Appeals against underutilized medical insurance denials, lawyer says
Patients whose medical claims are denied by insurers have the right to appeal the decision. However, despite a cleanup of rules by the Affordable Care Act (ACA) aimed at making appeals easier, a decade in only about 0.2% of denials are disputed by consumers.
It’s particularly unfortunate, advocates say, because around 50% of calls are successful, so patients miss out.
“The appeals process is an underused tool,” said Monica Fawzy Bryant, JD, an attorney with patient support organization Triage Cancer. Medscape Medical News. “Most people don’t realize they have this right.”
“One of the challenges,” said Fawzy Bryant, “is that science moves much faster than the law…so science, particularly in the area of precision medicine, has moved so fast that policies are lagging behind.”
She said the most common route to winning the appeal is for the healthcare team to provide evidence of “medical necessity”.
The Affordable Care Act required all health insurance plans that came into effect after March 23, 2010 to meet a series of new requirements for their internal and external appeals processes. The aim of the new rules, the drafters of the legislation said, was “a more uniform, rigorous and consumer-friendly complaints and appeals system”.
The new rules hinted at a previous environment of intimidation and delaying tactics by insurers, which could be off-putting to any patient considering an appeal.
Among the new rules the ACA put in place, for example, were continued coverage while an internal call was in progress and allowing only one internal call before a patient could file a complaint. before an external arbitrator.
Some insight into the success of the appeals process comes from numbers gathered in a 2020 analysis by the Kaiser Family Foundation (unrelated to Kaiser Healthcare).
They show that in 2019, 122 major medical insurers together rejected 17% of claims in the network, representing more than 40 million claims denied. Of these, consumers appealed to less than 64,000 (0.2%). However, on internal appeal, 40% of decisions were reversed (range:
If a patient has an equal chance of winning the appeal, why aren’t more patients benefiting from the cleaning process?
Lawyer Fawzy Bryant said: “The law is actually relatively simple in terms of what is required in the appeal process; the complexity comes in demonstrating medical necessity…and that has to be done by the care of health [teams].”
She said other approaches could also work. Sometimes a plea that there is a financial benefit to the insurer because the patient doesn’t have to try “a bunch of other treatments as well” is successful.
However, all calls rely on a concerted and well-organized effort by the patient’s care team.
“And that’s actually one of the complaints that medical professionals keep coming back to us,” Fawzy Bryant said. Mounting an appeal and gathering all the necessary documents, she noted, takes a lot of time.
Healthcare professionals are “incredibly overworked, inundated with everything they have to do. So it’s an added burden not just for patients, but certainly for healthcare providers as well.”
Healthcare software company Change Healthcare estimated that US hospitals spent $8.6 billion in administrative costs to appeal denied claims.
What about biomarker testing coverage for cancer treatment?
Fawzy Bryant said she hasn’t seen any data relating specifically to insurance denials for biomarker testing.
His hope is that data on calls for biomarker testing would “prompt more insurance companies to start covering these types of tests in their policies.”
One state is already taking direct action for biomarker testing, rather than relying on the power of appeals. California passed a bill last October that prohibits pre-authorization of biomarker testing in patients with advanced cancer, which goes into effect next July 1.
Fawzy Bryant is employed by Triage Cancer, which receives funding from Astellas, Pfizer, Pharmacyclics and Janssen.
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