Dealing With Insurance Denials

Brian Lehrer: It's the Brian Lehrer Show on WNYC. Good morning again, everyone.

The public outcry over health insurance delays and denials since the assassination of UnitedHealthcare CEO, Brian Thompson, has brought little in the way of policy change proposals. Elizabeth Benjamin, Vice President of the Community Service Society of New York, which does both advocacy on behalf of policies that they believe help lower income people, and a community health advocates program that offers advice for individuals on navigating the health care system, joins us now. She is the Community Service Society Vice President. She joins us now to advise anyone who calls in who is dealing with a delay or denial issue. Hopefully the explanations we get for a few callers will help the rest of you know what some of your rights and available strategies are for if you find yourself in a similar situation. We'll talk some policy with Elizabeth Benjamin, too. We cover that a lot, as most of you know, including the national special on the topic that I co-hosted in October before the killing.

The premise of this segment is mostly that while Congress remains stalemated on the issue, we can at least help individuals with some of your situations. Listeners, who needs delay or denials advice? Patients, doctors, doctors' office staff workers, you're all welcome to call in. 212-433-WNYC. 212-433-9692. Again, our guest is Elizabeth Benjamin, Vice President of the Community Service Society of New York, which does advocacy on behalf of related policies, but also has a community health advocates program that offers advice for individuals on navigating the healthcare system. Elizabeth Benjamin is a navigator extraordinaire. I know from her time working to help people sign up for Obamacare. I know some people personally who used her services.

Elizabeth, we always appreciate you coming on. Welcome back to WNYC.

Elizabeth Benjamin: Thanks for having me. I'm really excited to be here again.

Brian Lehrer: Let me jump right in with one piece of overarching advice that I think you give. Many people don't realize that insurance company denials can be appealed, and that with an appeal, you often win. Would you say that's right?

Elizabeth Benjamin: That is right. If you don't believe me, you can look at the State Department of Financial Services. They actually have a little database of people that make it to them through the external review process. After you lose your internal appeals at the health plan, you do have a right to go to an external review judge, essentially who's usually a doctor, and they will take a look and see if the plan's internal decisions are correct.

Tens of thousands of New Yorkers have availed themselves of this right in New York since we, I think, put it in place in around 2008, I believe. Our database has been up and running for the last four or five years. You can search to see if people with the same issue as you, what happened in their case. You can search by type of plan, name of the carrier, type of procedure or whatever you're looking for. It's quite helpful.

Brian Lehrer: Your advice page is great, by the way, at communityhealthadvocates.org, now that I've given it a look over the last day or so. One section is simply called What Are My Appeal Rights? So what are they generally for privately insured people?

Elizabeth Benjamin: Oh, gosh, now I feel like I have to go on to that web. The first thing I would say is, if you get a denial, call your health plan. Number one, just call them because they'll tell you what's going on. It might be that your healthcare provider put in the wrong claim code. Sometimes you can get the health plan and your provider on the phone together and make sure that the right code is gone in.

The other thing that you should do is if you do get a denial, review that notice you get from the insurance company. It's called an explanation of benefit in the industry, and it's supposed to be explaining the benefits you got. Sometimes the denial codes, which are in mouse print and with tiny little Roman numerals and footnotes, are hard to understand. It might be it's not medically necessary, or it's an allowed amount. They'll have all this jargon. If you don't understand that jargon, call your health plan and get them to explain it to you. That's the first thing you should do, is just read the paperwork that you have.

The second thing you should do is try to figure out, from that paperwork, why it might have been denied. Did the provider put the wrong code in? Did the provider not get pre-authorization, or did you not get a referral or what they call pre-authorization? You didn't get permission to do the service or procedure, and take a look at that. Then you can definitely try to appeal if you think you followed their rules and you didn't.

The other thing is, you know, they may say it wasn't medically necessary. That's where we often get a lot of joy on appeals because when we get it finally to that external review level, we can get doctors to really think, look through the medical literature on your case.

Then sometimes people are just asking for something that isn't a real covered benefit. That's where we can call and look at your contract and make sure that the service you're looking for is actually covered under your contract. Then last but not least, a lot of times, people go out of network and they end up with these balance bills that only pay a fraction of what you paid, and that can be quite frustrating to be stuck with that balance bill.

The one thing I want to say is that according to the KFF, 17% of health insurance claims are denied, of a big analysis of 250 million claims that they looked at. I would love to know how many claims are denied in New York State. I can't tell you, and neither can the Department of Financial Services, and neither can the Department of Health, and even the governor can't tell you. Why is that? We don't collect that data and we don't report it out. About 15 states around the country do not collect and report that data. I think that's really a problem that we don't have a standard national data set on the number of insurance claims that are denied by carrier and the reasons why. We really need major reform in this area.

I think that's why people are so mad in the wake of the assassination of the UnitedHealthcare executive. People are mad. United is the face of all these denials, and it's a very visceral experience for people, to have your healthcare suddenly denied and be facing tens of thousands of debt.

Brian Lehrer: Let's take a phone call. Lorna in Queens, you're on WNYC. Hello, Lorna.

Lorna: Good morning. My issue has to do with medical test blood work that was done in the office of my doctor, and it appears that they sent these tests out to an out of network lab. Normally they would send it to Quest, but they sent it somewhere else, and now my insurer won't pay, and I don't know who to call first, the doctor or the insurance company.

Elizabeth Benjamin: I would definitely call the insurance company first. If it's a state regulated plan, for sure they should be covering that claim even if it went out of network. I would also talk to your doctor and see what they thought they were doing. I just actually had a similar case come in today where somebody got a colonoscopy, and they searched the United app and went to the in network doctor, and the facility and the anesthesiologist were out of network. Those cases should never happen. That's what the No Surprises Act is supposed to prevent. The federal one, we have our own state one. Please call your health insurance company, and if that doesn't work, you can give us a call or call the Department of Financial Services.

Brian Lehrer: Lorna, I hope that's helpful. Let's take another one. Lou in Glenrock, you're on WNYC. Hi, Lou.

Lou: Hi, how you doing? My story is I have UnitedHealthcare, and I had a small surgery done about two years ago to remove a lump on my neck. I called and I got the codes. I called the insurance company, made sure everything was right. I took good notes, and I came back and they hit me up for the $3,000 bill saying I'm not covered because the procedure was done in a hospital. It was not done in a hospital. Done in an outpatient center owned by a hospital. That was the reason for denying me.

I even got the recording. I said, "Look, look at the recording." The lady I spoke with told me I was covered. They looked at it and still deny me. Then I looked on the bill and I also called my broker. They said there's a number to call for the state of New Jersey. I called the state of New Jersey. They were very responsive. I forget what division it was. I sent them all the information. They sent a letter to UnitedHealthcare. Next day they paid.

Elizabeth Benjamin: Bravo for you.

Lou: It took a while, but if you do the right thing, you can sometimes-- You've got to take notes. Anyway, that's my story.

Elizabeth Benjamin: That's amazing advice. I'm sorry, I didn't say that, I should have, please take notes. Take the name of the person you talk to, or if they have a plan representative number, because they're not going to give your name, get that number of their little code. Always take notes. Contemporaneous notes are really helpful for us when we're helping you appeal a denial. Great, great self advocacy. I'm really impressed.

Brian Lehrer: Lou, thank you. Here's a story from a listener in a text that might be somewhat related to Lou. This says, "My mom is a hospice social worker, so she knows her way around insurance issues. In her personal life, I've seen her skip the internal appeal process and go straight to the state board. That's in Illinois. In her case, that's been much faster and more effective." She also says you can always negotiate on a medical bill. If your bill goes to collections, the provider pays them half. At the minimum, they'll usually be able to reduce it by 50%.

There's two things in there. The first one, what do you think about that idea of skipping the internal insurance company appeals process and going right to the state board?

Elizabeth Benjamin: I'm not a huge fan of that because it depends on what state you're in. I'm glad it works in Illinois, but many states require you to exhaust the internal appeal before you go to an external appeal. Sometimes they have timeframes, like 60 days, and you wouldn't want to miss those time frames. I think what's really frustrating is, according to the same KFF report, of these 250 million claim reviews, only less than 0.1% of the population actually appeals their denials. We really, really need to bump that number up. Because what's happening is people are just paying or negotiating a deal with their providers, which I think is a great idea, too, if all else fails, and we do that a lot, but I think it's really important to try to appeal internally and then get to that external review process. Most plans are now required, throughout the United States, to have some kind of external review process, and you can prevail there. You're likely to prevail there.

Brian Lehrer: The other thing that listener brought up, negotiating on the medical bill to maybe avoid going through all these appeals. I don't know if maybe if you have the money, and the money's worth less to you than your time, but what do you think about that approach?

Elizabeth Benjamin: I have to say, I thought about that this Tuesday when my daughter's specialty shot was not-- I started getting a $350 copay from CVS Specialty Care Pharmacy. I called the drug company, and I called the Prescription Assistance Program. I called everybody, and literally it took me 45 minutes, seven people, but eventually they put together a conference call, which I suggested right away, and they figured out the problem and resubmitted the claim. It's maddening to do that. I have two advanced degrees in this particular area. I feel like it's worth it because I don't feel like we should be eating these bills just because the industry makes it hard for us. It probably Wasn't worth my time for $350. I felt like it's important on the principal. They shouldn't just stick us with the bills.

Going back to whether it's a good idea to negotiate, a lot of people have a thing called a deductible, which means that you're on the hook to spend the first $2,000 or even $4,000 of your own money after spending on your premiums on your healthcare. In those cases, I think it's really important to know that you can negotiate and providers often will discount the care that they provided to you when you're stuck with that bill, that pre-deductible bill. Also with people that have coinsurance, which means your health insurance company at least pays 50% of the cost of care, and the provider charges full freight, $40,000, and the insurance company is only paying $20,000, often the provider will negotiate how much you owe down from that $20,000 balance.

I think it's really worth trying to negotiate your bills, but I don't know that it's fair to always stick the providers with making the discount when it's really a question, like it was with my daughter, that CVS and-

Brian Lehrer: The insurance company.

Elizabeth Benjamin: -they should have paid. Yes.

Brian Lehrer: Tina in Manhattan, you're on WNYC with Elizabeth Benjamin, Health Insurance Denials Navigator for the Community Service Society. Hi, Tina.

Tina: Hi, Brian. Thanks for taking my call. Just real quickly, I wanted to mention my brother had lost his leg and he had his prosthetic leg stopped. It really needed to be placed. It was causing him a lot of pain. The insurance company kept saying no, no, no. He just made it his business to appeal, and every appeal, he'd get a letter back denying. He just appealed so many times, he wasn't going to stop, so that he got a cover letter from a big wig at the insurance company saying, "Okay, we're clearing you, but only because we want your letters to stop."

Brian Lehrer: Ah, the squeaky wheel. Tina, if I may ask, on what grounds did they deny adjustment of his prosthetic leg?

Tina: I can't say that I asked him that or that he told me. That, I can't be sure of. He definitely needed a new leg, and he hasn't needed one in all the years since.

Brian Lehrer: Tina, thank you.

Elizabeth Benjamin: I have a great story just like that.

Brian Lehrer: Go ahead.

Elizabeth Benjamin: We were reached out by an Albany area mom of a child with spina bifida, six-year old child. The insurance company would only give the child an adult wheelchair. I said, "Can you just take a picture of your child in an adult wheelchair?" They did. It showed the seat belt was two feet out. Then faxed that little photo, that little Polaroid, we still had Polaroids then, to the insurance company. I said, "Your call. It's the week before Thanksgiving, front page of the Albany Times Union or he gets his wheelchair, his kiddie wheelchair." He got his kiddie wheelchair. He didn't get it before Thanksgiving, but he got it the following week.

Brian Lehrer: That's another way to be a squeaky wheel, it's threaten to go to the media.

Elizabeth Benjamin: If your brother's leg was having blisters or cuts or whatever, pictures are often worth a thousand words, especially on these medical equipment denials, because they can be really unsafe.

Brian Lehrer: This is, I guess, probably the most infuriating category of denial. Not medically necessary. After a doctor says it's medically necessary, do you know in that case why they wouldn't give a kid a kid's wheelchair instead of an adult wheelchair?

Elizabeth Benjamin: It was maddening. They never had a good reason. They just said, "That's what we're going to cover. That's what's the benefit is." They tried to pretend that having a child's wheelchair was not part of the benefit package, but that's nonsense. If you're providing child coverage, you have to have child wheelchairs. It was really just a shocking situation. We got it.

Brian Lehrer: One more call. Louise in Brooklyn, you're on WNYC. Hi, Louise, we've got about a minute for you.

Louise: Okay, Brian. This is a long story, I'll try to cut it short. I was denied coverage for a breast ultrasound by Medicare. I've been getting them for many, many years, and I've been getting them since I'm on Medicare. This year, they denied it. I found out, through great research for six months, that they are now not considering history of breast cancer in the family, my sister, or dense breasts. Valid reason for coverage of an ultrasound despite the fact that I have a script from my doctor requiring it. I submitted all kinds of documentation going back about 30 years, and Medicare finally approved it. I continue to get a bill every single month from the radiology company. It's very frustrating. I'm not the only one. About four other people that I know personally are having the same issue. My own primary care doctor called me today to ask me what I did to navigate this, because they're having so much trouble with some of their patients.

Brian Lehrer: Louise, thank you for that story. It raises several questions, Elizabeth. One is, oh, this happens with Medicare, too, not just with private insurance, and, well, take that one.

Elizabeth Benjamin: I guess my question is, we didn't quite get that answer. Was the caller in original Medicare or were they in a Medicare Advantage plan? Because about 50% of the population are in Medicare Advantage plans. It does seem that Medicare--

Brian Lehrer: That would be good to know because then Medicare Advantage is private insurance. Louise, do you know?

Louise: Yes, I am on regular Medicare, and I can also tell you that the ultrasounds have been required of me for something like 25 years. I'm supposed--

Brian Lehrer: Louisa, forgive me for cutting you short there, but I want to get the answer in from Elizabeth. Even regular Medicare. Another implication of her question is, because she was working with the doctor's office, do you do advice at the Community Service Society for doctors and their staffs, or just for individuals who are the patients?

Elizabeth Benjamin: We, of course, the new hospital financial assistance law came out, hospital billing staff called us. We, of course, will answer anybody's call. That's our job. We have a program dedicated to people with mental health and substance use issues and insurance, and that program is specifically designed to provide assistance to providers, as well as patients. All our programs will help providers, as well as patients.

I think there was a change in policy for Medicare recently, it looks like it may be even in mid '24, that they don't cover dedicated dense breast screenings. They're trying to cut back on that. In this case, it sounds like the caller had a history. If you have other clinical reasons for needing the dense breast exam screening, mammography screening, then they will cover it. I think it's why she was able to flip the script in her case, and bravo to her.

Brian Lehrer: One quick policy question, then. I think you're an advocate for Medicare for all. Would it be any better in this respect if they had to cover every expense and we're trying to keep their expenses down? Real quick.

Elizabeth Benjamin: I think Medicare for all would be easier for patients. I think right now, our system, where all these insurance companies are regulated by random states and, in some cases, the Department of Labor, that we don't have any federal overarching regulatory structure over insurance. Insurance is such a huge part of our economy. I think it's why we see so much frustration from the general public. I really urge our policymakers, at both the state and federal level, to really think more carefully through whether we're going to require health insurance companies to report out denials of care by carrier, by type of procedure, because then we can figure out where they are just making mistakes, where a policy may need to be reversed. I think that would not.

I think if we had just a national health insurance program, we'd at least know, okay, we don't agree with, for example, this dense breast mammogram policy. We're all going to organize around that and get it changed. Now it's like guacamole. You go to one state, you see one policy, and one carrier within that state, you see another policy. It's too incoherent, the way we regulate health insurance in America at this point.

Brian Lehrer: Elizabeth Benjamin, Vice President of the Community Service Society of New York. Listeners, you can look for more advice--

Elizabeth Benjamin: Oh, wait, Brian. Can I just give out our phone number, maybe?

Brian Lehrer: Yes, I was going to give the web address, but go ahead and give the phone number.

Elizabeth Benjamin: Oh, I'm sorry. I should have known you would know. 888-614-5400. I'm really sorry, Brian.

Brian Lehrer: No, no, that's okay. Say it again, in fact.

Elizabeth Benjamin: 888-614-5400. That's Community Health Advocates. That was something that was a victim of the Affordable Care Act. We were originally funded in the first year of the Affordable Care Act, and then Congress has never funded State Consumer Assistance programs since then. It's very sad.

Brian Lehrer: Their webpage with a lot of advice right there is communityhealthadvocates.org. There are so many people we couldn't get to. Maybe we should do this from time to time, Elizabeth, until policy change actually comes. Thank you for today.

Elizabeth Benjamin: I would love that. Thank you. Bye.

 

 

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