Health Insurance Company Misbehavior & What You Can Do
Despite requests & recommendations from national physician organizations such as the American College of Physicians (which represents internists such as myself), the health insurance industry has not undertaken reform and continues some disreputable practices.
A recently published review caught my eye. It simply and succinctly explains what most physicians and many patients have discovered -- in the past few years, health insurance companies have manipulated the health care system to their benefit, victimizing their customers through deceit and predatory behavior.
Since 2010, when the Affordable Care Act ("Obamacare") was passed, the major insurance companies have seen their stock prices soar. Though the act expanded coverage to millions, a report last year by the Robert Wood Johnson Foundation revealed that 41 percent of health plans sold on the government exchanges had physician networks described as “small” or “extra-small,” covering less than 25 percent and 10 percent of local doctors, respectively. Individuals may have to change doctors or choose out-of-network services, incurring extra costs.
Wendell Potter, a former Cigna executive turned whistle-blower and a co-author of the recent book “Nation on the Take,” says that “insurance companies profit by introducing hurdles in the coverage and claims process.” These hurdles lead some patients to simply give up and pay or forego treatment altogether. He calls this the companies’ business model. (The New York Times, June 30, 2016)
A major part of health care spending by health insurers actually bankrolls a PR campaign and lobbying effort focused on protecting insurance company profits. The rise in contributions is shown below (from The Center for Responsive Politics):
Health insurers now treat physicians as vendors ("Dear Healthcare Provider" was the salutation on a recent letter to me), and try to influence decision making on patient care by grading doctors on "quality" (spending less per company policyholder), requiring prior approval or outright denials of coverage for test & treatments. A 2011 study by the U.S. Government Accountability Office found that claim denial rates varied significantly across insurers. For example, just over a quarter of insurers had denial rates from 0-15 %, while another quarter of insurers had rates of 40 percent or higher.
Although it's unlikely that an individual doctor or patient can expect to correct this trend of bad behavior, with persistence a patient can battle their insurer over a coverage denial. One of the good changes made by the Affordable Care Act, commonly called Obamacare, gives health insurance policy holders rights to demand an insurer reconsider any health claim denial, and even appeal to an independent third party, whose decision the insurer must accept. Almost half of these challenges are decided in favor of the policyholder.
You must formally appeal a denial within 180 days of being notified. Although some insurers have telephone contacts to call, I suggest a personal letter, and then a more firm followup letter 10 days later if no response is received (I have posted some examples). Also contact our office to write a letter that supports your case. If your claim is still rejected after your appeal, you can file for an "external review," in which an independent third party will go over your case. I also recommend reporting the insurer to the Florida Office of Insurance Regulation, and notifying the insurer that you have done so.
