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What to do if you need an expensive medical procedure, and the insurance company refuses to pay for it

Your doctor says you need expensive treatment, but your insurance company says they're not going to pay. It's unclear how often consumers experience this horrific scenario. When this happens, patient advocates say you don't always have to accept a health insurance denial of coverage. Startribune.

Photo: IStock

They recommend asking insurers and health care providers two questions: why is the service not covered? And can it be reversed?

If this gives unsatisfactory answers, there are more options, including filing a formal appeal, calling regulators, and asking employers to intervene when it comes to workplace coverage.

“I think the first step is to try informally to see if you can fix it,” said Karen Pollitz, co-director of the Patient and Consumer Advocacy Program at the Kaiser Family Foundation. “When there’s a problem, I usually pick up the phone — I wait to see how much music they can play for me while they wait — and ask if they can change their mind.”

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In July, the California Foundation released its annual report, which is one of the most visible, albeit limited, estimates of health insurance coverage denials.

Using data from 2020 health insurance plans sold on the government marketplace HealthCare.gov, the researchers estimated that insurers turned down an average of about 18% of in-network claims this year. Failure rates varied significantly across insurers, ranging from 1% to over 80%.

The Kaiser report only looked at denials of coverage sold to individuals estimated to make up less than 6% of the US population. Meanwhile, the market data covers participants in just 33 states - Minnesota is not included in this group.

“The failure rate reported for market plans seems significant to me,” Pollitz said. "We don't have any baseline comparison, like the level of employer-sponsored insurance coverage that most people have."

Why are some claims denied?

The rates, however, do not reflect whether claims will eventually be paid out, said Kristin Grow, a spokeswoman for Health Plans of America, a trade group for insurance companies. Denials can happen because health care providers didn't provide enough information, the application lacked prior authorization or referral, or a particular service is excluded from coverage, said Lucas Nesse, executive director of the Minnesota Board of Health Plans, a trade group for nonprofit insurers. state.

“Rejections typically result in delays in payments to providers and sometimes require physicians to reapply,” Nesse said in a statement.

However, there are plenty of waivers in which patients are financially responsible for huge medical bills, said Jonathon Hess, chief executive of Athos Health. Neither health care providers nor insurance companies publicly disclose these denials, Hess said, making it impossible for outsiders to know exactly how many people are left with tens of thousands of dollars of uncovered costs.

That's why Oakdale-based Cancer Legal Care, a nonprofit organization that provides free legal services to Minnesota residents with cancer, launched a program a few years ago to help cancer patients secure coverage when health plans fail.

Since 2020, the program has helped 31 patients receive about $1,8 million in coverage.

“They were turned down for all sorts of reasons, and our clients and their suppliers weren't able to get the denials overturned,” said Bill Foley, health insurance attorney at Cancer Legal Care. The non-profit group "made a commitment by hiring a pair of uniquely qualified lawyers to help design and manage the program."

Where to start if denied

Not all medical services will be covered, Foley said. But patients who look at the wording of their health plan's contract and think coverage was denied in error have the option to challenge it.

Even before filing an appeal, patients should talk to their health care providers to see if there is a way to resolve the situation, as denials may be due to billing errors that can be corrected.

Insurers have an internal and external appeals process. To prove their point, Foley said, consumers must obtain and review health plan materials that detail the details of their insurance coverage. He noted that these are detailed documents, typically over 100 pages long, rather than the few page benefit summaries that clients typically see.

“If you keep getting stuck, you need someone to protect you,” Foley said. “Your CFO calls the insurer, or your benefits manager calls the broker that signed your company with the insurer—these aren’t the first places to go, but they can get your claim reconsidered.”

What if the internal appeal fails?

After trying to file an internal appeal with an insurance company, people with fully insured health plans can file an external appeal by filing a request with the Minnesota Department of Commerce or the Minnesota Department of Health. Some employer plans are regulated by the federal government.

The state Department of Commerce has employees who help consumers determine which agency regulates their health plan and therefore should address their issue, said Julia Dreier, deputy in the department's insurance division.

Federal data suggests that relatively few people are filing formal appeals against denied claims, says Amy Monahan, an employee benefit law expert at the University of Minnesota. It's a potentially missed opportunity for people with fully insured health plans in Minnesota, Monahan said, because the state's court rules here for external appeals are more consumer-friendly than in other states.

Why coverage may vary

With fully insured plans, insurers take on the financial risk for the cost of claims. While individuals and many small and medium-sized businesses buy fully insured coverage, many employers, especially large companies with large employees, use self-insurance plans regulated by the federal government.

Increasingly, health insurance companies are adopting guidelines that specify the circumstances under which they will provide coverage for new and expensive treatments, Monahan said. This "medical need adjustment" is a growing problem for patients, she says, because they are forced to argue "about whether you fit the list, not whether it's the right treatment."

“I know there aren’t any large comprehensive sources that tell you the average percentage of denied medical applications,” Monahan said.

How insurance companies in Minnesota work

A report from the Kaiser Family Foundation says Bloomington-based Bright Health had a abandonment rate of over 18% for individual market coverage in six of the eight states it operated in during 2020. The insurance company did not respond to questions about the results.

Minnetonka-based Medica had above-average rejection rates for its individual market businesses in Kansas, Missouri and Oklahoma, Kaiser reports.

Overall, Medica said it wouldn't be surprising if Minnesota's insurer failure rate is lower than other states because health care providers here have been working with a non-profit health plan for many years. Through experience, doctors and hospitals learn Medica's billing rules and when a permit or referral is needed, the insurer said.

“In states where we develop provider relationships, we are seeing more rejections due to incorrect or incomplete billing, lack of referrals, or out-of-network services,” Medica said in a statement. – Not every failure is a clinical decision. Many, if not most, are administrative."

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HealthPartners officials said they are actively working with members and health care providers to avoid unexpected denials, which in 2021 resulted in a 3,5% denial rate for all individual market-based health plans. A subset of HealthPartners subscribers receive care at hospitals and clinics owned by a non-profit insurance company.

“Contract providers and health insurance plans work with contracts and administrative policies,” the insurance company said in a statement. – If a contract provider's application is rejected due to coding or shipping issues, the provider cannot claim full payment from their patient. Claims rejected for other reasons may be issued to the patient.”

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