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.
October 21st, 2008 at 7:42 pm
I have M.A.C. a rare Lung disease and was miss diagnosis in 1995 as TB and after treatment complication and emergency life saving experience at UCLA Hospital in 2004 was it found to be M.A.C. I was told the disease was to for gone and unoperable and for me to inform my family to make burial preparation but instead they found the National Jewish Research Center on the internet and they removed the whole Lung and now I am still alive but only 58 years of age and need special medication to fight the disease. My husband is disable and on SSI I don’t gualify because of my age and his income I need help with my $810 health insurance I live in Los Angeles
March 7th, 2009 at 2:25 pm
Recently my daughter who is 25 and working full time and going to school has come down with what we believe is ms, not fully diagnosed yet. Her employer is getting health insurance, but has not received it yet. When she signed the paper work she was not having these symptoms. We are paying out of pocket right now to get a diagnosis but no one will help us. No one wants to touch us because she does not have an insurance card and she is suffering greatly. I am scared we will be spending are retirement years and money trying to get her help. We are not rich. We are not sure what will happen with insurance, they could totally deny us because of pre-existing condition. This means we will lose everything.
May 16th, 2009 at 1:22 am
This is becoming more and more of an epidemic that frankly I think is sickening. Perhaps we should get those running the show and introduce them to the system at the level they are creating.
-Andrew
August 10th, 2009 at 7:25 am
Your post motivates me to get maximum coverage for the amount I am paying for my health insurance. Health care costs are alarmingly increasing and I am not sure of what will be left for me when I retire