When insurance isn’t enough…

Much of the political discussion around access to affordable care is focused around how many Americans have health insurance. But increasingly, insurance coverage is failing to protect Americans from high health care costs. According to the Commonwealth Fund, 28% of Americans with insurance are still paying 5-10% of their incomes or more on health care costs.

Rising health costs certainly play a role in the unaffordability of health care, even with insurance. However, there’s another reason for this disturbing trend – insurance companies finding new ways to shift the risk of health costs back onto patients. Recent news stories show how three large insurance companies are denying  claims, and the impact this has on patients’ health and financial security.

Charging for false alarms

Last year, insurance giant Anthem rolled out a new policy in three states that punishes patients who use the emergency room for non-emergencies. The policy, designed to reduce inappropriate emergency room use, would not cover claims for emergency room visits later deemed to be not emergencies. 

The policy drew criticism from doctors and policymakers, who are concerned that patients having a life-threatening episode will be deterred from going to the emergency room for fear of having to pay in case it’s not an emergency. Putting the responsibility on patients to determine whether they’re having a medical emergency is illogical and exacerbates an already stressful situation. And yet, this year Anthem expanded the policy to three more states

Anthem’s policy is already hurting patients. One patient in Missouri was hit by a car and transported to the ER by paramedics. After several scans, he was found to have no serious injuries. Later, Anthem denied his insurance claim, even though he had no choice about going to the ER. 

Another patient in Frankfort, Kentucky, came to the ER with a high fever and extreme pain, worried it could be appendicitis. The doctors determined she had ovarian cysts and gave her treatment, but Anthem would not cover the claim. She received a bill for $12,596. Unfortunately, we will likely see more of these cases as Anthem’s policy is implemented in more states in 2018. 

The dental care coverage gap

As we’ve written previously, dental care is often expensive or inaccessible for those without insurance. However, even for those with dental and medical insurance, the costs can be severe if an insurance provider denies the claim. When 7-year-old Victoria Crovo lost several teeth in a sledding accident, her parents had to cough up $20,000 to pay for her restorative dental work, because their dental insurance only paid a couple thousand dollars.

Their medical insurer, United Health, wouldn’t pay for any dental care, because they have a 12-month limit on payments for dental care for accidents. But she couldn’t receive the implants until her mouth had fully grown, 11 years after the accident. According to health insurance experts, this loophole is unfair but legal. After battling with the insurance company unsuccessfully for several years, the Crovos had to refinance their home to pay for Victoria’s care. 

“It’s just so frustrating,” said Lisa Crovo, Victoria’s mother, in The Boston Globe, “We’ve paid premiums all these years for insurance. But when we need it, it’s not there.”

Denying without reviewing

Every claim an insurance company receives is supposed to be reviewed by a physician before being approved or denied. However, while testifying in a lawsuit, former Aetna medical director Dr. Ken Iiuma revealed that he had never looked at a patient’s medical record for the three years he reviewed treatment authorization requests. Instead, he relied on nurses’ recommendations, only following up with nurses once a month or every other month. This means he had little knowledge of patients’ conditions, symptoms, or treatment, and never followed up with a patient’s physician to find out more about a case. 

Not only was Iiuma’s practice completely against Aetna’s stated policy, it also demonstrates a disturbing lack of empathy toward patients. Because Iiuma had not looked at any patient’s medical record, he was closed off from the patient’s experience. In the case of Gillen Washington, a patient with a rare immune deficiency disorder whose treatment pre-authorization Aetna denied, Iiuma’s testimony revealed that he did not know what symptoms Washington had, or what would have happened to Washington if he could not receive treatment.

Since CNN broke this story, California Insurance Commissioner Doug Jones has launched an investigation of Aetna to see how widespread this practice is. They might want to investigate other insurance companies too, while they’re at it.