Screenshot of March 25 ProPublica article, “How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them”, captured on Sept. 26, 2023.
Mary Chris Jaklevic, AHCJ’s well being beat chief for affected person security, contributed to this text.
Previously yr, journalists and well being researchers have uncovered troubling details about how well being insurers fail members by delaying or denying care by way of prior authorization. Additionally referred to as prior approval, this course of is a cost-cutting software that well being insurers use to require sufferers or docs to get an okay earlier than agreeing to pay for assessments, procedures and prescribed drugs, as Lauren Sausser reported for KFF Health News in August.
Amongst many vital issues with prior approval, the largest could also be that each sufferers and docs should wait whereas insurers overview the requests, which might take days, weeks or months, in keeping with the American Medical Association. It can lead to denials, delays and requests for a distinct check, process or drug. Delaying care exacerbates sicknesses and might even result in dying, the Association said in a March report.
Reporting about prior authorization is essential as a result of:
- It reveals how well being insurers usually put revenue over affected person care and the way having medical insurance doesn’t assure protection.
- Exact numbers and the frequency of well being insurers’ denied claims are intently held secrets and techniques, as ProPublica’s Robin Fields reported in June.
- Well being insurers deny an estimated 10% to twenty% of all claims obtained, Fields famous, including that such percentages obscure how denial charges can differ from one plan to a different or throughout totally different medical companies. supply of knowledge comes from KFF, which revealed “Claims Denials and Appeals in ACA Marketplace Plans in 2021” on Febuary 9, 2023.
- When well being insurers deny claims, the appeals course of is so onerous and sophisticated that few sufferers accomplish that, Cheryl Clark reported for ProPublica final month. KFF’s February report confirmed that buyers enrolled in plans underneath the Inexpensive Care Act appealed lower than two-tenths of 1% of denied in-network claims in 2021, and insurers upheld most (59%) denials on attraction.
Insured customers left uncovered
Since August 2022, two investigative information organizations, ProPublica and The Capitol Forum, have collaborated to report on insurers’ denial charges in a sequence titled “Uncovered: How the insurance industry denies coverage to patients.” On August 18, 2022, ProPublica’s David Armstrong and Maya Miller and The Capitol Forum’s Patrick Rucker defined on this article, “Do You Have Insights Into Health Insurance Denials? Help Us Report on the System,” that having medical insurance doesn’t assure protection for care. Additionally, they famous, when sufferers push again, they face vital obstacles. “Difficult the insurance coverage firm can require submitting an attraction with the insurer, requesting an impartial medical overview and even submitting a lawsuit,” they wrote.
In a single story, “UnitedHealthcare Tried to Deny Coverage to a Chronically Ill Patient. He Fought Back, Exposing the Insurer’s Inner Workings,” Armstrong, Miller and Rucker detailed how UnitedHealthcare, the nation’s largest well being insurer, flagged costly claims for elevated scrutiny. The affected person, Christopher McNaughton, had ulcerative colitis that triggered extreme arthritis, debilitating diarrhea, numbing fatigue and life-threatening blood clots, they reported. His medical payments had been totaling virtually $2 million yearly and UnitedHealthcare determined it will not pay for what it decided had been pricey medicine. His battle to get protection uncovered the insurer’s hidden procedures for rejecting such pricey claims.
In another article, Armstrong, Miller and Rucker reported that over two months final yr, the well being insurer Cigna denied greater than 300,000 requests for fee utilizing a system referred to as PXDX. With PXDX, Cigna’s doctor reviewers spent a mean of 1.2 seconds on every case, permitting them to reject claims immediately on medical grounds with out opening every affected person’s recordsdata and leaving Cigna members with sudden payments, ProPublica reported.
To keep away from unfair denials, insurance coverage legal guidelines and rules in lots of states require well being insurers’ medical administrators to look at affected person information and overview protection insurance policies earlier than denying claims, regulators informed ProPublica. In response, Cigna mentioned the reporting was biased and incomplete.
In her article, Sausser famous {that a} retired doctor in Kentucky mentioned well being insurers acquire premiums after which don’t pay claims, including, “That’s how they earn money.” Beforehand, the retired doctor labored as a medical claims reviewer for Humana and later turned a whistleblower who testified earlier than a Congressional subcommittee in 2009.
Sausser additionally quoted Brad D. Fixed, M.D., a gastroenterologist and assistant professor at Colorado Youngsters’s Hospital, whose research showed prior authorization can improve the probabilities that youngsters with inflammatory bowel illness will want hospitalization.
In a survey of its members, the American Medical Affiliation confirmed that prior authorization denials exacerbate sufferers’ circumstances. One third of the 1,001 doctor respondents mentioned prior authorization led to critical opposed occasions for sufferers; 25% mentioned it led to a affected person’s hospitalization; 19% mentioned it led to a life-threatening occasion or required intervention to forestall everlasting injury; and 9% mentioned it led to a affected person’s incapacity or everlasting bodily injury, congenital anomaly or start defect or dying.
Scarce information on prior authorization denials
To estimate the frequency of denials, ProPublica’s Fields reported that well being insurers reject about 10% to twenty% of all claims obtained, including that such percentages shed no gentle on how denials differ from one plan to a different or throughout totally different medical companies.
“There’s nowhere {that a} shopper or an employer can go to search for all insurers’ denial charges — not to mention whether or not a specific firm is prone to decline to pay for procedures or medicine that its plans seem to cowl,” she wrote. “The dearth of transparency is very galling as a result of state and federal regulators have the facility to repair it, however haven’t.”
Citing KFF’s February report, Fields famous that just about 17% of in-network claims had been denied in 2021 however that insurers’ denial charges diverse broadly and ranged from 2% to 49%. Amongst in-network claims, KFF reported that about 14% had been denied as a result of the declare was for an excluded service, 8% had been as a result of lack of preauthorization or referral, and about 2% had been primarily based on medical necessity.
And customers enrolled in these plans appealed lower than two-tenths of 1% of denied in-network claims, and insurers upheld most (59%) denials on attraction, the KFF report confirmed.
Utilizing information from the federal Facilities for Medicare and Medicaid Providers, KFF researchers analyzed well being insurers’ claims denials and appeals for non-group certified well being plans supplied on HealthCare.gov throughout 2021. On this desk, KFF confirmed denial charges for insurers that acquired greater than 5 million in-network claims that yr. Supply: “Claims Denials and Appeals in ACA Marketplace Plans in 2021”, KFF, Feb. 9, 2023, accessed Sept. 13, 2023. Reprinted with permission.
The complicated and onerous appeals course of
Some of the irritating features of denials is the appeals course of, as Cheryl Clark confirmed in her article, “I Set Out to Create a Simple Map for How to Appeal Your Insurance Denial. Instead, I Found a Mind-Boggling Labyrinth.” Each insurers and regulators have made submitting an attraction so difficult that solely a tiny proportion of sufferers ever accomplish that, she famous.
“The central drawback: There are lots of sorts of insurance coverage within the U.S., and so they have totally different processes for interesting a denial,” she wrote. “And no lawmakers or regulators in state and federal governments have compelled all insurers to comply with one easy normal.”
