UofL law student diagnoses health insurance claim denial dilemma

LOUISVILLE, Ky. (WAVE) – Have you ever needed a checkup or surgery ordered by your doctor, but your health insurance company kept denying it? I’ve done it several times.

“After reviewing the information available to us, we have determined that we cannot approve this request,” one of my letters read. “We have found that the requested service is not medically necessary in your case.”

You know the language if you’ve ever received one. The same thing happened to Frank Beifuss and his wife, who were diagnosed with a rare genetic disorder.

“To me, it was inexplicable how much we had to fight with the insurance company to get their coverage,” Beifuss said. “And we lost a lot of those fights. Usually, a losing fight meant she didn’t get the care she needed.

It was so infuriating that he started researching it, and what he learned prompted him to write an article called “Illusory Cures: Why Lack of Oversight and Sanctions Leaves Half the Country with Only L ‘shadow of health care’. It was peer-reviewed and recently published in the University of Louisville Law Review.

He specifically looked at employer-sponsored health plans, which cover more than 50 percent of the U.S. population. The first thing he thought was certainly verifiable was how often claims are denied.

“What I was able to find is that we now know how many applications are denied and how often applications are denied,” Beifuss said. “The answer is simple: Everyone thinks someone else is doing it, and no one is essentially empowered to do it.”

That’s correct. “No entity tracks the prevalence of health plan-related claim denials,” he wrote. “The lack of oversight makes it impossible to see the prevalence of unjustified claim denials. »

The Centers for Medicare and Medicaid Services is the only entity that tracks claims, and it found that it denied more than 18 percent of in-network claims.

“If you look at the Medicare/Medicaid data on denials, less than 1 percent of those claims are appealed,” Beifuss said. “The denials anyway. And about 70% of applications appealed are generally approved. It just creates obstacles. They know they get plenty of free roadblocks. There is no reason not to put up obstacles. They can deny people access to care and a lot of people will say, “Well, I guess I didn’t get that.” » These treatments are not for me.

How many roadblocks? In most states, you can appeal twice internally. Processing each one can take months. Then he said you can make an outside call handled by a company hired by the insurer.

“If you follow all these steps, then you can say you’re wrong and I’m going to sue you,” Beifuss said. “But there are very few lawyers who take these kinds of cases.”

“So you’re just unlucky?” I asked.

“You’re out of luck, yeah,” he said.

Your health may deteriorate during the wait, and even if you ultimately win, and then try to sue, he found that you “will recover, with near certainty, zero dollars beyond the cost of care initially.” refused.”

“The insurers of these group health plans are immune to all sorts of different damages, basically punishments for doing wrong,” Beifuss said.

“Surrounded by the security of legislation and precedent,” he found, “insurers can avoid covering claims because the penalties for failing to meet their obligations are far less costly than for fulfilling them.”

“The only punishment for theft in these cases is having to return what you stole, sometimes,” Beifuss said.

Beifuss said even doctors that insurers hire to determine whether a claim is medically necessary benefit from immunity from consulting physician malpractice.

“Your doctor meets with you and says, John, I think after meeting you and taking your vitals and knowing you for years, I think you need this,” Beifuss said. “If this physician makes critical errors or fails to meet his or her standard of care, he or she may be subject to medical malpractice liability. This can be quite serious. Conversely, doctors who review your insurance claims are not treated to the same standards. They are not required to meet this standard.

And the situation is only getting worse for health care consumers. Beifuss observed: “After decades of litigation and legislation, the position of insurers has greatly improved. »

“The United States Supreme Court” has “defended the interests of insurers, generally in near-unanimous decisions.”

Beifuss finally got the better of his wife’s healthcare denials after years of learning how to write what he calls “sophisticated appeals.”

“Most people are not good at health care,” Beifuss said. “They have a giant network at their disposal. Ultimately, it puts ordinary people in a position where they can’t get health care, and it puts doctors in the position of essentially being their own law firm when it comes to insurance, and that It’s a weird place for us.

So what are we supposed to do about it?

“Call, call, call,” he said. “Make yourself a squeaky wheel.”

Read Beifuss’ full article on the subject: