When Colleen Henderson’s 3-year-old daughter complains about pain while using the bathroom, doctors brush it off as a urinary tract infection or constipation, a common illness in potty training years.
However, Henderson suspected that this might be worse and asked for an ultrasound. The doctor and ultrasound technician told her that her insurance provider, UnitedHealthCare, would not cover it, but Henderson decided to do it anyway and charged her credit card $6,000. Then there was the news: Her child had a grapefruit-sized tumor in her bladder.
That was in 2008. Henderson said the next five years became a protracted battle with United Healthcare as they paid experts who eventually diagnosed and treated their daughter’s rare condition, Inflammation pseudo-tumor. She called for denying coverage of hospitalization, surgery and medications from insurance companies and state regulators, but to no avail. She said a family in the Sacramento area had more than $1 million in medical debt because UnitedHealthCare has decided that the treatment recommended by doctors was unnecessary. The family declared bankruptcy.
“If I hadn’t had teeth and nails in every step, my daughter finally recovered and is now a 20-year-old at Oregon State University,” Henderson said. “You’ve paid a lot of money to have health insurance, and I hope you Health insurance is at the forefront of health conditions, but this simply doesn’t happen. ”
Denied insurance is rise,,,,, investigation Shows very few Americans appeal them. Various analyses found that many people escalated their complaints Government regulatory agencies Successfully obtained Denied being overturned (Unlike Hendersons). Consumer advocates and policy makers say it is a clear sign of insurance companies that usually deny that they should not take care of them. Now, a proposal from the California Legislature attempts to punish insurance companies that repeatedly make wrong calls.
And measures, Senate Bill 363, Experts say this may be the largest attempt in the country to control Californians rejected by health insurance companies, whose health plans are regulated by the state, with only about one-third of Californians insurers. California could be one of the few states in which states require insurance companies to disclose rejection rates and reasoning, and the industry often considers proprietary information.
The measure also tries to force insurers to be smarter about rejected insurance companies, fined up to $1 million if more than half of the appeals filed within a year are overturned.
In 2023, National data show that About 72% of appeals to the custodial health care department most of the health plans incurred insurers’ initial denials were revoked.
“When you have health insurance, you should believe it will meet your health care needs,” said Scott Wiener, a San Francisco Democrat who introduced the bill. “They can only delay, deny, hinder, and in many cases avoid the need to cover medically necessary care, which is unacceptable.”
A spokesperson for the California Association. The Health Plan declined to comment, saying the group is still reviewing the bill’s language. Elana Ross, a spokesman for Gov. Gavin Newsom, said his office does not usually comment on pending legislation.
Worry about consumer health costs, Members of states across the country There are increasingly looking for ways to verify that insurance companies are paying claims fairly.
2024, 17 states Formulate According to the National Legislative Council meeting, legislation involving the advance authorization of care by private insurance companies. For example, Connecticut, which has one of the most powerful denial rate disclosure laws, has published The year’s The report card details the number and percentage of claims denied by each insurer, as well as the share of the final reversal. Oregon publishes similar information Until recently, When the state disclosure requirement disappears.
In California, there is no way to know how long insurance companies refuse care, and health experts say that as mental health needs reach Crisis level Among children and young people. Keith Humphreys, a professor of health policy at Stanford University, said it would be easier to refuse mental health care because a diagnosis of depression is more subjective than a ruptured limb or cancer.
“We don’t think the state absolutely has no idea how big this is a problem is unacceptable,” said Lishaun Francis, senior director of child behavioral health, the sponsor of the bill.
According to Wiener’s proposal, private insurers hosted by the state Department of Health Care or Insurance Department or both must submit detailed data on rejection and appeal. They also need to explain these denials and report the outcome of the appeal.
For appeals to the state’s independent medical review process or IMR, denial insurance companies will face astonishing penalties as overturned for more than half of the time. The first case that takes a company to the 50% threshold will be fined $50,000, with fines ranging from $100,000 to $400,000. Each company will spend $1 million after that.
If passed, the measure would apply to private insurance for approximately 12.8 million Californians. It does not apply to patients with Medi-Cal, state Medicaid, or Medicare, and it will exclude self-insurance programs provided by large employers, which is regulated by the U.S. Department of Labor and covers approximately 5.6 million Californians.
After this kill In December, UnitedHealthCare CEO Brian Thompson worked. exist Poll The University of Chicago NORC research organization conducted shortly after the attack, and one in 10 respondents said they believed that denying health coverage and profits from health insurance companies was large or moderately responsible for Thompson’s death.
United Healthcare said in a statement after Thompson’s death “Highly inaccurate and severely misleading information” Already circulated about the way companies treat their claims, and highly regulated insurance companies “usually have Low to the edge of the middle number. ”
Vienna says Thompson killed “cold-blooded assassination” and says his measures have been taken from one Narrow suggestions Last year, it aims to improve mental health coverage for children and adults under 26 years of age.
Humphreys, a professor at Stanford University, said the U.S. health system has created strong economic incentives for insurers to refuse care. And, he added, state and federal penalties are trivial enough to be written off as a cost of doing business.
“The more they deny, the more money they make,” he said.
Shawn Gremminger, president of the National Healthcare Buyers Alliance, said that more and more large employers are starting to incorporate language into contracts with claims managers to sentence insurance providers to over- or too little approvals claim.
Gremminger represents funding its own insurance, most employers under federal supervision, and will be excluded from Wiener’s bill. But even for so-called self-funding plans, it is almost impossible to determine the denial rate of an insurer that is used only to manage claims.
While the bill may be too late for many families, Rialto’s Sandra Maturino said she hopes lawmakers resolve insurance denials so other Californians can avoid what she’s going through Saga comes to receive treatment from her niece.
After her sister passed away, she adopted a 13-year-old girl. Her niece has long struggled with self-harm and violence, but her insurance company, Anthem Blue Cross, only covers 30 days when the therapist recommends hospitalized psychiatric care.
Maturino said her niece has biked into and out of the facilities and consulted for more than a year, because her insurance won’t cover long-term accommodation. Doctors tested the prescription medication and dosage list. None of them worked.
The National Anthem declined to comment on the story.
Unlike many other situations in similar situations, Maturino was eventually able to obtain external assistance to correct this situation. She sought help from the adoption agency, eventually covering her niece’s accommodation costs in Utah’s hospitalization program, where she was diagnosed with bipolar disorder and had been under treatment for a year.
Maturino said she was not capable of attracting Anthem.
“I’m not going to wait for insurance to kill her, or she hurts someone,” Maturino said.
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