LOUISVILLE, Ky. (WAVE) – Have you ever had a medical test or surgery ordered by your doctor but denied by your health insurance company? I have – several times.
“After reviewing the information available to us, we have decided that we cannot approve this request,” one of my letters read. “We have determined that the requested service is not medically necessary in your case.”
You know the language if you've ever received one of these. The same thing happened to Frank Beifuss and his wife, who were diagnosed with a rare genetic disease.
“It was unfathomable to me how much we had to fight the insurance company to get her coverage,” Beifuss said. “And many of those battles we lost. Usually, a losing battle meant she didn't get the care she needed.
It was so infuriating that he began researching, and what he learned prompted him to write an article titled “Illusory Remedies: Why Lack of Oversight and Penalties Leave Half the Country with Only a Shadow of Health Care.” It was peer reviewed and published recently in the University of Louisville Law Review.
He specifically looked at employer-sponsored health care plans that cover over 50% of the US population. The first thing he certainly thought could be checked was how often claims were denied.
“What I was able to find is that it's really already known how many claims are denied and how often they're denied,” Beifuss said. “The simple answer is that everyone thinks someone else is doing it, and basically no one is authorized to do it.”
that's right “No entity tracks the prevalence of health plan claim denials,” he wrote. “The lack of monitoring makes the prevalence of wrongful claim denials impossible to know.”
The Centers for Medicare and Medicaid Services is the only entity that tracks claims, and it found that more than 18 percent of network claims are denied.
“If you look at the Medicare/Medicaid data on denials, less than 1 percent of those claims are appealed,” Beifuss said. “Yet you refuse. And usually about 70% of those appealed are approved. It just creates obstacles. They know they are getting so many free blocks. There is no reason not to put up roadblocks. They can deny people access to care, and a lot of people will go “well, I guess I didn't get it.” This care is not for me.'
How many blockades? In most states, you can appeal internally twice. Each can take months to process. Then he said you can file an external appeal handled by a company hired by the insurer.
“If you go through all these steps, then you can say you're wrong and I'll take you to court,” Beifuss said. “But there are very few lawyers who will take on such cases.”
“So you're just out of luck?” I asked.
“Mostly unlucky, yeah,” he said.
Your health can deteriorate while you wait, and even if you eventually prevail and then try to sue, he found, you'll “almost certainly recover zero dollars beyond the cost of the care initially denied.”
“The insurers of these group health plans are immune from all kinds of different damages, the penalties, essentially, for bad behavior,” Beifuss said.
“Covered by the certainty of law and precedent,” he found, “insurers can avoid covering claims because the penalties for breaching their obligations are much cheaper than enforcing them.”
“The only punishment for stealing in these cases is sometimes you have to give back what you stole,” Beifuss said.
Beifuss said even the doctors that insurers hire to determine whether a claim is medically necessary have malpractice immunity.
“Your doctor meets with you and says, John, I think after meeting you, taking your vitals, knowing you for years, I think you need this,” Beifuss said. “If that doctor makes critical mistakes or fails to meet their standard of care, they are subject to medical malpractice liability. This can be quite severe. Conversely, the doctors who handle your insurance claims are not held to the same standard. They don't have to meet that standard.
And it gets worse for health care consumers. Beifuss found, “After decades of litigation and legislation, insurers' position has mostly improved.”
“The Supreme Court of the United States” has “protected the interests of insurers, usually in near-unanimous decisions.”
Beifuss eventually prevailed in his wife's health care denials after years of learning how to write what he calls “sophisticated appeals.”
“Most people don't understand when it comes to health care,” Beifuss said. “There is a huge network that comes for them. What it ends up doing is it puts normal, everyday people in a position where they can't get health care, and it puts doctors in the position of essentially being their own insurance law firm, and that's a weird place for us to be. “
So what should we do about it?
“Appeal, appeal, appeal,” he said. “Make yourself a squeaky wheel.”
Read Beifuss' full article on the subject:
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