How to find out if your health plan is denying coverage

Your doctor says you need expensive treatment, but your health insurance says they won’t pay.

It is not known how often consumers face this problem. When that happens, patient advocates say you shouldn’t always accept a health plan’s denial as the final word.

He recommends asking insurers and health care providers two questions: Why isn’t the service being offered? And can the decision be reversed?

If this gives unsatisfactory answers, there are other options, including filing an appeal, calling the regulator and asking the employer to intervene if they want to spread the word.

“I think the first step is to try to see, hopefully, if you can fix it,” said Karen Pollitz, director of the Patient and Consumer Protection Program at the Kaiser Family Foundation. “When there’s a problem, I usually pick up the phone – I’ll wait until the song is over – and I’ll ask if they’ll reconsider.”

In July, the California foundation released it annual report This is one of the most common – albeit rare – screening tests for health insurance coverage.

Using 2020 data from health plans sold at the federal government HealthCare.gov In the market, researchers calculated that insurers rejected about 18% of their online claims that year. Denial rates varied widely among insurers, from as low as 1% to as high as 80%.

Kaiser’s report only looks at resistance to products sold to the general public, which is estimated to be less than 6% of the US population. Federal market data, meanwhile, covers enrollees in just 33 states — a group that doesn’t include Minnesota.

“The negativity that’s being expressed about the business really bothers me,” Pollitz said. “We don’t have any kind of matching to begin with, like [the] amount of employer-sponsored income, which is what most people have. “

Why some claims are disputed

The rates, however, do not indicate whether the claim will be covered, said Kristine Grow, a spokeswoman for America’s Health Insurance Plans, a health insurance trade group. Denials can happen because health care providers didn’t provide enough information, the claim didn’t have a prior authorization or referral or a specific service isn’t included, said Lucas Nesse, executive director of the Minnesota Council of Health Plans, a trade group. non-profit state insurance companies.

“Refusals often result in payment delays to providers and sometimes require doctors to resubmit claims,” ​​Nesse said in a statement.

However, there is a small group of patients with high medical expenses, said Jonathon Hess, CEO of Athos Health. Neither health care providers nor insurers publicly report these denials, Hess said, making it difficult for outsiders to know how many people are left facing thousands of dollars in unpaid bills.

That’s why Cancer Legal Care, an Oakdale-based nonprofit that provides free legal services to Minnesotans with cancer, launched a program a few years ago to help oncology patients transition when health plans refuse coverage.

Since 2020, the program has helped 31 patients win a total of $1.8 million.

“Their objections were for various reasons and our clients and their agents did not succeed in getting the objections resolved,” said Bill Foley, a health insurance attorney at Cancer Legal Care. The non-profit group “committed to this by hiring specially qualified attorneys to help develop and administer the program.”

Where to start if they are rejected

Not every medical treatment will be covered, Foley said. But patients who review their medical contract language and think the issue has been wrongly denied have options against it.

Even before filing an appeal, patients should talk to their health plan and health care providers to see if there is a way to resolve the issue, because denials can stem from payment errors that can be corrected.

Insurers have an internal and external complaints process. To answer that, consumers need to find and review health plan materials that detail what they’re learning, Foley said. These are detailed articles that often exceed 100 pages in length, he said, not summaries of benefits that take up only a few pages that subscribers see.

“If you’re going to keep doing what you want, you need someone to stand up for you,” Foley said. “Your CFO is calling the insurance company, or your benefits manager is calling the broker who signed your company up with the insurer — that’s not the first place to go, but they can review what you need. It’s a senior executive in the health plan.”

What if the internal appeal fails?

After trying to make a claim with the insurance company, people with health plans that have enough insurance can apply abroad. sending a request to the Minnesota Department of Commerce or give it to Minnesota Department of Health. Some employer policies are regulated by the federal government.

The state Department of Commerce has staff to help consumers find out which agency administers their health plans so they can report their concerns, said Julia Dreier, deputy commissioner of the insurance department.

Federal data shows that few people try to file formal complaints in response to complaints, said Amy Monahan, an expert on employee benefits law at the University of Minnesota. This is a missed opportunity for people with health insurance in Minnesota, Monahan said, because state courts rule here that out-of-state appeals are easier to buy than in other states.

Why coverage may be different

With fully insured plans, insurers take the financial risk for the premiums. While individuals and small to medium-sized businesses purchase insurance premiums, many employers – especially large companies – operate self-insured plans regulated by the government.

Increasingly, health insurers are adopting regulatory documents that outline how they will cover emerging and expensive health care, Monahan said. “Managing this medical need,” he said, is a growing problem for patients because they are forced to argue “if you meet the criteria, not if this is the right treatment.”

“You want to make sure you see the document … because it will tell you the basis on which the insurance company is evaluating your claim,” Monahan said. He added: “There are no reliable sources that I know of that tell you approximately how many medical claims are rejected.”

How Minnesota insurers do it

A report by the Kaiser Family Foundation found that Bloomington-based Bright Health had more than 18% interest rates on the private market in six of the eight areas it served in 2020. The insurer did not respond to questions about the findings.

Minnetonka-based Medica has declined significantly in its market business in Kansas, Missouri and Oklahoma, Kaiser said.

Using the base method, the Star Tribune looked at the filings of Minnesota carriers on the private market and found that they could not deny claims in 2020. The lowest rate was 6.4% at Bloomington-based HealthPartners, according to a Star Tribune review, while the highest was 15.5% in Medica.

Insurers said they could not confirm the Star Tribune’s calculations.

In general, Medica said that it would not be surprising if the insurance refusal rate was lower in Minnesota than in other states because health care providers here have been working with a non-profit health plan for many years. Through experience, doctors and hospitals learn Medica rules for billing, insurance claims, and when authorization or referral is required.

“In the states where we are building relationships with service providers, we are seeing more resistance to incorrect or incomplete reimbursements, missing deliveries or outsourced services,” Medica said in a statement. “Not every refusal is a medical decision. Many, if not most, are management.”

At HealthPartners, executives said they work proactively with members and health care providers to avoid unexpected rejections, which in 2021 resulted in rejections of 3.5% of all market proposals. The majority of HealthPartners enrollees receive care from hospitals and clinics that are owned by nonprofit organizations.

“Contract agents and health plans work with contracts and policies,” the insurer said in a statement. “If a contract provider’s claim is denied due to problems with writing or delivery, the provider cannot seek full payment from their patient. Objections to denials for other reasons can be made against the patient.”

This form requires JavaScript to complete.