(C) Daily Kos This story was originally published by Daily Kos and is unaltered. . . . . . . . . . . KosAbility: Insurance's frivolous denial of necessary medical care is common and it could kill you [1] ['This Content Is Not Subject To Review Daily Kos Staff Prior To Publication.'] Date: 2023-06-25 Imagine that someone, or some algorithm, in an insurance company office a thousand miles away arbitrarily decides the standard medical procedure your doctor prescribed is unnecessary even though it is essential. They then justify the rejection using nonsensical reasons that have nothing to do with the condition nor the treatment and were not even mentioned in the approval request. How can you fight that? Can you rely on your doctor’s office to resubmit the request for approval, adding new details or reiterating the previous details that were shoved aside in the initial assessment? Does your doctor have the time and staff available for this process? Do you have the knowledge, time, and ability to go it alone? Sadly, you don’t need a lively imagination to envision this scenario because it is occurring right now throughout the U.S. as insurance companies devise new ways to circumvent protections built into the ACA. There’s a despicably apt new title for the person sitting in an office rejecting your treatment—denial nurses. These individuals, sometimes an automated system, already provide ample real-life examples of the frivolous excuses used to refuse coverage, issuing “rapid-fire denials of claims — sometimes bundles at a time — without reviewing the patient’s medical chart,” reports PBS News Hour. x Can you imagine a depraved job titled Denial Nurse?! wherein you deny claims for lifesaving medical care i.e. an asthma inhaler, heart medication, epinephrine to treat anaphylaxis, or a heart procedure to treat arrhythmia. Have Humanity#MedicareForAllhttps://t.co/SLxC9alwMB — Kay 🌎 (@KayKosmos) May 28, 2023 Stories from real patients suffering the consequences of these denials, as reported by PBS, are heartbreaking. One person with “arrhythmia, which had caused him to faint with a heart rate of 300 beats per minute,” was denied a standard $143,206 heart procedure because “he had ‘asked for coverage for injections into nerves in your spine’ (he hadn’t) that were ‘not medically needed.’” A newborn child was denied “coverage for his fourth day in a neonatal intensive care unit. ‘You are drinking from a bottle,’ the denial notification said, and ‘you are breathing on your own.’” Good enough, kid, time to get a job and buy your own bottles. The PBS story is based on a ProPublica investigation of Cigna, “an insurance giant, with 170 million customers worldwide,” that found that “an automated system, called PXDX, allowed Cigna medical reviewers to sign off on 50 charts in 10 seconds.” According to ProPublica’s story published in May 2023, “The company has built a system that allows its doctors to instantly reject a claim on medical grounds without opening the patient file, leaving people with unexpected bills, according to corporate documents and interviews with former Cigna officials. Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method, spending an average of 1.2 seconds on each case, the documents show.” Unfortunately, at the patient-doctor end of this contemptible arrangement there is no automated system to challenge denials, a process that can take hours, days, of patient and doctor time. “Many people don’t have the knowledge or stamina to take on the task, unless the bill is especially large or the treatment obviously lifesaving. And the process for larger claims is often fabulously complicated.” The PBS story concludes by observing that the “Affordable Care Act clearly stated that HHS “shall” collect the data on denials from private health insurers and group health plans and is supposed to make that information publicly available. (Who would choose a plan that denied half of patients’ claims?) The data is also supposed to be available to state insurance commissioners, who share with HHS the duties of oversight and trying to curb abuse.” But so far, “such information-gathering has been haphazard and limited to a small subset of plans, and the data isn’t audited to ensure it is complete … The government has the power and duty to end the fire hose of reckless denials harming patients financially and medically. Thirteen years after the passage of the ACA, perhaps it is time for the mandated investigation and enforcement to begin.” What’s up KosAbility? Our meetings are held in the comments of each month's story, published the last Sunday of the month at 4 PM Pacific time (7 pm Eastern U.S. time). Everyone is welcome to bring up whatever you wish to discuss in the comments, as long as it fits with our purpose to support and inform on topics related to illness, health, disability and to provide a place for disabled members and their loved ones to connect. 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