Imagine that you need surgery to correct a serious condition. You have health insurance, so you begin the process of getting your insurer to approve the operation. It does.
A month later, as you are on the road to recovery, you get a bill for the full cost of the surgery and related expenses. When you contact your insurer to determine the next steps, you’re horrified to hear that the company has changed its mind and denied your claim, so it won’t be covering the surgery after all.
That’s not a hypothetical scenario. In 2017, the California Department of Managed Health Care (DMHC) fined Anthem Blue Cross $5 million for its systemic violations of the denial of claims grievance system. In its press release announcing the fine, the department described the case above. Despite more than 22 phone calls made to Anthem to resolve this issue by the patient, his spouse, provider, and insurance broker, the company steadfastly refused to pay. In desperation, the patient filed a grievance with the DMHC, which triggered an independent medical review. That review found Anthem at fault and forced it to reverse the denial.
While that is an especially egregious case, it is not an isolated one. My Patient Rights, an online resource launched nationwide in April by the Chronic Care Policy Alliance, a multistate network of chronic care coalitions I founded in 2017, regularly hears from frustrated consumers trying to resolve issues with their health insurers. It could be a grievance system that fails to effectively and efficiently assist consumers — even though insurers are required by law to help consumers resolve issues in a timely manner — or other obstacles to care like step therapy.
Step therapy, sometimes called “fail first,” lets insurers undermine doctors and force patients to try and fail on one or more medications before the plan will cover the cost of the originally prescribed medication. Like a faulty grievance system, I call step therapy and similar practices like prior authorization health plan barriers because they can prevent access to the quality, affordable care patients expect to receive.
Fortunately, there are policymakers focused on ensuring patients are able to access the care they need. Earlier this month, U.S. Reps. Raul Ruiz (D-Calif.) and Brad Wenstrup (R-Ohio) introduced federal legislation called the Safe Step Act to ensure that doctors have the ability to appeal step therapy requirements. It mirrors legislation that more than 20 states have enacted.
While legislation is critical in preventing health plan barriers, consumers also play a role. By knowing their rights, appealing denials, and fighting back, patients can stand up for themselves. But first they need to know that is an option.
A recent Kaiser Family Foundation report looked at data on claim denials and appeals from the Centers for Medicare and Medicaid Services. Among other findings, the report showed that consumers rarely appeal claims that have been denied. In 2017, 121 major health insurance issuers denied a total of more than 42 million claims. Consumers appealed less than 200,000 (0.05%) of these denials. Although consumers have the right to bypass their insurer’s internal appeals process and go directly to an external review, this happens in fewer than 1 in 11,000 denied claims (0.009%).
Not appealing is a lost opportunity. A recent report by the California Chronic Care Coalition, “Standing Up For Your Rights Creates Results,” showed that the California Department of Managed Health Care reversed or overturned 61% of health plan decisions in 2017. This finding shows that consumers can get coverage for the care they need after appealing.
No one should take their health plan’s denial as arbitrary and final, especially now. Just last month, UnitedHealth Group lost a class-action suit filed by 50,000 patients because one of its arms, United Behavioral Health, denied coverage for mental and behavioral health issues.
Everyone should be equipped with the tools necessary to stand up for their rights. My Patient Rights is a place where consumers can find those tools and learn how to use them. At the end of the day, people whose health insurance claims have been denied must know they have options and are not alone.
Liz Helms is president and CEO of the California Chronic Care Coalition, founder of the Chronic Care Policy Alliance, and author of “Health Care Unhinged: The Making of an Advocate“ (Page Publishing, 2016).
I’m a “ snowbird from mi. Wintering in az. My surgeon in mi wants me to get stints in my legs for blockage but BCBSM of mi denied me and all doctors in both states say I need it now but some nurse at BCBSM denies it so there telling me it’s ok to die of blood clots what should I do?
I have a problem getting Bluecross Blueshield to pay for a surgery that was preauthorized and approved by them. In the Eob they claim It was not covered.
Good evening Ms.Helms,
I recently had surgery and had been experiencing severe abdominal pain. I contacted my surgeon who in turn set me up for blood work and a CT scan. My Insurance Anthem Blue Cross denied coverage and I had to pay nearly $1,000 out of my pocket. They said I didn’t meet the criteria for coverage and that I only complained of nausea and not pain. This is false. I am retired and on a fixed income.
I appreciate any advice you can provide. Coincidentally, Anthem Blue Cross was just fined close to 10 million dollars for they way they handle grievances and complaints.
Respectfully,
John
A legal system should be in place that – on presentation of printed proof of prior approval – instantly denies and stiffly fines Insurance Companies that attempt to reverse decisions or approvals. Their actions are what in other industries is called a broken contract, deceipt and theft, and these actions should be judged and punished accordingly. Preferably with an automatic compensation to the patient for the hassle incurred to seek compliance to the original agreement = approval. One should not need to go broke on this, it should be quick & swift & standard compliance enforcement.
Hi Mary, thank you for your comment! I absolutely agree that patients are suffering from the way the system currently operates, which is why the California Chronic Care Coalition and Chronic Care Policy Alliance helped create My Patient Rights. Many users of mypatientrights.org find the “File a Complaint” tab particularly useful, and it leads them to the resources they need to get the care they deserve.
It’s good that many denials of benefits are overturned, but good Lord the stress! Stress is a major contributor to ill health so making patients have to go through this at all is just adding to the cost of health care. Not to mention that it is sometimes near impossible to have the time and energy to fight such denials in the midst of a serious injury, or chronic or terminal illness. What is the point of paying exorbitant admin costs for billers and coders only to still be stuck with the bill? What is the point of paying insurance premiums if you’re the one who, in the midst of trying to recover, also has to do all the leg work to get your damn bills paid?
Hi Amy, I agree! My Patient Rights aims to help alleviate some of the stress that typically accompanies filing a complaint. We try to make it easy for patients to find all the resources they need so that they can learn how to best advocate for themselves.
We also need a grievance system and policy changes for Medicare, as supplemental plans pay only if Medicare does. Some of its dated rules are hazards to health.
Hi Laura, My Patient Rights was established to help patients with all types of insurance file grievances with their insurer, including those with Medicare. Our recent national expansion of My Patient Rights also ensures that patients in all 50 states can access this resource and get the help they need!
The process of appeal requires a white privileged set of skills and nerves of steel that no human I know has. When goes through it, the stress factor in and of itself probably takes a year off of one’s life.
So true! And you cannot work full time and pursue a medical appeal. They have a million techniques to grind you down. You can spend four hours holding on the phone and then being told to call back the following day, that the office is now closed. Unicorn hunting would be a far more rewarding pursuit.
Indeed!
Hi Mary, the process of appealing can indeed be incredibly frustrating. The good news is many people who do appeal can get the justice they deserve! My Patient Rights wants to encourage patients to appeal because of this success rate, and helps consumers know they are not alone in challenging the healthcare system. If you have a story of your own you would like to share, I encourage you to visit http://www.mypatientrights.org/share-your-story/. We would love to hear your story!