Louisville company bridges the gap in health claim denials

LOUISVILLE, Ky. (WAVE) – “It feels like someone put a paper bag over my face and I can’t breathe at all,” said Kim Watts of Radcliff. “It literally suffocates me to the point that I lose consciousness.”

Watts lives alone and wears a defibrillator in a room full of medical papers documenting her acute respiratory problems, chronic obstructive pulmonary disease, chronic congestive heart failure and many other health problems.

Expecting weeks of rehabilitation after her last intensive care stay, she received a letter stating, “Your health plan has determined that Medicare is unlikely to pay for your skilled nursing facilities after the above date.”

“I said this isn’t fair because I don’t even know these people and they don’t know me either,” Watts said. “They don’t know my condition.”

“Have you tried to appeal this or something?” I asked.

“Yes, I did,” she said. ‘I tried to appeal, but the appeal was lost the next day. They said if you appealed again you had to wait fourteen days before the decision came back on this. I said that makes no sense at all.”

Many of us recognize the letter she received because important tests, procedures, or rehabilitation we needed, ordered by our doctor, were denied by insurance.

“If you don’t have anyone to stand up for you, you’re basically just lost,” Watts said.

That’s the subject of an article that UofL law student Frank Beifuss researched and wrote and was recently published in the UofL Law Review. He examined employer-sponsored health care plans that cover more than half the U.S. population. He found that “no entity tracks the prevalence of health plan claim denials,” so it is impossible to know how often this happens.

“It just puts up roadblocks,” Beifuss said. “They know they’re getting so many free roadblocks. There’s no reason not to put up roadblocks. They can deny people access to care and many people will say, ‘Well, I guess I didn’t understand that, that care isn’t for me.’

He found that the insurers of doctors hired to review claims have malpractice immunity. He also found that insurers are immune from damages or punishment.

“The only punishment for stealing in these cases is that sometimes you have to give back what you stole,” he said.

Beifuss wasn’t the only one to notice a problem for patients. Some local doctors and hospital administrators also saw it from the front lines. So they started their own business in Jeffersontown, aimed at bridging the gap.

“After working in hospital operations for 35-40 years, we saw a shift in what was going on at insurance companies from a patient denial perspective in the hospital,” said Gayle Dickerson.

It’s called PC3 – Physician Care Coordination Consultants.

“We really advocate for the patients,” said PC3 founder Dr. Karan Shah. “We act as an intermediary between insurance companies and hospitals. We communicate because we understand both sides. Many of us have hospital surgery experience and we have seen this happen. That’s where we come into the picture. We ensure that claims are handled properly. We file appropriate claims so they are not denied.”

Since opening last year, the workforce has increased from three to 21 employees. The number of hospitals they support has increased from two to almost 30. They are growing as the number of denied healthcare claims increases.

“Over time it has become more,” Dickerson said. “It started when the federal government looked at spending on Medicare patients. Next, the state looks at Medicaid spending. Then it blossomed further with the commercial payers, just through the use of services and the cost of services.”

They said claims are often denied because insurers do not have proper documentation.

“One of the most common mistakes is not having all the information,” said Dr. Shah. “Sometimes you need something and no paperwork is sent at all. So we get these calls and we talk to the other doctor on the other side, and they have nothing to rely on. And that’s where we come in and present the right information to them to get things approved.”

Instead of your doctors spending valuable time arguing your claim over the phone when they could be treating patients, PC3 does that work. They claim they have more success getting denials approved and that there are no “bad guys.”

“Honestly, I don’t think it’s the hospital’s fault,” said Dr. Shah. “It’s not the doctors’ fault. It’s not the payers’ fault. It is the system we are stuck in today. And this is unfortunately the byproduct of the system.”

Currently, PC3 works with hospitals, not individuals. However, they see patient concierge case management coming in the future.

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