Jayapal’s Medicare For All legislation. It addresses all of these issues.
Background – Healthcare – How Expensive Is It?
The US has the most expensive healthcare system in the industrialized world. US healthcare spending is now at $4.3 Trillion according the CMS, the Center for Medicare and Medicaid Services (2021). It is $12,914 for each of us and now is 18.4% of the Gross Domestic Product.
Most of our peer industrialized countries are in the 10% to 12% range. Japan – 10.7%, Germany 11.7%, France 11.6%, etc. And they cover everyone. Here we have 10% of the population with no healthcare whatsoever and we are paying at least 50% more. How did we get this so bollixed up? Mostly because we did not design a system, we let the system evolve a little at a time based on inputs from the health care and insurance lobbies. According to opensecrets.org, the healthcare industry provided about $350M to candidates in the 2020 election and insurance companies provided over $100M. I want to think that my representatives represent me but they sure are getting a lot of money elsewhere.
Keep in mind that one of the crises we saw in the pandemic was that since most Americans get health insurance through employment, when they lose their job, they lose healthcare.
Here are couple of videos showing British reactions to the cost of individual healthcare items in the US.
References
Contact elected officials
Senate email/phone
https://www.senate.gov/senators/senators-contact.htm
House of Representatives email/phone
https://www.house.gov/representatives/find-your-representative
Congress
Use the search tool at the top
or a refined search
Claims Denials
Overturning Claims – National Nurses United
Claims Denied Never Resubmitted
Healthcare Financial Management Association
Quality of Care in the US
Kaiser Family Foundation –a good source of current data and problems with healthcare.
Physicians for a National Health Plan (PNHP) has a number of good background presentations and often describes actions you can take.
The Commonwealth Fund, a good source of healthcare research.
Alan, thank you for another in your series about our patchwork, for-profit healthcare system. Today you documented the insurance industry’s use of denials of 20% of claims with only 35% appealed and most of the resubmitted claims paid as a coldly calculated tactic to use blood money to increase profits. I appreciate your showing that politicians warning that “death panels” would deny life-saving care is cover for profiteers denying life-saving treatment without transparent accounting of how such decisions are made. You also write that some of our representatives are reaping large contributions for blocking healthcare reform. I look forward to your documenting the millions paid to c suite healthcare executives. This is a call to contact our elected representatives to vote for Medicare for all, a common-sense solution that is successfully practiced by advanced countries too all of their citizens at 2/3 of our cost, when 10% of Americans go without any healthcare coverage.