A
recent article by ProPublica health care reporter Cheryl Clark exposes the extreme complexity consumers face when trying to appeal health insurance denials. Clark explains how she attempted to create a simple chart for consumers to guide them on how to appeal a health insurance denial. What she found she described as a “mind-boggling labyrinth” that is so complicated only a small percentage of patients ever appeal.
In detailing her research, Clark indicates the complexity starts with simply knowing what plan you have. While a consumer might know they have insurance through a particular company, the type of plan often dictates the appeals process. Whether the insurance product is through Medicare, Medicaid or the commercial market also makes a difference.
Clark explains how health care providers often try to take the burden off their patients. Health care providers spend huge sums of money on staff resources just to request prior authorizations and deal with claims denials. The doctors she interviewed noted that insurers often use delay tactics, such as saying they haven’t received records that the providers know they have sent multiple times.
Clark writes that she spoke with over 50 health care experts, including doctors, attorneys and patient advocates, in her quest to develop a simple tool to navigate insurance appeals. “Nearly everyone said the same thing: Great idea. But almost impossible to do.”
This story echoes a similar sentiment WHA members recently heard from Wisconsin’s Office of the Insurance Commissioner (OCI). When Commissioner Houdek and Deputy Commissioner Cissne Carabell met with the WHA Board of Directors in
August, they noted that their primary mechanism for learning about and investigating insurer concerns is through the grievance process. The top driver for complaints in the group and individual market, they said, is claim denial.
WHA is continuing to urge policymakers at the state and federal levels to hold insurers accountable for these improper denials and to pursue reforms that ease provider and patient burden by streamlining the prior authorization process.