TAMPA, Fla. — More than two out of five working-age adults report being charged for a health service that they thought was free or covered by insurance and fewer than half challenged those bills by contacting their provider or insurer.
It's important for patients to know they can fight back and have a good shot at winning.
The Commonwealth Fund, a nonpartisan nonprofit based in New York City, conducted the survey that led to this recent study on health insurance denials.
The Commonwealth Fund | Unforeseen Health Care Bills and Coverage Denials by Health Insurers in the U.S.
The ABC Action News I-Team spoke with Sara Collins, who heads the healthcare coverage and access program at The Commonwealth Fund.
"We conducted this survey, it was in 2023, and it sheds light on a very troubling reality, that many people with insurance are facing coverage denials for care that’s recommended by a doctor and many people are just simply at a loss about what to do about it," Collins said.
Furthermore, about half of those who didn't challenge their bill said they didn't have the right to do so.
"That is really a troubling finding, people absolutely have the right to challenge their denials, they have a right to challenge denials even after a denial has been upheld by an insurance company. You can still go back and challenge it and appeal that decision again," Collins told the I-Team.
She also said many people don't know who to contact.
"There is a lot of confusion, clearly, about people's understanding of their rights," Collins said.
Some tips, if you get a denial:
- Contact your insurance provider and ask about the steps to appeal the decision
- Contact your healthcare provider to make them aware and ask for any advice and supporting documentation
- Ask your healthcare provider to write a letter about the medical necessity of the denied treatment
- If you are a Medicare recipient and suspect fraud, waste or abuse, the hotline is 1-800-MEDICARE
“If you do challenge, you often do have success. So about half of adults who challenge coverage denials reported success in getting some or all of the denied services approved," Collins said.
Another question the I-Team has received is, "At what point do I contact and attorney?" And, "Is it worth it?"
The I-Team asked that question to attorney Thomas LaGreca, who is the executive director of medical revenue recovery at Callagy Law in New Jersey.
“Most of our representation is the medical community against the insurance industry," LaGreca said.
He told the I-Team that unless a lawyer takes on a case representing a patient in a pro bono capacity, they will be charged for billable time, which can add up fast.
“So if it takes six hours to draft a comprehensive complaint, to meet with the patient and all of that, it may be $400 an hour and it may be $2,500 that the patient is already not getting the care they need, needs to fork over to a lawyer to send some sort of demand letter to a carrier, and that may not even work. So it just adds insult to injury to the patient community," LaGreca said.
LaGreca said he sees three big problems:
- “The patient is caught in the middle of the payment dispute between the medical provider and the carrier, and the patient doesn’t belong in the middle of the dispute.”
- “There’s all sorts of challenges that the medical community faces — and therefore the patient community faces — when it comes to having the carrier community behave appropriately. And by appropriately, I genuinely mean under the law. But if there’s no convenient forum to enforce the law against carriers, then what good does it do?”
- “Not every case and not every claim and not every situation is going to warrant a full-blown judicial enforcement process. So you need a more convenient forum to enable the medical community to enforce not just the medical community’s rights, but the patient’s rights against the carriers... It’s the insurance industry that’s sitting there with all the power and all the control. ‘Cause they have the money. And they have all the decision-making power. So it’s a terrible scenario.”
With the federal "No Surprises Act", LaGreca said he would like to see the arbitration process expanded.
“That forum is set up for the narrow slice of ER treatment. For the most part. There’s other categories that come in there, but for the sake of simplicity, we talked about the emergency category. But there’s all sorts of care, primary care, that does not go into that process. So you could have primary surgeon denials and pre-service authorization denials go into that process," LaGreca said. “Any medical dispute can go into this arbitration process. So, to me, that would solve 95% of the problems with the American healthcare industry. Because patients now will be happy, because they’re out of the dispute, they’re going to be treated as if it’s some in-network situation, the medical community has a convenient forum to resolve these, that doesn’t involve the patient, and the carriers lose their grip on medical treatment and it’s passed over to a set of presumably neutral, fair arbitrators."
Collins told the I-Team that patients deserve better.
"They shouldn't have to navigate a labyrinth to get the insurance coverage they pay for when it comes to critical recommended doctor care," Collins said.
"If there had just been a trooper up there, maybe this whole thing could have been avoided."
A judge in Florida is sharing the story of his son's death in hopes of helping the Florida Highway Patrol trooper shortage.