REPORT: Access Denied Part Two: How Insurance Coverage Denials Can Block Access to Preventive and Emergency Care

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You can find the full report here: Access Denied Part Two: How Insurance Coverage Denials Can Block Access to Preventive and Emergency Care

 

Health insurers are using opaque and inconsistent standards to deny coverage for both preventive medical and emergency services, according to a new report from healthcare advocacy coalition the Doctor-Patient Rights Project (DPRP). The report contains previously unreleased data illustrating the rate at which insurers are denying access to medical screening and testing and also examines an insurer policy of denying coverage for emergency care by retroactively claiming an emergency service was “avoidable.”

The new report, Access Denied Part Two: How Insurance Coverage Denials Can Block Access to Preventive and Emergency Care, examines how insurers are restricting access to medical services and treatments across some stages of care. The report also looks at how those coverage denials discourage early detection and intervention of chronic illnesses, thereby increasing costs for patients and putting more of a burden on emergency departments and the health care system as a whole.

“More people are living with chronic illness than ever before,” said Stacey Worthy, counsel to Aimed Alliance (Alliance for the Adoption of Innovations in Medicine). “Insurers should be working with doctors and patients to better diagnose and treat chronic conditions before they become serious and costly, not erecting barriers to preventive treatments that benefit patient health and reduce the cost of care in the long run.”

DPRP’s report also found many patients are even denied emergency room care retroactively because the insurer deems the visit “avoidable,” often leaving patients responsible for thousands of dollars in emergency care costs that they assumed would be covered.

“By retroactively denying coverage for emergency visits based on a patients’ diagnosis and not his or her symptoms, insurers are expecting patients to play doctor and diagnose themselves when they’re potentially facing a life-threatening medical event,” said Vidor Friedman, MD FACEP, president of the American College of Emergency Physicians (ACEP). “How can we expect people who don’t have medical training to do this? This is a violation of what’s known as the “prudent layperson standard” – which is part of federal law, including the Affordable Care Act – and requires health insurance companies to cover patients based on their symptoms, not final diagnosis. If someone is experiencing chest pain, it could be severe heartburn, or they might be having a heart attack. A patient shouldn’t second guess going to the emergency room and put their life at risk just because their insurer might send them a large bill if their diagnosis isn’t deemed serious after the fact.”

DPRP’s report details how insurer denials impact patients seeking both preventive and emergency care:

  • Insurers Deny 1 in every 10 Claims for Medical Testing or Screening

Denials for medical testing and screening affect as many as 7.7 million insured Americans seeking medical services to prevent potentially life-threatening diseases. Approximately 40% of patients appeal denials of claims for testing or screening and a majority of those appeals – 51% – are unsuccessful.

  • Insurer Denials Create Barriers to Preventive Care and Prophylactic Intervention

Around 25 of the 30 years of additional life expectancy gained by Americans in the last century are due to prophylactic interventions, which can help patients both avoid and slow the progression of disease. Although prophylactic interventions can be expensive, they can generate substantial cost savings for high-risk patients when paired with preventive care and genetic testing. But cost-sharing burdens – such as copayments and high deductibles – can deter insured patients from utilizing valuable services to prevent or slow the development of disease and negate the value of genetic testing and medical screening.

  • “Not Medically Necessary” is the Most Common Insurer Reason for Denying Coverage

Insurers are overriding doctors’ treatment decisions by questioning the medical necessity of a procedure, putting the burden on the patient and their doctor to prove that the procedure they want is necessary. Other barriers erected by insurers, such as cost-sharing burdens like copayments and deductibles, deter patients from utilizing valuable preventive care when they have to pay for it out-of-pocket.

  • Retroactive Denials for Emergency Care a Worrying Trend

In the second half of 2017, Anthem BlueCross/BlueShield denied more than 12,000 emergency care claims on the grounds that patients’ emergency room visits were “avoidable.” Federal law forbids insurance companies from denying coverage for emergency care that a “prudent layperson” would deem reasonable. However, insurers have utilized that ambiguous standard to deny claims for emergency room care retroactively, arguing that a visit was “avoidable” based on the final diagnosis, not the symptoms that prompted the emergency department treatment.

A patient may present to the emergency room with “chest pain when breathing,” potentially a sign of a life-threatening pulmonary embolism. However if the diagnosis proves to be non-urgent, the insurer could retroactively deny coverage because the visit – based on the diagnosis and not the symptoms – is deemed avoidable, potentially resulting in patients being sent a bill for tens-of-thousands of dollars.

  • Financial Debt Causes Patients to Neglect Healthcare

A 2016 Kaiser Family Foundation survey found 31% of households with medical debt fail to treat other health problems and families with medical debt are up to three-times more likely to have delayed or skipped healthcare than families without medical debt.

Through both Access Denied reports, The Doctor-Patient Rights Project has found that medical insurers blur the lines between doctor and insurer by effectively choosing which procedures are available for patients seeking preventive and emergency care, thereby discouraging the detection and mitigation of disease in its early stages as well as the treatment of those conditions when they become life threatening. This issue increases the burden on emergency departments and the health care system as a whole, and must be addressed to truly empower patients and their doctors to make the best decisions about their care.

Access Denied Part Two: How Insurance Coverage Denials Can Block Access to Preventive and Emergency Care can be downloaded at www.doctorpatientrightsproject.org.

Other reports available at DPRP’s website include:

Access Denied: How Utilization Management Protocols Can Block Access to Life-Saving Treatments, DPRP’s 2017 report exploring how five specific insurance company cost-saving strategies can block access to vital treatments for many patients when insurance companies pursue them too aggressively.

The De-List: How Formulary Exclusion Lists Deny Patients Access to Essential Care, DPRP’s 2017 report on how pharmacy benefit managers use of “formulary exclusion lists” could deny coverage to hundreds of thousands of insured Americans each year.

Not What the Doctor Ordered: Barriers to Healthcare Access for Patients, DPRP’s report on its 2017 survey of insured Americans about their access to medications, tests, and medical procedures can also be downloaded at the DPRP website.

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The Doctor-Patient Rights Project is a non-profit coalition of doctors, patients, caregivers and advocates fighting to restore the fundamental practice of medicine and ensure doctors, in partnership with their patients, drive patient care decisions. DPRP believes treating practitioners should be the primary voice helping patients determine their best course of treatment, and that third-party payers should partner with physicians to facilitate care and not impose treatment decisions on doctors or patients.