Report outlines tactics health insurers use to deny preventive and emergency care claims

Report outlines tactics health insurers use to deny preventive and emergency care claims
Health insurance companies can retroactively determine emergency room visits were "avoidable."

(RNN) – A new report has outlined how insurers are exploiting gaps in regulations to reject claims made for emergency room visits and as many as 1 in every 10 claims for tests and screenings.

These claim denials can leave people on the hook for thousands of dollars in bills for a trip to the ER or unable to get preventive care.

The report, “Access Denied Part 2: How Insurance Coverage Denials Can Block Access to Preventive and Emergency Care” was released by the organization The Doctor-Patient Rights Project on Tuesday.

It lays out how, in one noted example brought to light by Sen. Claire McCaskill, D-MO, earlier this year, the nation’s second-largest health insurer, Anthem, systematically denied claims made for ER visits by claiming they were “avoidable.”

Anthem rejected more than 12,000 such claims in Georgia, Kentucky and Missouri in the second half of 2017. According to the report, that represented almost six percent of all the ER claims made in that time period.

“Under federal law, insurance companies cannot deny coverage is a ‘prudent layperson’ would believe that they required emergency care and services,” the report states. “However, such an ambiguous standard has created an intricate web of state regulations that have allowed insurance companies to implement policies that flout the intent of the law.”

It cited one example in which a woman went to the emergency room in Kentucky “with severe abdominal pain thinking her appendix burst,” but when it turned out to be ovarian cysts Anthem determined the visit hadn’t been necessary.

She was left with a $12,000 bill.

“By retroactively denying coverage for emergency visits based on a patient’s 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,” Vidor Friedman, the president of the American College of Emergency Physicians, said in a Doctor-Patient Rights Project news release.

The report also outlines how testing and screening is scrutinized, and how it deters preventive care generally.

Insurers often claim these diagnostic procedures are “not medically necessary,” which can stop patients before they even seek out preventive medicines and treatments known as prophylactic interventions.

This practice disproportionately affects black Americans, 63 percent of whom reported receiving such a denial.

And, even while federal law for the most part requires insurers to cover tests and screenings, insurers can still “impose cost-sharing obligations or deny coverage for the prophylactic interventions necessary to prevent” chronic illnesses.

The report concludes that “medical insurers are blurring the lines between doctor and insurer by effectively choosing which procedures are available for patients seeking preventive and emergency care.”

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