Tag: Health Insurance

How to Fight A Health Insurance Denial

Many Americans increasingly find themselves dealing with huge medical bills after medical procedures their health insurers should have covered.  All too often, the insurance company says “it’s not our problem, talk to the hospital;” the hospital says “it’s not our problem, talk to your insurer;” and the insured is left holding the bag, often at a time they’re already dealing with the stress of major surgery or illness.

The good news is Washington insureds have specific rights they can enforce to hold their health insurer accountable.  Insurers must follow the specific terms of the policy contract and cannot deny coverage for medical bills without a reasonable basis.  If insurers fail to live up to their obligations, the insurer has legal rights under Washington’s Consumer Protection Act and Insurance Fair Conduct Act, or the federal Employee Retirement Income Security Act, to seek a court order requiring coverage and requiring the insurer to pay the insured’s attorney’s fees.

Unfortunately, fighting a health insurance denial takes significant time and effort, which can be hard when you’re already recovering from surgery or illness.  This is why many health carriers have been criticized for making the process difficult and confusing in the hope that insureds will simply give up without fighting the denial.

There are three common reasons why health insurance claims are denied:

  1. The insurer determines the procedure, treatment or medicine was not “medically necessary.”  The definition of “medically necessary” depends on the specific policy, but, generally, when the insurer says the procedure wasn’t medically necessary they basically mean “we don’t believe you really needed it.”  Sometimes the insurer uses the same rationale to deny coverage on the basis the treatment is supposedly “experimental.”
  2. The hospital or doctor who provided the treatment was out-of-network, meaning the provider didn’t have a contract with the insurance company.  Most health insurance severely limits or eliminates coverage for out-of-network providers.
  3. The doctor or hospital who provided the care used improper billing and coding, causing the insurer to reject coverage because the hospital didn’t properly detail what care was performed.

The good news is many people successfully fight their health insurer’s denial of coverage.  Each of the three common reasons health claims are denied can be subject to attack:

  1. Denials on the basis treatment was not medically necessary can often be fought with the support of the doctors who prescribed the treatment or care at issue.  Too often, health insurers misread, gloss over, or outright ignore a physician’s rationale for prescribing treatment.  Especially where treatment is expensive or time consuming, insurers have a powerful temptation to “miss” the medical records demonstrating the patient needs the treatment in order to justify denying coverage for treatments that will cost the insurer a lot of money.
  2. Denials for out-of-network treatment can be fought by insisting the insurer follow the policy contract and the federal Affordable Care Act (a/k/a Obamacare).  Often, the policy contract requires the insurer to provide at least some degree of coverage even where the treatment is out-of-network.  Furthermore, if the insured was treated by an out-of-network provider for emergency care, the Affordable Care Act requires the insurer to treat the care as though it was provided in-network.
  3. Improper billing and coding by the hospital can often be challenged by a thorough review of the medical records, procedure codes and billing codes.

Importantly, your insurer cannot deny health care coverage without a reasonable explanation.  This means you have the right to know specifically why coverage was denied and to get the information you need in order to fight the denial.  Most health insurers are required to allow you to “appeal” the denial before filing a lawsuit.

Lastly, in fighting a health insurance denial, be mindful of the applicable deadlines.  All health insurance disputes are subject to deadlines that will cause the insured to lose their right to challenge the health coverage denial if the insured fails to act within a certain time period.  The specific deadline varies, so it is critical to be diligent and stay aware of any applicable deadlines when fighting a health coverage denial.

Washington State Insurance Commissioner Fines United Healthcare for Denying Women’s Health Claims

On September 13, 2018, Washington’s Insurance Commissioner entered into a Consent Order with United Healthcare regarding violations of Washington insurance law governing women’s health claims.  United Healthcare is a health care service contractor that sells individual and family health insurance coverage.

The Insurance Commissioner’s investigation was prompted by a consumer complaint that United Healthcare improperly denied coverage.  According to the complaint, United Healthcare told the consumer her claim was denied because she needed a referral for the women’s health services she received.

That violated Washington’s Direct Access law, which gives women the right to access women’s healthcare from the provider of their choice without having to obtain a referral.

In the course of the investigation, United Healthcare admitted it improperly denied similar claims for 276 insureds.  As a result, many women were improperly told they needed a referral in order to obtain coverage for medical treatment.

The investigation is a reminder to insureds to know their rights under Washington law, and to carefully scrutinize coverage denials to make sure the insurer followed the law.

Out of Network Billing for Emergency Room Visit: New Legislation Aims To Fix Loophole In Existing Law

In a medical emergency, patients are typically concerned with getting to the emergency room as fast as possible.  They often don’t stop to check whether the closest emergency room is at a hospital that is “in-network” with their health insurance plan; or, even if they do, the nearest in-network emergency room may be too far away.

Most health insurance plans exclude coverage for treatment with out-of-network hospitals, so this can cause insureds who seek treatment in an emergency without carefully checking whether their hospital is in-network with their insurer to pay astronomical out of pocket costs for treatment.

The federal Affordable Care Act (a/k/a “Obamacare”) imposed new rules on insurers that partially fix the problem of coverage for out-of-network emergency healthcare.  The ACA requires covering emergency care without limiting coverage on the basis care was rendered by an out-of-network provider.  The statute provides:

If a group health plan, or a health insurance issuer offering group or individual health insurance issuer [sic], provides or covers any benefits with respect to services in an emergency department of a hospital, the plan or issuer shall cover emergency services … in a manner so that, if such services are provided to a participant, beneficiary or enrollee … such services will be provided without imposing any requirement under the plan for prior authorization of services or any limitation on coverage where the provider of services does not have a contractual relationship with the plan for the providing of services that is more restrictive than the requirements or limitations that apply to emergency department services received from providers who do have such a contractual relationship with the plan….

42 U.S.C. § 300gg-19a(b)(1) (emphasis added).

Courts have summarized this rule as requiring insurers “to cover out-of-network emergency services in a way ‘that is [no] more restrictive than the requirements or limitations’ applicable to emergency department services received from in-network providers.”  Northside Hosp., Inc. v. Ambetter of Peach State, Inc., 2017 WL 8948348, at *1 (N.D. Ga. Dec. 1, 2017) (quoting 42 U.S.C. § 300gg-19a(b)(1)(ii)).

Washington State’s Patient Bill of Rights similarly precludes insurers from limiting coverage for emergency care on the basis the provider was out-of-network.  Washington law provides:

A health carrier shall cover emergency services necessary to screen and stabilize a covered person if a prudent layperson acting reasonably would have believed that an emergency medical condition existed…With respect to care obtained from a nonparticipating hospital emergency department, a health carrier shall cover emergency services necessary to screen and stabilize a covered person if a prudent layperson would have reasonably believed that use of a participating hospital emergency department would result in a delay that would worsen the emergency.

RCW 48.43.093 (emphasis added).

But there’s an important loophole in this rule.  Health insurers have to cover out-of-network emergency care under the rule, but the rule never states how much of the bill an insurer must pay.  This is a critical omission.  Most health plans limit the amount the insurer pays to special discount rates the insurer negotiated with its in-network providers.  But out-of-network providers haven’t agreed to accept this rate, which is often a tiny fraction of the out-of-network provider’s charge for an emergency room visit.

Thus, even where the insurer nominally covers emergency treatment at an out-of-network hospital, the insurer is only required to pay the amount it negotiated with its in-network providers.  Since the out-of-network emergency room hasn’t agreed to accept those rates, the insurer’s coverage will be inadequate – often by hundreds of thousands of dollars.  The patient then receives a bill for the difference despite having “coverage” for the emergency room visit.

This leads to the unfair situation where a person goes to an out-of-network emergency room and supposedly has coverage under the ACA and Washington Patient Bill of Rights, yet still winds up on the hook for medical bills that would have been paid had the provider been in-network.  As a practical matter, this renders the intent of the ACA and Washington Patient Bill of Rights – protecting insureds from crippling medical bills for visiting an out-of-network emergency room – completely ineffective.

Unfortunately, until a legislative solution emerges, insureds must still check the in-network status of their providers with agonizing precision – even in the event of a life-threatening medical emergency – despite the ACA and Washington Patient Bill of Rights.  Washington State’s legislature has proposed such a solution: HB 2114 – 2017-18 (“Protecting consumers from charges for out-of-network health services”).  That bill remains in legislative committee and faces harsh opposition from industry groups.

Think Twice About Your Health Plan’s “Wellness” Review

It’s currently trendy for health plans to try to get their insureds to undergo a “wellness” screening in which the insurer collects personal health and lifestyle data from the insured.  These are often pitched as a benefit to the insured with the health plan saying, basically, “let us give you this great free screening!”   Sometimes the insurer even offers gift cards or other goodies to insureds who participate.

But as is typical for anything the company is incentivizing insureds to do, “wellness” screenings are often in the insurer’s interest – not the individual’s.

Health insurers have begun routinely collecting insured’s personal health and lifestyle data to justify premium increases based on the minutia of an individual’s daily life.   Just like tech companies can use the minutia of your personal data for marketing purposes, health insurers can use insured’s lifestyle and biometric data to raise premiums.

A recent NPR report details how “the health insurance industry has joined forces with data brokers to vacuum up personal details.”  Besides mundane details like race or education, insurers also reportedly track what TV you watch, your social media habits, and your online shopping, among other things.   One company boasts it collected health data on 150 million Americans going back to 1993.  Another filed a patent application to gather health-related information from social media.

Insurers use this data to price health care plans.  For instance, insurers reportedly consider women purchasing plus-size clothing to be at risk of depression; minority insureds to be more likely to live in dangerous neighborhoods; and recently-married insureds to be more likely to need childbirth care.

Insurers’ use of this data raises broader questions about the use of the data we readily share in the digital age, but it also emphasizes that the health insurer’s “wellness” exam might not be the altruistic offer it’s pitched as.

Health Insurer Fined For Violating Independent Review Rules

Washington’s insurance commissioner recently announced a $100,000 fine in response to a consumer complaint that Kaiser Foundation Health Plan, an HMO, ignored consumers’ rights in the health claims appeal process.  The commissioner found that Kaiser failed to follow several rules related to appeals of health insurance claims to an Independent Review Organization (“IRO”).

At issue are rules contained in Washington’s statutes and administrative codes protecting insurance policyholders.  Among other things, Washington law required Kaiser to provide the IRO with any records, documents, or information relevant to the claim within three business days; ensure that expedited reviews are adjudicated within 72 hours of the policyholder’s request; and provide the policyholder the IRO’s name and contact information within one business day.

In Kaiser’s case, the insureds had the right to provide evidence supporting the insured’s claims to the IRO within five days.  However, Kaiser failed to notify most consumers they had the right to do this.  The commissioner also found Kaiser dragged its feet in the IRO process.  Kaiser was found to have failed to timely send claims files to the IRO; failed to process expedited claims on time; and failed to timely give consumers the IRO’s name and contact information.

The commissioner found these violations occurred during the period from January 2016 through March 2017.

Kaiser signed a Consent Order regarding the above violations, pursuant to which Kaiser acknowledged its duty to comply with the law and consented to imposition of the fine.