Medicaid & Debt Ceiling DON'T MIX

& CLAIM DENIED - What to do. April 4, 2023

Apr 04, 2023

Good Morning Healthcare Advocates

I’m very thankful for your advocacy for healthcare reform. Let me take a moment to point out some resources for you. At the bottom of every newsletter are links to additional sources. The first is a link to the League of Women Voters Healthcare Reform Toolkit. It is a rich source of material on healthcare reform, especially single payer.

The second link is our collection or resources. As we find new important sources I save them there for you. There are links to lists of healthcare reform groups, reproductive health sources (where to get medication, for instance), US government and other healthcare data sources and more.

If there are sites that you think are useful, please send them to me in the comments (which we all can see) and I will include them in our resource list.

News

You may remember that we expanded Medicaid so that more people would have coverage in the face of the COVID-19 pandemic. That coverage and automatic renewals into the Medicaid systems came to an end at the end of March, 2023. People now have to enroll and be requalified. Since many states did not expand Medicaid coverage to 138% of the Federal poverty level millions are expected to drop off the rolls. The government is offering subsidies to ACA plans for many of those who do not qualify at about $10/person/month but if you are a poor family of 4 that’s still $480.

The Federal Government is discussing approving a new debt ceiling and Republicans have said they want to cut spending. They have been reviewing cutting Medicaid costs in exchange for approving the debt ceiling. This is just nefarious.

They are threatening the healthcare of the poor and their lives in exchange for paying bills they have already agreed to pay.

TAKE ACTION

RESISTBOT Text SIGN PTQKYC to 50409 to tell your Federal Officials

I do not want any negotiations to cut Medicaid spending in exchange for raising the debt ceiling. It is just cruel to cut people’s healthcare in exchange for paying bills we have already agreed to pay. It is really important for me that you DO NOT jeopardize American’s health and lives for political advantage. You were sent to Washington to work for us NOT HURT US. Please take care of it. Millions are counting on you.

Claim Denied

Last week we discussed how Cigna was using a software package to approve and deny claims, as many as 300,000 denials in two months. Remember that they make money when they deny the claim. The part that was most offensive to me was their representative saying that they were not denying service, just the payment. You could pay for it yourself.

Regarding ACA plans, according to a recent Kaiser Family Foundation report (February 2023), the average across insurers reporting to CMS was 17% of all claims are denied for in network service. The lowest rate was 2% and the highest was 49%. WOW.

Quoting from KFF “CMS requires insurers to report the reasons for claims denials at the plan level. Of in-network claims, about 14% were denied because the claim was for an excluded service, 8% due to lack of preauthorization or referral, and only about 2% based on medical necessity. Most plan-reported denials (77%) were classified as ‘all other reasons. In 2021, HealthCare.gov consumers appealed less than two-tenths of 1% of denied in-network claims.” Almost all denials were not appealed.

But when people did appeal the decisions were overturned more than 40% of the time.

LESSON - Appeal the denial.

There are a number of actions to take depending on the situation in which you find yourself.

Most policies have to follow ACA guidelines and here is Federal government advice regarding appealing a denied claim.

If your health insurer refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party.

You can ask that your insurance company reconsider its decision. Insurers have to tell you why they’ve denied your claim or ended your coverage. And they must let you know how you can dispute their decisions.

There are two ways to appeal a health plan decision:

Internal appeal: If your claim is denied or your health insurance coverage canceled, you have the right to an internal appeal. You may ask your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must speed up this process.
External review: You have the right to take your appeal to an independent third party for review. This is called external review. External review means that the insurance company no longer gets the final say over whether to pay a claim.

Your state may be able to help

Your state may have a Consumer Assistance Program that can help you file an appeal or request a review of your health insurance company’s decision if you are not sure what steps to take.
If you have questions about internal appeals and external reviews, call your health plan or state insurance regulator .

I decided to check my state, Washington, and found that there is a law, RCW 48.30.015, titled Unreasonable denial of a claim for coverage or payment of benefits. Residents in Washington can sue the insurer and recover attorney fees and damages. The state’s website has details on how to proceed. Still, that’s a lot of work.

I am working on covering two related stories to appear shortly.

One has to do with unreasonable bills (especially from hospitals) - A resource link is be below and in our reading list.

The other addresses what insurance companies choose to cover as medically necessary. It varies quite a bit depending on the type of policy and where you live and can make the difference between life and death. Wendell Potter, who was a Cigna executive and is now an outstanding lobbyist for healthcare reform, experienced this. Here is his substack newsletter and his Wikipedia page so you can read about the tragedy that turned his life around.