California’s insurance commissioner has opened an investigation into Aetna insurance company after a former medical director testified that he didn’t consult patients’ medical records before approving or denying claims.
Since then, Colorado, Washington, and Connecticut have also launched their own investigations.
Aetna declined to comment on the investigation, but the third largest insurance provider in the United States issued a statement saying that “medical records were in fact an integral part of the clinical review process.”
However, some experts say a lack of transparency in health insurance is nothing new.
The claims process can be opaque and confusing, they say. Part of the problem is that most of the heavy lifting on insurance oversight is left to states. So regulations vary widely.
“I don’t know what the criteria is for denial or approval of medical claims,” Dr. Andrew Murphy, a fellow of the American Academy of Allergy, Asthma and Immunology who has served on the group’s board of directors, told Healthline. “It’s very difficult to find out.”
Cost is frequently a concern, he said, so he presents the risks and benefits of treatments to insurers before they’re approved.
Healthcare is indeed a big business in the United States. The $3 trillion-plus industry is the world’s largest. By 2025, healthcare spending is expected to reach $5.5 trillion — or nearly 20 percent of gross domestic product (GDP).
That bottom line emphasis is beginning to worry physicians.
Dr. Theodore Mazer, president of the California Medical Association, told CNN that “California physicians are increasingly concerned with the growing trend of for-profit insurance companies adopting policies that restrict access to care while their profits soar.”
Not a new problem
Dave Jones, the California insurance commissioner, asked patients and medical professionals who have had inappropriate denials to report them to the Department of Insurance consumer hotline at 800-927-4357.
“We want to make sure consumers’ rights are protected,” Nancy Kincaid, press secretary for the California Department of Insurance, told Healthline.
But this isn’t a new problem, say experts.
“Operating behind closed doors is not a shock,” Dr. Arthur Caplan, founding director of the division of medical ethics at New York University, told Healthline. “Insurers delay, fight, and not pay. The ethics are you deserve a fair hearing when health is at stake.”
Not that insurers are totally at fault though.
Rising drug costs and higher-priced tests can complicate claims too.
One student in Texas was billed $17,850 for a urine test taken at a doctor’s office. The insurer Blue Cross and Blue Shield of Texas refused to pay the bill because it was “out of network.”
But other times, pricey procedures can bog down the medical approval process, say experts.
“At least weekly and occasionally daily, insurance companies deny payment for some cancer treatment that I prescribe,” wrote gynecologic oncologist Dr. Rick Boulay on the social media blog KevinMD.com.
The upshot is treatment can be delayed for weeks, he said.
Just understanding a bill can be daunting for consumers too, Ruth Linden, a health advocate in San Francisco, told Healthline.com.
The explanation of benefits alone can contain confusing codes.
“The process is overwhelming,” she said.
No simple solution
Solutions are multipronged, say experts.
Since power rests with the states, that’s one place to begin.
“They have to take this whole thing into their grip,” Dr. Rebecca Quigg, a cardiologist and healthcare reform policy expert, told Healthline. “We need systems where complaints turn into prosecutions.”
Frustrated by the healthcare system, she ran for Congress in Georgia’s 6th House District.
“Inappropriate denial of claims is widespread among all insurers nationwide,” explained Quigg.
Other experts agree.
State insurance commissioners must impose strict regulations on the claims review process, such as who conducts reviews and how they’re conducted, said Linden.
“Protocols need to be standardized and regulated by the state,” she said.
They also need be easily accessible to subscribers.
Consumers also need to advocate for themselves, experts add. Complaints can be filed with state insurance commissions and appeals can be logged with insurers.
“Patients need to step up and say what’s going on,” said Murphy. “Physicians can only do so much. Until individuals demand clarity and appropriate care, things won’t change a lot.”
Quigg has an even bolder solution.
“We need an Elizabeth Warren for healthcare companies,” she said. “They have to be held accountable, and this is the next target of consumer protection.”