Propublica: Appealing Health Insurance Claim Denials

… another reason you don’t want a $30 million/year health insurance CEO between you and your doctor.

{{ It’s especially complicated in oncology, said Dr. Barbara McAneny, a former president of the American Medical Association who runs a 6,000-patient oncology practice in Albuquerque, New Mexico.

“My practice is built on the theory that all the patients should have to do is show up and we should manage everything else … because people who are sick just cannot deal with insurance companies. This is not possible,” she said.

McAneny told me she spends $350,000 a year on a designated team of denial fighters whose sole job is to request prior authorization for cancer care — an average 67 requests per day — and then appeal the denials.

For starters, she said bluntly, “we know everything is going to get denied.” It’s almost a given, she said, that the insurer will lose the first batch of records. “We often have to send records two or three times before they finally admit they actually received them. … They play all of these kinds of delaying games.” }}



If only there was a way to get the government involved to enforce the laws.


I remember a skinny guy, with a funny name, talking about his mother, arguing on the phone with the insurance company, from her hospital bed, because she was being treated for cancer. He tried to do something about health insurance in Shiny-land.



I’m going through this now, though so far on a very small sum of money. Initial scan from the cardiologist denied because it was not necessary given symptoms. It eventually led to discovery of a bad P2 mitral valve, so I think it was pretty fracking necessary myself.

I hate our medical system.


What laws are you talking about here?

For one, Medicare Advantage is supposed to cover at least everything that’s approved by traditional Medicare. Yet 13% of the claims denied by Medicare Advantage insurers are for items approved by Medicare. And since everyone is “bought & paid for”, nobody goes to jail over this.

It’s no coincidence that corrupt AF, Sen. Joe Manchin would be leading 63 bipartisan senators in strong support of Medicare Advantage.



State Boards of Insurance are supposed to be there to address unfair claim settlement practices.

Depends on what state regs are.

In CT it was bad enough a few decades ago to pass a law the insurers needed to pay the doctors within 6 months.

The insurers do not mind working in less than ethical ways. It profits them.

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