Be the ‘squeaky wheel’ if health claim denied

Introduction

The good news from last week was that 8 million Americans have signed up for health insurance through the Obamacare-created exchanges. The not so good news is that because most of us have to buy coverage from a private insurer, we will always have to be vigilant to make sure our medical claims get paid and that an insurance bureaucrat miles from where we live doesn’t succeed in denying coverage for medically necessary care.

While we’ve heard a lot recently about the growing number of folks who are at long last able to join the ranks of the insured, we haven’t heard much at all about the important provisions of the law that make many of the previously common industry practices unlawful.

Among other things, insurers can no longer refuse to sell us coverage because we’ve been sick in the past or even take the status of our health into consideration when figuring out how much to charge us for a policy. They also can’t charge women more than men or older folks more than three times as much as younger folks. And they must allow young adults to remain on their parents’ health plans until age 26.

The reason health insurers discriminated against women and people of a certain age as well as anyone not in tip-top shape was because their discriminatory underwriting practices enabled them to sell policies with relatively low premiums to people who were least likely to need medical care. And for the big for-profit insurers that now dominate the industry, those practices made it much easier for them to meet Wall Street’s relentless profit expectations.

Don’t think for a minute, though, that the large institutional investors that own health insurers’ stock these days are cutting the companies any slack when it comes to their profit margins.

As I’ve often said, the one thing most health insurers know how to do is make money. They make billions off of us every year. Obamacare won’t change that. In fact, because Congress succumbed to pressure from the industry’s lobbyists and ditched plans to create a “public option” to compete with insurers, billions more in premium revenue and federal subsidies will flow to them for years to come.

But investors and Wall Street financial analysts look far more closely at profit margins and earnings per share than total revenues.

To keep Wall Street happy, insurers undoubtedly have begun shifting resources from their underwriting departments to their so-called medical management teams. I’m confident that people who work in medical management are under more pressure than ever from the executive office to avoid paying claims whenever possible.

That has been my fear since the reform law was passed and the consumer protections went into effect. So it’s especially important now to scrutinize those “Explanation of Benefits” statements our insurers send us after we get medical care.

Insurers know that many if not most of us do little more than glance at them before throwing them away. They’re hard to understand by design. If you can’t decipher them, chances are you’ll give up and just hope that your insurer and health care providers are treating you fairly and that you are not being billed for care that your policy should cover.

Numerous studies over the years have shown, however, that patients have at least an even chance of prevailing if they go to the trouble of appealing a claim denial or a ruling by somebody in medical management that your doctor-ordered care was not medically necessary.

The most recent proof of that came last week in a Capital Public Radio story out of Sacramento. CPR found after analyzing several years of data compiled by California’s insurance department that patients won about half of the appeals they filed with state regulators after getting a claim denial from their insurer. CPR also noted that a 2011 GAO report based on data from several states prior to the implementation of the Affordable Care Act found that patients were successful between 39 and 59 percent of the time when they appealed directly to their insurer.

Many patients who don’t succeed that way, however, go the additional mile of reaching out to their state insurance departments or their state legislators or members of Congress — or even the media. That enhances the chances their insurers will agree to pay the disputed claims.

“When appealing to a third party (such as the state insurance commissioner), patients also were often successful in getting the service in question — winning as many as 54 percent of such decisions in Maryland, for example,” CPR reported.

Bottom line here: With profit margins under pressure because of Obamacare, insurers likely will be denying more of your claims and inserting themselves even more between you and your doctor when it comes to medically necessary care, but you should never take a “no” as the final answer. Appeal — and be a squeaky wheel — whenever you get a denial. Chances are that if you do, you’ll get the care you need, and get your insurer to pay for it.