LOUISVILLE, Ky. (WAVE) – Have you ever needed a medical test or surgery ordered by your doctor, but your health insurance company kept denying it? I have—multiple times.
“After reviewing the information we have, we determined we cannot approve this request,” one of my letters read. “We found the service requested is not medically necessary in your case.”
You know the language if you’ve ever received one of those. The same thing happened to Frank Beifuss and his wife, who was diagnosed with a rare genetic disease.
”To me, it was inexplicable how much we’d have to fight with the insurance company to get her coverage,” Beifuss said. “And a lot of these fights we lost. Typically, a lost fight meant she didn’t get the care she needed.”
It was so maddening he started researching and what he learned prompted him to write a paper titled “Illusory Remedies: Why Lacking Oversight and Penalties Leave Half the Country with only a Shadow of Healthcare.” It was peer-reviewed and published recently in the University of Louisville Law Review.
He specifically looked at employer-sponsored healthcare plans, which cover over 50% of the US population. The first thing he certainly thought would be verifiable is how often claims are denied.
”What I was able to find is it’s really now known how many claims are denied and how often claims are denied,” Beifuss said. “The simple answer is everybody thinks someone else is doing it, and no one is empowered to do it, essentially.”
That’s right. “No entity tracks the prevalence of health plan claims denial,” he wrote. “The lack of monitoring makes the prevalence of wrongful claim denial impossible to know.”
The Centers for Medicare and Medicaid Services is the only entity that tracks claims, and he found it denied over 18% of in-network claims.
”If you look at the Medicare/Medicaid data on denials, less than 1% of those claims are appealed,” Beifuss said. “The denials anyway. And about 70% of the ones appealed are usually approved. It’s just throwing up roadblocks. They know they get so many free roadblocks. There’s no reason not to throw up roadblocks. They can deny people from getting care and a lot of people are going to go ‘well I guess I didn’t get that. That care’s not for me.’”
How many roadblocks? In most states, you can appeal internally twice. Each one can take months to process. Then he said you can make an external appeal handled by a company that the insurer hires.
”If you go through all these steps, then you can say you are wrong, and I’m going to take you to court,” Beifuss said. “But there’s very few attorneys who will take these kinds of cases.”
“So you’re just out of luck?” I asked.
“You’re mostly out of luck, yeah,” he said.
Your health can worsen during the wait and even if you ultimately prevail, and you then try to sue, he found you would “recover, with near certainty, zero dollars outside the cost of the originally denied care.”
”Insurers of these group health plans are immunized from all kinds of different damages, the punishments, essentially, for acting badly,” Beifuss said.
”Cloaked in the safety of legislation and precedent,” he found, “insurers can avoid covering claims because the penalties for breaching their duties are far cheaper than performing them.”
”The only punishment for stealing in these cases is having to give back what you stole, sometimes,” Beifuss said.
Beifuss said even the doctors that insurers hire to determine if a claim is medically necessary have consulting physician malpractice immunity.
”Your doctor meets with you and says, John, I think after meeting with you, taking your vitals, knowing you for years, I think you need this,” Beifuss said. “If that doctor makes critical errors, or doesn’t meet their standard of care, they’re exposed to medical malpractice liability. That can be pretty severe. Conversely, the doctors reviewing your insurance claims are not treated by that same standard. They don’t have to meet that standard.”
And it’s only getting worse for healthcare consumers. Beifuss found, “After decades of litigation and legislation, the insurers’ position has mostly improved.”
”The United States Supreme Court” has “upheld the insurers’ interests, typically in near unanimous decisions.”
Beifuss ultimately prevailed in his wife’s healthcare denials after years of learning how to write what he calls “sophisticated appeals.”
”Most people are not savvy when it comes to healthcare,” Beifuss said. “They’ve got a giant network coming for them. What it ends up doing is it puts normal ordinary people in a position where they can’t get healthcare, and it puts doctors in a position of essentially being their own insurance law firm, and that’s a bizarre place for us to be.”
So what are we supposed to do about this?
“Appeal, appeal, appeal,” he said. ” Make yourself a squeaky wheel.”
Read Beifuss’ entire paper on the subject:
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