Options If Coverage Denied by Insurance

From GI & Hepatology News (3/27/21): Fighting back against payer coverage policies

  • Ask for the credentials of the payer representative who initially denied the request. Even when payer representatives are physicians, they are often not gastroenterologists. Ask to speak with a representative actively practicing gastroenterology.
  • Ask to record your conversation with the payer representative for documentation purposes.Ask to speak directly to the payer’s medical director.
  • Bring the complaint to the payer’s attention on social media. Using social media to bring attention to a denial can sometimes elicit quick, personal outreach from the payer to address the issue.
  • Let the AGA know what’s happening. Reach out to the AGA via the AGA Community, via Twitter, or by emailing Leslie Narramore, the director of regulatory affairs at AGA (lnarramore@gastro.org).
  • File a complaint with the State Insurance Commissioner. State Insurance Commissioners are responsible for regulating the insurance industry in their state and can investigate to ensure the laws in their state are being followed and providers and patients are being treated fairly. While insurance law and regulation are established at the state level, the insurance commissioners are members of the National Association of Insurance Commissioners (NAIC), which allows them to coordinate insurance regulation among the states and territories. Find out your state’s complaint process because many state insurance commissioners have on online complaint forms. Keep records of all interactions with the insurance company to document that you have attempted to resolve the matter with the payer first.
  • File a complaint at the federal level for states without an external review process. If your state doesn’t have an external review process that meets the minimum consumer protection standards, the federal government’s Department of Health & Human Services oversees an external review process for health insurance companies in your state. See www.healthcare.gov/appeal-insurance-company-decision/external-review/ for more information. In states where the federal government oversees the process, insurance companies may choose to participate in an HHS-administered process or contract with independent review organizations. If your plan doesn’t participate in a state or HHS-Administered Federal External Review Process, your health plan must contract with an independent review organization.

Related blog post:

Screenshots and Tweets; MCAT Exposures, Uninsured in Texas, Health Inequalities, a Joke, Other News

Good Reads:

  1. Wired: Bill Gates on Covid: Most US Tests Are ‘Completely Garbage’
  2. MMWR: Hospitalization Rates and Characteristics of Children Aged <18 Years Hospitalized with Laboratory-Confirmed COVID-19 — COVID-NET, 14 States, March 1–July 25, 2020 “Analysis of pediatric COVID-19 hospitalization data from 14 states found that although the cumulative rate of COVID-19–associated hospitalization among children (8.0 per 100,000 population) is low compared with that in adults (164.5), one in three hospitalized children was admitted to an intensive care unit…Among 222 (38.5%) of 576 children with information on underlying medical conditions, 94 (42.3%) had one or more underlying conditions . The most prevalent conditions included obesity (37.8%), chronic lung disease (18.0%), and prematurity (gestational age <37 weeks at birth, collected only for children aged <2 years) (15.4%)end highlight.”  Key finding: Using a multisite, geographically diverse network, this report found that children with SARS-CoV-2 infection can have severe illness requiring hospitalization and intensive care.

COVID-19 Physician’s Personal Experience

Link: MY COVID-19 Excerpts:


Healthcare: “Where the Frauds Are Legal”

A recent NY Times commentary: “Where the Frauds Are Legal” details another group of problems with health care economics.  These problems are on top of a long list of other problems which at their core relate to lack of price transparency/hidden charges and excessive charges for some services.

Here’s an excerpt:

Much of what we accept as legal in medical billing would be regarded as fraud in any other sector…

Medical Swag…Companies are permitted by insurers to bill for “durable medical equipment,” stuff you receive for home use when you’re in the hospital or doctors’ office. That yields some familiar marked-up charges, like the sling you can buy at Walgreens for $15 but for which you or your insurer get a bill for $120 after it is given to you at urgent care…

The Cover Charge…Trauma activation fees have been allowed since 2002, after 9/11, when the Trauma Center Association of America, an industry group, convinced regulators that they needed to be compensated for maintaining a state of “readiness.”…

Impostor Billing…We received bills from doctors my husband never met… for bedside treatment from people who never came anywhere near the bed to deliver the care…

The Drive-By…There was no significant health service given. Just an appearance and some boxes checked on a form. It’s a phenomenon called drive-by doctoring.

The Enforced Upgrade…[like meeting] in the emergency room [because clinic is closed]

Why do insurers pay? Partly because insurers have no way to know whether you got a particular item or service. But also because it’s not worth their time to investigate the millions of medical interactions they write checks for each day. Despite the advertised concern about your well-being, as one benefits manager enlightened me: They’re “too big to care about you.”…these are all everyday, normal experiences in today’s health care system, and they may be perfectly legal. If we want to tame the costs in our $3 trillion health system, we’ve got to rein in this behavior, which is fraud by any other name.

My take: I find it troubling to be a cog in a system that has such devious billing practices.  This particularly relates to my interactions when providing hospital-based care.  In our office, we have at least some measure of control and we can offer services like outpatient endoscopy at one-third of the cost compared to hospital-based endoscopy; similarly, our outpatient infusions are much more cost-effective than hospital-based infusions.

In terms of the health care system, my expectation is that there is not a strong enough incentive or empowerment for physicians to tackle rising health care costs (& low value care) and as such the industry will face a reckoning from outside forces.

Related blog posts:

Mandated Malpractice in IBD Care?

A recent study (A Yada et al. Inflamm Bowel Dis 2017; 23: 853-7) finds that insurance policies are not in compliance with expert guidelines.  The authors reviewed 79 policies from the top insurance companies to examine their policies regarding anti-TNF agents, vedolizumab, and ustekinumab.  These policies were compared with the American Gastroenterological Association (AGA) clinical pathway recommendations for ulcerative colitis (UC) and Crohn’s disease (CD).

Key findings:

  • “90% of the policies required step-wise failure prior to starting anti-TNF for non-fistulizing CD.”
  • “When choosing anti-TNF therapy, 26% of policies required the use of adalimumab as the first anti-TNF agent.”
  • 98% of policies are inconsistent with AGA IBD guidelines

Discussion from authors:

  • “The plans do not allow for treatment based on disease severity but rather dictate treatment based on the required failure of different drug classes.”
  • “Only 2% of UC policies and 10% of CD policies allowed for early initiation of biologic therapy to reduce the risk of complications.”
  • “The goal of medical management is to minimize the use of corticosteroids…However, the majority of the current policies…preclude this standard-of-care management.”

My take (from authors): “Most insurance companies do not comply with the current standard of care for treating IBD.” My expectation is that these problems will continue and/or worsen as the options for IBD treatment become more complex.

Normandy American Cementary


Why Do Canadians with Cystic Fibrosis Live Longer than Patients in U.S.?

NY Times Summarizes the reasons why Canadians with Cystic Fibrosis Live Longer: Link:  Canadians With Cystic Fibrosis Live 10 Years Longer Than Americans With the Disease

Cystic fibrosis is an inherited disease that causes recurrent lung infections and other problems. The average lifespan for an American with the illness is 37 years. In Canada, it is 49.

Researchers studied records of 5,941 Canadian and 45,448 American cystic fibrosis patients between 1990 and 2013. After controlling for severity of disease, age and other factors, they found that overall death rates were 34 percent lower in Canada than in the United States.

There was no difference in death rates between Canadians and Americans with private health insurance. But Canada provides universal health care coverage under a single-payer system, so every Canadian has some kind of health insurance. The Canadian death rate was 44 percent lower than that of Americans on Medicaid or Medicare, and 77 percent lower than Americans without insurance.

 AL Stephenson et al.  Ann Intern Med. 2017. DOI: 10.7326/M16-0858


Background:In 2011, the median age of survival of patients with cystic fibrosis reported in the United States was 36.8 years, compared with 48.5 years in Canada. Direct comparison of survival estimates between national registries is challenging because of inherent differences in methodologies used, data processing techniques, and ascertainment bias.
Objective:To use a standardized approach to calculate cystic fibrosis survival estimates and to explore differences between Canada and the United States.
Design:Population-based study.
Setting:42 Canadian cystic fibrosis clinics and 110 U.S. cystic fibrosis care centers.
Patients:Patients followed in the Canadian Cystic Fibrosis Registry (CCFR) and U.S. Cystic Fibrosis Foundation Patient Registry (CFFPR) between 1990 and 2013.
Measurements:Cox proportional hazards models were used to compare survival between patients followed in the CCFR (n = 5941) and those in the CFFPR (n = 45 448). Multivariable models were used to adjust for factors known to be associated with survival.
Results:Median age of survival in patients with cystic fibrosis increased in both countries between 1990 and 2013; however, in 1995 and 2005, survival in Canada increased at a faster rate than in the United States (P < 0.001). On the basis of contemporary data from 2009 to 2013, the median age of survival in Canada was 10 years greater than in the United States (50.9 vs. 40.6 years, respectively). The adjusted risk for death was 34% lower in Canada than the United States (hazard ratio, 0.66 [95% CI, 0.54 to 0.81]). A greater proportion of patients in Canada received transplants (10.3% vs. 6.5%, respectively [standardized difference, 13.7]). Differences in survival between U.S. and Canadian patients varied according to U.S. patients’ insurance status.
Limitation:Ascertainment bias due to missing data or nonrandom loss to follow-up might affect the results.
Conclusion:Differences in cystic fibrosis survival between Canada and the United States persisted after adjustment for risk factors associated with survival, except for private-insurance status among U.S. patients. Differential access to transplantation, increased posttransplant survival, and differences in health care systems may, in part, explain the Canadian survival advantage.
Primary Funding Source:U.S. Cystic Fibrosis Foundation.

Sainte-Chapelle, Paris

What physicians can learn from fast-food restaurants and retail shops

Going to a physician is worse than going to a jeweler.  At a jeweler’s, it is commonly said that if you have to ask how much it costs, then you probably cannot afford it.  When seeing a physician, in all likelihood the costs of various tests are not completely known (until the bill arrives).  In contrast, when going to a fast-food restaurant or to most shops, the price is clearly posted and this helps make an informed decision.

Not surprisingly, a recent study from Johns Hopkins has shown that physicians order less tests when the fee for the test was displayed (JAMA Intern Med 2013; 173: 903-08).

This study randomly assigned 61 inpatient diagnostic laboratory tests to an “active” arm with the fee displayed or to a control arm with no fee displayed.  The displayed fee was based on the Medicare.  During a 6-month baseline period 208-2009, no fees were displayed.  allowable fee.  Pediatrics was one of the smallest hospital services involved in this study (0.8%); internal medicine service accounted for 52.1% and intensive care 26.6%.

Results: Rates of test ordering were reduced from 3.72 tests per patient-day in baseline period to 3.40 tests per patient-day in the intervention period (8.59% decrease).  In contrast, the control arm tests increased during the same period from 1.15 to 1.22 (5.64% increase).  The net result was $400,000 charge reduction in a 6-month period.

The study limitations included the practice setting where most orders are placed by residents. In addition, it is not known whether the reductions in testing led to any detrimental affects.

Trying to sort out the price of laboratory tests, imaging, and procedures for the individual are complicated by the unfathomable world of insurance contracting and discounts. Yet, providing the baseline cost, even without knowing what part insurance would cover, would be worthwhile.  Presumably, somebody is paying.

Bottomline: How many physicians know how much that blood test, the endoscopy, or the CT scan is going to cost? In medicine, physicians frequently discuss risk-benefit ratio.  I think an effort to understand the cost should be part of the equation as well.

Related blog entries: