Lauren Sausser
Leah Kovitch was pulling invasive crops within the meadow close to her residence one weekend in late April when a tick latched onto her leg.
She didn’t discover the tiny bug till Monday, when her calf muscle started to really feel sore. She made an appointment that morning with a telehealth physician — one beneficial by her medical insurance plan — who prescribed a 10-day course of doxycycline to stop Lyme illness and strongly steered she be seen in individual. So, later that day, she went to a walk-in clinic close to her residence in Brunswick, Maine.
And it’s a superb factor she did. Clinic staffers discovered one other tick on her physique throughout the identical go to. Not solely that, one of many ticks examined optimistic for Lyme, a bacterial an infection that, if untreated, can cause serious conditions affecting the nervous system, coronary heart, and joints. Clinicians prescribed a stronger, single dose of the prescription remedy.
“I could have gotten really ill,” Kovitch mentioned.
But Kovitch’s insurer denied protection for the walk-in go to. Its motive? She hadn’t obtained a referral or preapproval for it. “Your plan doesn’t cover this type of care without it, so we denied this charge,” a doc from her insurance coverage firm defined.
Health insurers have lengthy argued that prior authorization — when well being plans require approval from an insurer earlier than somebody receives remedy — reduces waste and fraud, in addition to potential hurt to sufferers. And whereas insurance coverage denials are sometimes related to high-cost care, resembling most cancers remedy, Kovitch’s tiny tick chew exposes how prior authorization insurance policies can apply to therapies which might be thought of cheap and medically mandatory.
Pledging To Fix the Process
The Trump administration announced this summer that dozens of personal well being insurers agreed to make sweeping modifications to the prior authorization course of. The pledge contains releasing sure medical companies from prior authorization necessities altogether. Insurers additionally agreed to increase a grace interval to sufferers who swap well being plans, in order that they received’t instantly encounter new preapproval guidelines that disrupt ongoing remedy.
Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, mentioned throughout a June press convention that among the modifications can be in place by January. But, up to now, the federal authorities has supplied few specifics about which diagnostic codes tagged to medical companies for billing functions shall be exempt from prior authorization — or how non-public corporations shall be held accountable. It’s not clear whether or not Lyme illness circumstances like Kovitch’s can be exempt from preauthorization.
Chris Bond, a spokesperson for AHIP, the medical insurance trade’s important commerce group, mentioned that insurers have dedicated to implementing some modifications by Jan. 1. Other parts of the pledge will take longer. For instance, insurers agreed to reply 80% of prior authorization approvals in “real time,” however not till 2027.
Andrew Nixon, a spokesperson for the U.S. Department of Health and Human Services, instructed KFF Health News that the modifications promised by non-public insurers are meant to “cut red tape, accelerate care decisions, and encourage transparency,” however they may “take time to achieve their full effect.”
Meanwhile, some well being coverage consultants are skeptical that non-public insurers will make good on the pledge. This isn’t the primary time main well being insurers have vowed to reform prior authorization.
Bobby Mukkamala, president of the American Medical Association, wrote in July that the guarantees made by well being insurers in June to repair the system are “nearly identical” to these the insurance coverage trade put forth in 2018.
“I think this is a scam,” mentioned Neal Shah, creator of the ebook “Insured to Death: How Health Insurance Screws Over Americans — And How We Take It Back.”
Insurers signed on to President Donald Trump’s pledge to ease public strain, Shah mentioned. Collective outrage directed at insurance coverage corporations was significantly intense following the killing of UnitedHealthcare CEO Brian Thompson in December. Oz particularly mentioned that the pledge by well being insurers was made in response to “violence in the streets.”
Shah, for one, doesn’t consider corporations will comply with via in a significant approach.
“The denials problem is getting worse,” mentioned Shah, who co-founded Counterforce Health, an organization that helps sufferers enchantment insurance coverage denials by utilizing synthetic intelligence. “There’s no accountability.”
Cracking the Case
Kovitch’s invoice for her clinic appointment was $238, and she or he paid for it out-of-pocket after studying that her insurance coverage firm, Anthem, didn’t plan to cowl a cent. First, she tried interesting the denial. She even obtained a retroactive referral from her main care physician supporting the need of the clinic go to.
It didn’t work. Anthem once more denied protection for the go to. When Kovitch known as to be taught why, she mentioned she was left with the impression that the Anthem consultant she spoke to couldn’t determine it out.
“It was like over their heads or something,” Kovitch mentioned. “This was all they would say, over and over again: that it lacked prior authorization.”
Jim Turner, a spokesperson for Anthem, later attributed Kovitch’s denials to “a billing error” made by MaineHealth, the well being system that operates the walk-in clinic the place she sought care. MaineHealth’s error “resulted in the claim being processed as a specialist visit instead of a walk-in center/urgent care visit,” Turner instructed KFF Health News.
He didn’t present documentation demonstrating how the billing error occurred. Medical information provided by Kovitch present MaineHealth coded her walk-in go to as “tick bite of left lower leg, initial encounter,” and it’s not clear why Anthem interpreted that as a specialist go to.
After KFF Health News contacted Anthem with questions on Kovitch’s invoice, Turner mentioned that the corporate “should have identified the billing error sooner in the process than we did and we apologize for the confusion this caused Ms. Kovitch.”
Caroline Cornish, a spokesperson for MaineHealth, mentioned this isn’t the one time Anthem has denied protection for sufferers in search of walk-in or pressing care at MaineHealth. She mentioned Anthem’s processing guidelines are typically misapplied to walk-in visits, resulting in “inappropriate denials.”
She mentioned these visits mustn’t require prior authorization and Kovitch’s case illustrates how insurance coverage corporations usually use administrative denials as a primary response.
“MaineHealth believes insurers should focus on paying for the care their members need, rather than creating obstacles that delay coverage and risk discouraging patients from seeking care,” she mentioned. “The system is too often tilted against the very people it is meant to serve.”
Meanwhile, in October, Anthem despatched Kovitch an up to date rationalization of advantages displaying {that a} mixture of insurance coverage firm funds and reductions would cowl the complete price of the appointment. She mentioned an organization consultant known as her and apologized. In early November, she acquired her $238 refund.
But she just lately discovered that her annual eye appointment now requires a referral from her main care supplier, based on new guidelines laid out by Anthem.
“The trend continues,” she mentioned. “Now I am more savvy to their ways.”
