Has your health insurer refused to cover a procedure or pharmaceutical? Time for Medicare for All?

ProPublica is an excellent source of accurate information about the government and its failings. (One might say it is the diametric opposite of FoxNews/QAnon/Tucker Carlson/Marjorie Greene/Donald Trump/MAGA, et al.).

Here are excerpts from an article about private healthcare insurance. Follow the link below for the full text.

ProPublica
Health Care
How Often Do Health Insurers Say No to Patients? No One Knows.
Insurers’ denial rates — a critical measure of how reliably they pay for customers’ care — remain mostly secret to the public. Federal and state regulators have done little to change that.
by Robin Fields
June 28, 5 a.m. EDT

It’s one of the most crucial questions people have when deciding which health plan to choose: If my doctor orders a test or treatment, will my insurer refuse to pay for it?

After all, an insurance company that routinely rejects recommended care could damage your health and finances.

The question becomes more pressing as many working Americans see their premiums rise as their benefits shrink.

Yet, how often insurance companies say no is a closely held secret.

There’s nowhere that a consumer or an employer can look up all insurers’ denial rates — let alone whether a particular company is likely to decline to pay for procedures or drugs that its plans appear to cover.

In collaboration with The Capitol Forum, ProPublica has been examining the hidden world of insurance denials.

A previous story detailed how one of the nation’s largest insurers flagged expensive claims for special scrutiny; a second story showed how a different top insurer used a computer program to bulk-deny claims for some common procedures with little or no review.

Cigna, one of the country’s largest insurers, has built a system that allows its doctors to instantly reject a claim on medical grounds without opening the patient file, leaving people with unexpected bills, according to corporate documents and interviews with former Cigna officials.

Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method, spending an average of 1.2 seconds on each case.

The insurance industry’s profit motive supersedes the mission to help people pay their medical bills.

In 2010, federal regulators were granted broad authority through the Affordable Care Act to require that insurers provide information on their denials. This data could have meant a sea change in transparency for consumers.

But more than a decade later, the federal government has collected only a fraction of what it’s entitled to. And what information it has released, experts say, is so crude, inconsistent, and confusing that it’s essentially meaningless.

Why? Because healthcare insurers fund massive bribes (aka “election contributions”) to politicians at all levels of government. They want the information to be hidden.

The national group for state insurance commissioners gathers a more detailed, reliable trove of information. ProPublica requested the data from every state’s insurance department, but none provided it.

Two states collect their information on denials and make it public, but their data covers only a tiny subset of health plans serving a small number of people.

The main trade groups for health insurance companies, AHIP (formerly known as America’s Health Insurance Plans) and the Blue Cross Blue Shield Association, say the industry supports transparency and complies with government disclosure requirements.

Yet the groups have often argued against expanding this reporting, saying the burdens it would impose on insurance companies outweigh consumers’ benefits.

You just read excuse #1. “It costs too much.” Then when #1 doesn’t work, they do the Trumpian dance and come up with excuse #2::

“Denial rates are not directly comparable from one health plan to another and could lead consumers to make inaccurate conclusions on the robustness of the health plan,” Kelly Parsons, director of media relations for the Blue Cross Blue Shield Association, said in an email.

And then they follow up with #3, #4, and #5. Most claims are paid; there are errors, and doctors provide incomplete information.

The trade groups stress that a substantial majority of patient claims are approved and that there can be good reasons — including errors and incomplete information from doctors — for some to be denied.

Not to be content, we are treated to five more excuses, #6 (no context), #7 (doesn’t indicate quality), #8 (doesn’t say why), and #9 (doesn’t tell what happened after) and #10 (what the patient or doctor should do).

“More abstract data about percentages of claims that are approved or denied have no context and are not a reliable indicator of quality — it doesn’t address why a claim was or was not approved, what happened after the claim was not approved the first time, or how a patient or their doctor can help ensure a claim will be approved,”

AHIP spokesperson Kristine Grow said in a written response to questions from ProPublica. “Americans deserve information and data relevant to their health and circumstances.”

I’ll leave the pious generalities to remind you that the insurance industry is one of the most data-driven industries on earth. Insurance companies employ well-paid actuaries who spend their lives determining such things as:

1. The likelihood of a claim
2. The cost variables of each claim
3. The coverages have proved to be and are likely to be the most expensive, and their cost?
4. The claims that have been and should be denied, based on such factors as immediate cost, long-term cost, likely results of lawsuits and their costs, details that affect costs, subrogation probabilities, etc., etc. etc?

In short, insurance companies already have all the data at their fingertips, but they don’t want you to know them.

The limited government data suggests that insurers deny between 10% and 20% of the claims they receive. Aggregate numbers, however, shed no light on how denial rates may vary from plan to plan or across types of medical services.

Some advocates say insurers have a good reason to dodge transparency.

Refusing payment for medical care and drugs has become a staple of their business model, in part because they know customers appeal less than 1% of denials, said Wendell Potter, who oversaw Cigna’s communications team for more than a decade before leaving the industry in 2008 to become a consumer advocate.

“That’s money left on the table that the insurers keep,” he said.

The insurers do what they know they can get away with. That is what keeps PI (personal injury) attorneys in the business.

If you watch TV, you might have noticed the hundreds of ads by lawyers who tell you that if they don’t collect, you pay nothing for their services.

How can they all do that? How can they give away millions of dollars worth of services and still pocket millions of dollars for themselves?

They know insurance companies too often deny claims that never should be denied. The insurance companies know it, too.

When lawyers enter the picture, they feel confident they will collect. The insurance company knows it will lose. So they settle. It’s a multi-billion dollar game.

But aren’t those billions of dollars in settlements costly? Yes, but less expensive than paying the claims that should have been borne in the first place.

At least one insurer disputes this. In an email, Potter’s former employer, Cigna, said that his “unsubstantiated opinions” don’t reflect the company’s business model.

In a separate written statement, Cigna said it passes on the money it saves “by lowering the cost of health care services and reducing wasteful spending” to the employers who hire it to administer their plans or insure their workers.

Blah, blah, blah. More double-talk. The undeniable fact remains that denying claims while paying their attorneys, paying claimants’ attorneys, paying settlements, and even paying penalties is still more profitable than paying rightful claims.

They know it because their well-paid actuaries tell them.

The few morsels insurers have served up on denials stand in stark contrast to the avalanche of information they’ve divulged in recent years on other fronts, often in response to government mandates.

Starting last year, for example, insurers began disclosing the prices they’ve negotiated to pay medical providers for most services.

Experts say it’ll take similar mandates to make insurers cough up information on denials, partly because they fear plans with low denial rates would be a magnet for people already ailing.

Insurance companies want to cover you if you never need them. If you need them, they don’t want you.

“Health plans would never do that voluntarily, would give you what their claim denial rates are, because they don’t want to attract sicker people,” said Mila Kofman, who leads the District of Columbia’s Affordable Care Act exchange and previously served as Maine’s superintendent of insurance.

They are in the business to make a profit, not to help people. Compare the profit motivation of an insurance company with the motivation of, for example, Medicare, the sole purpose of which is to aid sick people.

It’s an attitudinal thing. To Medicare, you are a patient. To an insurance company, you are a customer. To Medicare, you have medical problems. To insurance companies, you have costly claims.

About 85% of people with insurance who responded to a recent Kaiser Family Foundation survey said they want regulators to compel insurers to disclose how often they deny claims.

In September 2009, amid a roiling national debate over health care, the California Nurses Association made a startling announcement: Three of the state’s six largest health insurers had each denied 30% or more of the claims submitted to them in the first half of the year.

Think about that astounding 30% denial rate. Can you imagine so many erroneous claims?

California insurers instantly said the figures were misleading, inflated by claims submitted in error or for patients ineligible for coverage.

But wait! The insurance companies complained the reporting would be too burdensome, which means they didn’t yet have the information. They would need to gather it.

But if they still need to gather the information, how do they know the figures are misleading?

The Affordable Care Act was a game changer when it came to policing insurers and pushing them to be more transparent.

The law aimed at insurers’ practice of excluding people with preexisting conditions, the most flagrant type of denial, and required companies offering plans on the marketplaces created under the law to disclose their prices and detail their benefits.

A less-noticed section of the law demanded transparency from a much broader group of insurers about how many claims they turned down, and it put the Department of Health and Human Services in charge of making this information public.

The disclosure requirements apply to health plans sold on the new marketplaces and employer plans that cover most Americans.

The law’s proponents in the Obama administration said they envisioned a flow of accurate, timely information that would empower consumers and help regulators spot problematic insurers or practices.

That’s not what happened.

The federal government didn’t start publishing data until 2017 and thus far has only demanded numbers for plans on the federal marketplace known as Healthcare.gov. About 12 million people get coverage from such plans — less than 10% of those with private insurance.

Federal regulators say they eventually intend to compel health plans outside the Obamacare exchanges to release details about denials but have made no move.

Within the limited universe of Healthcare.gov, Kaiser Family Foundation’s analyses show that insurers, on average, deny almost 1 in 5 claims and that some reject more than 1 in 3 each year.

But there are red flags suggesting insurers may not report their figures consistently. Companies’ denial rates vary more than expected, ranging from as low as 2% to as high as almost 50%.

Plans’ denial rates often fluctuate dramatically from year to year. A gold-level plan from Oscar Insurance Company of Florida rejected 66% of payment requests in 2020, then turned down just 7% in 2021.

That insurer’s parent company, Oscar Health, was co-founded by Joshua Kushner, the younger brother of former President Donald Trump’s son-in-law Jared Kushner.

That doesn’t sound suspicious at all. Nor does the fact that Jared received $2 BILLION unexplained dollars from the Saudis, but that’s another story.

An Oscar Health spokesperson said in an email that the 2020 results weren’t a fair reflection of the company’s business “for a variety of reasons” but wouldn’t say why.

A reasonable guess would be that the “variety of reasons” features, “We made up the numbers, and when they didn’t look good, we made up new numbers.”

“We closely monitor our overall denial rates, and they have remained comfortably below 20% over the last few years, including the 2020-2021 time period,” the spokesperson wrote.

It’s not clear what is “comfortable”about a 20% denial rate. When you buy insurance, do you feel good about “only” 20% of your claims being denied?

The federal government provides numbers on insurers’ denials of claims for services from what the industry calls “in-network” medical providers, those with contracts with the insurer.

But it doesn’t include claims for care outside those networks. Patients often shoulder more costs for out-of-network services, ramping up the import of these denials.

In recent years, doctors and patients have complained bitterly that insurers require them to get approval in advance for an increasing array of services, causing delays and, in some instances, harm.

Medicare doesn’t require prior approval, but private insurance does. Why? Because prior approval provides an additional venue for denial of claims, and almost never is litigated.

The government, however, hasn’t compelled insurers to reveal how many requests for prior authorization they get or what percent they deny.

These and other specifics — particularly about which procedures and treatments insurers reject most — would be necessary to turn the government’s data into a viable tool to help consumers choose health plans, said Eric Ellsworth, the director of the health data strategy at Consumers’ Checkbook, which designs such tools.

The U.S. Department of Labor regulates over 2 million health plans, including many in which employers pay directly for workers’ health care coverage rather than buying it from insurance companies.

According to the Kaiser Family Foundation, roughly two-thirds of American workers with insurance depend on such plans.

In short, employers of 2/3 of American workers are finding the insurance industry so profitable (and so crooked) they have decided to dip into that trough themselves.

And how many employees are willing to risk suing their own employer for denying a claim?

In July 2016, an arm of the Labor Department proposed rules requiring these plans to reveal a laundry list of never-before-disclosed information, including how many claims they turned down.

In addition, the agency said it was considering whether to demand the dollar amount of the denied care cost, as well as a breakdown of why plans turned down claims or denied behavioral health services.

The disclosures were necessary to “remedy the current failure to collect data about a large sector of the health plan market,” as well as to satisfy mandates in the Affordable Care Act and provide critical information for agency oversight, a Labor Department factsheet said.

Trade groups for employers, including retailers and the construction industry, immediately pushed back.

Of course, they did. The companies have a captive audience –people held captive not only by their jobs but by ignorance of the facts — so the employers fight like hell to keep things as they are.

The U.S. Chamber of Commerce said complying with the proposal would take an amount of work not justified by “the limited gains in transparency and enforcement ability.”

How do they know what will be “the limited gains in transparency and enforecement ability”? They know because they know how much the insurance companies have been cheating  customers.

The powerful business group made it sound like having to make the disclosures could spark insurance Armageddon: Employers might cut back benefits or “eliminate health and welfare benefits.”

Fact: Those so-called “benefits” are not benefits at all. They are paid for by the employees in that they are deducted from employees’ salaries.

How? The companies determine the cost of those “benefits” when determining what to pay people.

The employer knows that if he pays someone a $50,000 salary, his actual cost must include his share of FICA, healthcare insurance, retirement, and all other so-called “benefits.”  That $50,000 salary comes to more than $60,000.

When hiring for a $50,000 salary, the employer has to ask himself, “Is this guy worth more than $60,000?

Trade groups for health insurance companies, which often act as administrators for employers that pay directly for workers’ health care, joined with business groups to blast the proposal.

The Blue Cross Blue Shield Association called the mandated disclosures “burdensome and expensive.” AHIP questioned whether the Labor Department had the legal authority to collect the data and urged the agency to withdraw the idea “in its entirety.”

“Burdensome and expensive,” not because they don’t already have the data. They have them but they don’t want anyone to know them.

The proposal also drew opposition from another, less expected quarter: unions. Under some collective bargaining agreements, unions co-sponsor members’ health plans and would have also been on the hook for the new reporting requirements.

The AFL-CIO argued the requirements created a higher disclosure standard for plans overseen by the Labor Department.

To be fair and avoid confusion, the group said, the Labor Department should put its rules on ice until federal health regulators adopted equivalent ones for plans this proposal didn’t cover.

That’s the “It’s unfair to tell us to do the right thing if the other guys don’t do the right thing.” See, it’s all about “fairness.” And then, when regulators “adopt equivalent plans, we’ll offer another excuse. We have an endless supply of excuses.”

By the time the Labor Department stopped accepting feedback, Donald Trump had been elected president.

One trade association for large employers pointed out that the Affordable Care Act, which partly drove the new rules, was “a law that the incoming Administration and the incoming leadership of the 115th Congress have vowed to repeal, delay, dismantle, and otherwise not enforce.”

The law survived the Trump administration, but the Labor Department’s transparency push didn’t. The agency withdrew its proposal in September 2019

A Labor Department spokesperson said the Biden administration has yet to make a plan to revive it.

By this time, you’re beginning to see a pattern. Those whose income relies on claims denial — insurance companies, politicians, unions, and employers — all fight against revealing the data to the public.

The profit motive does not burden the Affordable Care Act and Medicare. Although Medicare does deny some claims, most of that is because of involvement with an unproven drug or procedure.

And much of the rest has to do with the false belief that FICA finances claim payments. But FICA pays for nothing. All Medicare payments are financed by new dollar creation.

Every dollar you pay into FICA is destroyed upon receipt by the federal government. (For an explanation of that startling fact, click here.)

Ultimately, the National Association of Insurance Commissioners, a group for the top elected or appointed state insurance regulators, has assembled the most robust details about insurance denials.

The association’s data encompasses more plans than the federal information, is more consistent, and captures more specifics, including numbers of out-of-network denials, information about prior authorizations, and denial rates for pharmacy claims. All states except New York and North Dakota participate.

Yet, consumers need access. The commissioners’ association only publishes national aggregate statistics, keeping the rest of its cache secret.

When ProPublica requested detailed data from each state’s insurance department, none would hand it over.

When even the government won’t disclose data like out-of-network denials, denial rates for pharmacy claims and other non-personal infomation, you know, for certain, that the data are hidden for a nefarious reason.

You can be positive there is something to hide that should not be hidden.

More than 30 states said insurers had submitted the information under the authority commissioners are granted to examine insurers’ conduct. And under their states’ codes, they said, examination materials must be kept confidential.

The commissioners association said state insurance regulators use the information to compare companies, flag outliers, and track trends.

Regulators can make that comparison, but you are not allowed to. What do the regulators do with the information? Apparently, nothing.

Birny Birnbaum, a longtime insurance watchdog who serves on the group’s panel of consumer representatives, said the association’s approach reflects how state insurance regulators have been captured by the insurance industry’s demands for secrecy.

“Many seem to view their roles as protectors of industry information, as opposed to enforcers of public information laws,” Birnbaum said in an email.

That is why the insurance industry is so lavish with its bribes.

Connecticut and Vermont compile their own figures and make them publicly accessible. Connecticut began reporting information on denials first, adding these numbers to its annual insurer report card in 2011.

Vermont demands more details, requiring insurers that cover more than 2,000 Vermonters to publicly release prior authorization and prescription drug information that is similar to what the state insurance commissioners collect.

Perhaps most usefully, insurers have to separate claims denied because of administrative problems — many of which will be resubmitted and paid — from denials that have “member impact.” These involve services rejected on medical grounds or because they are contractually excluded.

Mike Fisher, Vermont’s state health care advocate, said there’s little indication consumers or employers are using the state’s information, but he still thinks the prospect of public scrutiny may have affected insurers’ practices.

The most recent data shows Vermont plans had denial rates between 7.7% and 10.26%, considerably lower than the average for plans on Healthcare.gov.

“I suspect that’s not a coincidence,” Fisher said. “Shining a light on things helps.”

SUMMARY
The insurance industry bribes the politicians not to reveal statistics on claim denial. The reason” Claim denial is an integral part of the insurance industry business model.

Too many denials must come not for medical reasons or for reasons the insurance industry wants you to know. They happen for profit reasons.

A comprehensive Medicare plan for every man, woman, and child in America is a threat to the insurance industry. They wrongly claim that somehow, privately funded insurance is better than federally funded insurance.

There is no functional reason why America needs privately-owned, for-profit insurance companies that collect medical dollars but provide no medical services.

It is a costly scam. The insurance companies, in essence, tell you, “Give me your healthcare dollars. We’ll give some of them to doctors, nurses, and hospitals and keep as much as we can for ourselves.”

What’s the purpose of having middlemen take some of your hard-earned medical dollars?

It would be far better for the federal government to tell you, “You don’t have to give us anything. We’ll create the dollars and pay them to the doctors, nurses, and hospitals. It won’t cost you a cent. You and your doctors will make the medical decisions. We’ll just pay for them.”

That is the way medicine should and could operate.

When Bernie Sanders offered his Medicare for All plan, even his “weak tea” version of coverage was denounced as unaffordable and socialism. It is neither.

The federal government, being Monetarily Sovereign, can afford anything that requires dollars, and has no need to collect taxes to pay for it. The federal government pays for everything by creating new dollars, ad hoc.

And forget about that ignorant “socialism” claim:

Socialism social and economic doctrine that calls for public rather than private ownership or control of property and natural resources.

Merely paying for things, which all governments do, is not socialism.

America needs a comprehensive, no deductible, leaning-over-backwards-to- be-generous form of Medicare for every man, woman, and child in America.

No public purpose is served by private insurance companies, who not only extract dollars from the public for no common good, but require government supervision to (failingly) prevent fraud on the public.

Further, they enrich the lawyers who must sue them. None of this benefits the public and all of it costs the public.

A federally funded, comprehensive, no-dedictible Medicare for every man, woman, and child in America, would cost nothing, suffer from much less criminality, and in fact add growth dollars to the economy.

Rodger Malcolm Mitchell
Monetary Sovereignty

Twitter: @rodgermitchell Search #monetarysovereignty
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The Sole Purpose of Government Is to Improve and Protect the Lives of the People.

MONETARY SOVEREIGNTY