Request Denied

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Happy Wednesday Healthcare Advocates

I would like to encourage comments and suggestions from you if you have time. If there is a special topic you’d like to see please let me know. Please use the comment button below. Some of the topics in work are funding for key medical research, rural healthcare, and healthcare in prison.

Health Insurance Claim Denials

If you are having claims denied - we have resources below for appealing the denials. Some states will even help you by arranging a third party review for you. If your appeal to the insurance company is rejected you may want to contact the insurance commissioner in your state. This website can get you their phone number.

Denials- Compare Traditional Medicare vs Commercial Insurance

Before we go too far I want to point out that when the government Medicare insurance trust (NOT Medicare Advantage) receives claims from private providers and they are pretty good about fair making payments.

Crowe RCA recently did a study of healthcare claims and found that Traditional Medicare (NOT Medicare Advantage) performs far better than commercial providers. A lot better. Crowe has access to data from over 200,000 physicians and 1800 hospitals and so the report is statistically significant.

Here are some examples:

Prior authorization and pre-certification denials for INPATIENT CARE: Commercial insurance vs Traditional Medicare - Commercial Insurance denies 3.2% Medicare 0.2%.

While a single-digit denial rate might seem minor, these denials for INPATIENT authorizations can trigger a major fight by providers to get paid. If and when they are paid, full payment is not always the case.

The Medicare Claim Denial rate for in and outpatient services is about 3.9% while commercial providers average 15.1% in this study.

So when you hear how much better commercial private insurance is to stand between you and your doctor - think again. You are much more likely to get needed treatment with fewer headaches when there is a government trust fund paying your private provider.

Let’s remember that many private insurance companies work hard to deny claims so they can hold the funds longer, keep them invested and make more money. They pay armies of people to support that operation and pay to have software developed to help them do more of it faster. Here are some noteworthy examples.

UNITED Healthcare - DENY DENY DENY

UMR, is a wholly owned subsidiary of United Healthcare and does their claims evaluations. In fact UMR, as a third party administrator, contracts with almost 2,140 self-funded plans to adjudicate their claims. They are the largest third-party administrator in the U.S. WOW what a profit center.

The federal government is suing United Healthcare and UMR for unlawful claims denials. Here is a link to the story. UMR did not comply with the prudent layperson standard established under the ACA which defines conditions based on symptoms and extends beyond the True ER and Sudden and Severe diagnostic lists, according to the the US Labor Department. UMR provided little information about how to appeal to the patient. They just denied all urinary drug screening claims from 2015 to 2018 whether or not they were medically necessary.

UMR only made changes to the policy in 2018 after it determined 98% of those claims from an emergency room setting were overturned on appeal, according to the suit. Beginning that year, UMR allegedly revised its policy from blanket denials of all urinary drug screening claims, to denying all claims that didn’t originate from an ER or urgent care center. So if the claim is from your doctor, not an urgent or ER setting - blanket denial.

CIGNA Software Super Denier

You may recall we reported on the Cigna PXDX software used to deny claims recently. About 18 million Americans have Cigna health insurance. Recently Cigna’s PXDX software was used to deny 300,000 claims in a 2 month period. Lightning speed, but not always accurate.

Here is an article in the Register on a new lawsuit against Cigna’s use of PXDX. California's insurance regulations state, "Every insurer shall conduct and diligently pursue a thorough, fair and objective investigation and shall not persist in seeking information not reasonably required for or material to the resolution of a claim dispute”.

The suit alleges that Cigna is not "thorough," "fair," nor "objective" because the evaluation is done by software without any investigation of the claim specifics. We will see how it plays out. But you get the picture.

If your Cigna claim is denied, you can try to resolve the issue by calling Cigna Customer Service at 1(800) 88Cigna (882-4462) before beginning the appeals process. 

If that doesn’t work you need to contact the insurance commissioner in your state. This website can get you their phone number.

State of Denial

Here is a review of in network claims denials by major commercial health insurance companies who had more than 5 million claims from the Kaiser Family Foundation. Here is the report. It isn’t pretty. The average of these denial rates for in network claims is about 17%. Most of these company’s denial rates are in double digits and one of the companies, Celtic Insurance, has a 41% denial rate for in network claims - people with whom they have contracts!!!

SUMMARY

Ok Let’s review. Commercial insurance is not necessarily on the side of the patient. They are in the business of making money. Part of that is to hold on to funds as long as possible by denying claims and refusing to authorize payment. They are doing more of it faster than ever before.

Meanwhile, Medicare, the government insurance trust, denies less than 4% of claims.

Let’s share this with our elected officials.

ACTION

Our Senators and Congressperson are not aware of what goes on in the health insurance marketplace so it is up to us to let them know. Here is their contact information.

You can use RESISTBOT by Texting to 50409 on your cellphone SIGN PXGSNB to send them this email.

I am your constituent. Commercial health insurance denies, on average 15% to 17% of claims and some insurance companies rates are up to 41%. Medicare denies 3.9%. HR 3421 or S 1655, the much improved Medicare for All Acts will be similarly administered and will have similar rates. Enact Medicare for All so we can all get the healthcare we deserve.

Find My Elected Officials

Contact the White House  https://www.whitehouse.gov/contact/

Contact State and Federal Representatives

https://www.commoncause.org/find-your-representative/addr/

Important Healthcare Resources

League of Women Voters Healthcare Reform Toolkit

Our Newsletter resources including reproductive healthcare

Healthcare Advocacy Reading List

Organizations to Contact

National Nurses United Medicare4All

Physicians for a National Health Plan

Reproductive Health

NARAL - Pro Choice America

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

Insurance Commissioner in your state- This website can get you their phone number.

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