How to fight if your health plan refuses to cover

Your doctor says you need expensive treatment, but your health insurance company says they won’t pay.

It is not clear how often consumers encounter this frightening scenario. When that happens, patient advocates say you shouldn’t always accept a denial of health plan coverage as the last word.

They recommend asking insurance companies and health care providers two questions: Why isn’t the service covered? Can the decision be reversed?

If this yields unsatisfactory answers, there are more options, including filing a formal appeal, contacting regulators, and asking employers to step in if it comes to job-based coverage.

“I think the first step is trying to see if you can fix it, informally,” said Karen Politz, associate director of the Patient and Consumer Protection Program at the Kaiser Family Foundation. “Whenever an issue arises, I usually pick up the phone – hold on whatever music they can play for me – and ask if they can reconsider.”

In July, the California-based foundation published a file Annual Report This is one of the more prominent – albeit limited – assessments of being denied coverage in health insurance.

Use of 2020 data from health plans sold to the federal government HealthCare.gov In the market, researchers calculated that insurers denied on average about 18% of claims within the network that year. Rejection rates varied widely across insurance companies, from 1% to above 80%.

The Kaiser report only looked at denials of coverage sold to individuals, estimated at less than 6% of the US population. Meanwhile, the federal market data covers enrollees only in 33 states — a group that doesn’t include Minnesota.

“The reported rejection rate of market plans appears to me to be high,” Politz said. “We don’t have any kind of basic comparison, like [the] The rate is in employer-sponsored coverage, which most people enjoy.”

Why are some claims denied?

Kristen Gro, a spokeswoman for American Health Insurance Plans, a trade group for health insurers, said the rates, however, do not reflect whether claims will end up paying. said Lucas Nessi, CEO of the Minnesota Board of Health Plans, a trade group for state nonprofit insurance companies.

“Denials typically delay payments to providers and sometimes require clinicians to resubmit claims,” ​​Nessi said in a statement.

However, there is a subset of rejections in which patients are financially responsible for huge medical bills, said Jonathon Hess, CEO of Athos Health. Hess said that neither health care providers nor insurance companies provide public information about these denials, making it impossible for outsiders to know exactly how many people are left facing tens of thousands of dollars in undisclosed costs.

That’s why Cancer Legal Care, an Oakdale-based nonprofit that provides free legal services to residents of Minnesota with cancer, launched a program a few years ago to help oncology patients look out for relapses when health plans refuse coverage.

Since 2020, the program has helped 31 patients obtain $1.8 million in coverage of care.

“Their refusals were for a variety of reasons, and our clients and their service providers were unsuccessful in getting the denials cleared,” said Bill Foley, a health insurance attorney with Cancer Legal Care. The nonprofit group “committed to this by appointing two uniquely qualified attorneys to assist in the development and management of the program.”

Where to start if denied

Foley said not all medical services will be covered. But patients who review their health plan contract language and believe coverage was denied in error have options to challenge it.

Even before appealing, patients should talk to their health plan and health care providers to see if there is a way to resolve the situation, because the refusal can stem from repairable billing errors.

Insurance companies have internal and then external appeal procedures. To prove their case, consumers must obtain and review health plan materials that detail their coverage, Foley said. He noted that these are detailed documents that routinely exceed 100 pages in length, not the benefits summaries of just a few pages that entrants typically see.

“If you keep getting stuck in a dead end, you need someone who can defend you,” Foley said. “Your CFO places a call with the insurance company, or your benefits manager, and makes a phone call to the broker who signed your business with the insurance company—these are not the first places to go, but they may be able to have your claim reviewed by a higher plan executive. health”.

What if the internal appeal fails?

After attempting an internal appeal with an insurance company, people with fully insured health plans can request an external appeal by Apply To the Minnesota Department of Commerce or Submit it to Minnesota Department of Health. Some employer plans are regulated by the federal government.

Julia Dreyer, deputy commissioner of the department’s insurance division, said the state’s Commerce Department has staff to help consumers determine which agency regulates their health plan, and therefore should address their concerns.

Federal data indicates that relatively few people attempt formal appeals in response to denied claims, says Amy Monahan, an expert in employee benefit law at the University of Minnesota. This would likely be a missed opportunity for people with fully insured health plans in Minnesota, Monahan said, because state court rules here for external appeals are more convenient for consumers than in other states.

Why coverage may vary

With fully insured plans, insurers bear the financial risk of the cost of claims. While individuals as well as many small and medium-sized businesses purchase fully insured coverage, many employers—particularly large multistate corporations—run self-insurance plans regulated by the federal government.

Monahan said health insurance companies are increasingly adopting guidance documents that specify the circumstances in which they will provide coverage for emerging and costly treatments. She said the “medical necessity judgment” is a growing problem for patients because they are forced to argue “about whether you meet the list, not about whether this is an appropriate medical treatment.”

“You really want to make sure you see that document…because it will tell you the basis on which the insurance company is evaluating your claim,” Monahan said. “There aren’t any great comprehensive sources that I know of that tell you, on average, the percentage of medical claims denied,” she added.

How insurance companies stack up in Minnesota

The Kaiser Family Foundation report found that Bloomington-based Bright Health had denial rates of more than 18% over individual market coverage in six of the eight states in which it operated during 2020. The insurer did not respond to questions about the findings.

Kaiser reports that Mintonka-based Medica has above-average denials for its single-market business in Kansas, Missouri and Oklahoma.

Using the foundation’s methodology, Star Tribune looked at Minnesota carriers’ regulatory filings in the individual market and found that they were least likely to have claims denied in 2020. The lowest rate was 6.4% at Bloomington-based HealthPartners, according to the Star Tribune review, while the highest was 15.5% in Medica.

Insurers said they could not verify Star Tribune accounts.

Overall, Medica said, it wouldn’t be surprising if the insurance company’s refusal rate was lower in Minnesota than in other states because health care providers here have worked with the nonprofit health plan for many years. With experience, doctors and hospitals learn Medica’s rules for billing, the insurance company says, and when an authorization or referral is required.

“In states where we’re developing relationships with providers, we’re seeing more rejections of incorrect or incomplete billing, missing referrals, or out-of-network services,” Medica said in a statement. “Not every refusal is a medical decision. Many, if not most, are administrative.”

At HealthPartners, officials said they are working proactively with members and health care providers to avoid unexpected denial, which in 2021 resulted in a 3.5% claims rejection rate for all individual health plans to market. Many HealthPartners subscribers receive care from hospitals and clinics owned by the nonprofit insurance company.

“Contracted service providers and health plans operate according to contracts and management policies,” the insurance company said in a statement. “If a contracted provider’s claim is denied due to coding or rendering problems, the provider will not be able to request full reimbursement from its patient. Claims denied for other reasons can be sent to the patient.”

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