Fight back when your health plan says No
Bernadine Healy, MD, former director of NIH and now health editor at US News & World Report, has written a chilling piece on how easy it is for insurers to deny claims. From the article, “How Crafty Health Insurers Are Denying Care“:
An estimated 10 to 15 percent of [health insurance] claims are denied for various reasons, some of them technical, such as not meeting filing deadlines or failing to get pretreatment authorizations. Denials that produce the most disputes are those where insurers judge the care to be unnecessary or unproven, pitting a proverbial sick David against a multibillion-dollar Goliath. What few Davids know is that insurance contracts by law grant companies the legal right to manage a patient’s care, including denying it, sight unseen, and give them the final say, if challenged. Unless the state steps in.
She notes that insurance companies use software that even they call “denial engines,” that reviews every claim in the hopes of turning it down, a practice that Dr. Healy calls “serving up excuses to deny legitimate coverage.” What’s a consumer to do?
Dr. Healy points out that in 43 states and the District of Columbia, you can file an appeal for a state review if you are denied coverage and have gone through the insurer’s opaque internal review process. The good news is that if you can stand the red tape, about half of the time the consumer wins her appeal. And what the state says is the final word.
It’s still troubling that insurers are doing such a poor job of adhering to the law that they are losing half the appeals brought to the state, and that consumers in seven states have no state-based recourse.
As always, reading your policy carefully is the first step in ensuring you get the coverage you’re entitled to.
If you still have concerns that you are being denied a policy or denied coverage without a good reason, our Consumer Guides to Getting and Keeping Health Insurance, for every state, can get you on the path to finding out what your state requires, and how to contact the appropriate authorities.
September 3rd, 2008 at 10:50 am
Call Karen Davis, head of the Commonwealth Fund for funding ideas. She is dedicated to such causes and knows the field/players, has contacts like no one else. NORD, the National Organization for Rare Diseases and medical foundations would probably either help with some minor funding or more likely place a paid order allowing a printing for their members. Try U.S. Chamber of Commerce & large educational/social foundations.
What an outstanding project, my health planning and policy program was good, much reading Paul Starr, needs analysis, etc but this project is actully useful, can help many though system broken.