North Carolina. Oklahoma. Michigan. Maine. Arizona. California.
These are just some of the states where health insurance companies are denying patients their due care — and, as a result, lawmakers are speaking out.
Over the last 40 years, states have enacted hundreds of laws that determine what exactly insurers must cover so that patients don’t go without needed medicines or procedures. But according to a recent investigation from ProPublica, health plans have violated these mandates dozens of times in the last five years. The article details some of the more dire cases where patients were denied lifesaving care.
Here’s how it works: Certain states have certain laws concerning what insurers are required to cover. (In Michigan, for instance, state law requires that health plans cover the cost of cancer drugs.) But many patients don’t know what care is covered under their state’s mandates — and health insurers take advantage of this.
State insurance departments are meant to enforce these laws. Unfortunately, many departments are ill-equipped to do so, as they oversee all types of insurance plans, including car and home insurance in addition to health insurance. These state departments are often understaffed and overworked, making it challenging to regulate payors’ bad behavior.
It often takes a complaint for an investigation or appeal to occur. But very few do so; people with plans purchased on HealthCare.gov appealed less than 1 percent of the time, according to one study that ProPublica cites. And when complaints are made, state regulators often treat them as singular instances and don’t address the pattern of behavior.
And here’s another kicker: Not all health plans are required to follow state laws. That’s because some employer-based health plans are paid directly to insurers. These are called self-funded plans, and because they’re regulated by the federal government, they’re exempt from state law requirements. As a result, regulations and consumer protections are piecemeal at best.
Health insurance companies continue to use claim denials as a tactic to preserve their profits as they avoid paying for patient care. In fact, insurers have found themselves in hot water recently for using algorithms to automatically deny claims.
Claim denials are on the rise. Nearly 1 in 5 insured Americans experienced claim denials in the past year, according to a Kaiser Family Foundation survey. The same survey also found that the more health challenges that patients experience, the more likely it is they’ll face denials. But the lesson learned from ProPublica is that the more insured Americans know about their state’s regulations to protect their care, the better.
For health plans bound by state laws, more must be done to ensure they cover patient care. In the meantime, insurers will continue to take advantage of the fact that state departments are overworked, overwhelmed, and unable to regulate their chronic denials.
