Doctors in Denial
A 2017 article published by Newsweek found that insurance coverage and reimbursement is increasingly being denied for patients with chronic health conditions, despite having a doctor recommend the treatment as medically necessary, and the patient having a fully paid insurance premium.
We’ve all been there. For example, you tweak your back (again!), meet with your trusted spine surgeon, and decide together that you need an MRI to localize the source of your new pain. You move forward only to learn that your insurance company is challenging the medical imaging until you try a round of steroids, something you know from experience is just going to delay the inevitable. The frustration that accompanies this is further compounded when it’s more than just an initial MRI being challenged, it’s the surgery itself being challenged – the surgery you and your surgeon believe will get you back to a quality of life, back to work.
For many patients, health insurance denials like these come as a surprise, especially given that a doctor has made a clinical recommendation to the insurance company. Why should insurance companies have the final say on what is best for your health? Sure, some level of oversight is necessary to make sure that physicians do not betray their oath and do more harm than good by prescribing unnecessary medical treatments. But what about when insurance companies challenge the coverage of a procedure simply because, from a budgetary perspective, they do not want to pay for it?
Most privately insured U.S. citizens, under the Affordable Care Act (ACA), have the right to a timely, independent, external opinion from a like-specialty physician. Thus, if an insurance company attempts to deny a treatment claiming that it is either not medically necessary or that it is considered investigational, the patient can appeal the decision. To be able to provide these independent reviews, a company must be accredited and meet certain standards established by the ACA. Independent review organizations are meant to be an appropriate check and balance to insure that necessary patient care is not interrupted by bottom-line minded insurance companies. Unfortunately, the oversight over these companies and their relationships with insurance providers is blurred. Thus, we will seek to explore in this article if these companies are working in the spirit of the law set forth by the ACA, and, if they are not, what you can do about it.
Let’s first examine the process.
The Appeal Process
Though your doctor may outline a treatment plan and deem it medically necessary, your insurance company may feel otherwise. When this happens, these are the steps you’ll likely have to go through, using the example of your back pain:
Pre-Authorization. Your doctor will be asked to submit documentation to your insurance provider to begin the approval process. Your insurance carrier will require your doctor to provide a history of your pain and a record of the unsuccessful treatments that led to his or her recommendation for surgery. Your health insurance provider then has 15 days to decide whether the evidence presented is enough to justify “allowing” the procedure. If not, you’ll proceed to the next step in the process.
Internal Appeal. If your health insurance provider still denies coverage, you and your doctor can file an appeal that is internal to your insurance company. Once submitted, your insurance provider must respond in writing within 30 days. Sometimes, during this process, the insurer may ask your surgeon for a “peer-to-peer” discussion through a conference call. Should your treatment again be denied, the next step is to file for an independent, external review.
External Review. Once you have a written denial from your health insurer, you may request an external review through what is called an Independent Review Organization (IRO). This is typically at no cost to you, although some IROs having minor filing fees. Your case is sent to an IRO on contract with your insurance plan (most plans have 2-3 IROs that they contract with, depending on the state requirements, and your case is sent to one of them at random). Your case is assigned to a relevant specialist within that IRO.
The external review process takes up to 45 days while the IRO reviews your case and all related documentation from your doctor. If the IRO agrees with you and your doctor that you should have the prescribed surgery, your health insurance plan must allow and pay for your surgery. If not, the decision of the IRO is unfortunately legally binding and you will have then exhausted your rights to any further appeal.
What are my Rights in the External Review Process?
It is a requirement in all 50 states, based on guidelines within the Affordable Care Act, that health insurance companies participate in an external review process that meets consumer protection standards.
These standards are designed to remove the insurance company from the decision-making process in an effort to reach an unbiased decision about your denied appeal.
Are these standards making the insurance appeal process fairer to patients?
Questions have been raised about the fairness of independent review organizations and the selection process used by insurance companies to choose them.
One patient advocate group cited that one of the IROs is denying external reviews at the startling rate of 99 percent. Another is not far behind at a 97 percent denial rate. These rates are clearly signaling that this process of “independent review” is not functioning in the way that it was intended to and is failing the health care consumer.
The motivations behind these IRO’s sweeping denials are unclear and further the oversight on how they conduct business is hard to trace. There is always an option for patients to litigate a denial if desired, which would be the next step after a failed external appeal. But that may come at an additional cost to the patient and further delay in getting back to a quality of life.
Unless the external review process is fair and is being conducted in a truly independent way, outside of pressure from insurers to enforce their initial denials, then patients and patient advocacy groups will need to start demanding changes to the appeal process through state insurance commissioners.
Share Your Story
While it can be disheartening to have your insurance company deny you coverage for a surgical procedure deemed necessary by your doctor, there are things you can do. Working with patient advocacy groups can give you a voice by putting people in your corner who understand how health care providers work. The people who work for patient advocacy groups can provide you the guidance necessary to navigate the appeal process.
Do you have a story regarding the insurance process as it pertains to your back/spine treatment? We'd love to hear it. Please share it with us and the BackerNation community.