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Health Payer Preventive Care, ED Denials Hamper Patient Care Access

Payer coverage denials for preventive screenings and emergency department visits may hinder patient access to care and treatment.

coverage denials patient access to care

Source: Thinkstock

By Sara Heath

- Health payers are denying coverage for preventive care screenings and emergency department (ED) care at a high rate, according to patient advocacy group Doctor-Patient Rights Project (DPRP). In doing so, payers are hindering patient care access.

In a second iteration of its Access Denied reports, DPRP outlined how health payers are denying patient access to preventive screenings and ED visits. Specifically, the report notes where payers deny coverage to preventive screenings the payer says are not medically necessary or ED visits for diagnoses that are not deemed emergencies.

The report also investigates how coverage denial for preventive screenings prevents the early detection of a chronic condition, which can ultimately lead to higher costs down the road.

“More people are living with chronic illness than ever before,” Stacey Worthy, counsel to Aimed Alliance (Alliance for the Adoption of Innovations in Medicine) said in a statement. “Insurers should be working with doctors and patients to better diagnose and treat chronic conditions before they become serious and costly, not erecting barriers to preventive treatments that benefit patient health and reduce the cost of care in the long run.”

Currently, insurers deny 10 percent of claims for preventive screenings. This practice impacts nearly 7.7 million insured individuals.

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Coverage denial occurrences can vary by race. While 63 percent of black patients faced a coverage denial, only 24 percent of white and 18 percent of Hispanic patients did, as well. DPRP did not state that a patient’s race may have influenced a coverage denial.

When facing a coverage denial, 40 percent of insured patients appeal that decision. Those appeals are successful 49 percent of the time, DPRP reported.

Questionable medical necessity is the top reason for coverage denial, the report added, with 28 percent of denials falling under this category.

Insurance companies are also denying coverage for prophylactic interventions, or measures intended to prevent certain chronic illnesses. These coverage denials may happen even when a patient has received coverage for a preventive screening.

Patients are also facing coverage denials for ED visits, DPRP reported. Specifically, the advocacy group said payers are “taking advantage” of ambiguous US law requiring insurance providers to cover ED charges for visits deemed reasonable by a “prudent layperson.”

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Payers may choose to limit ED coverage to discourage patients from visiting the costly treatment facility for minor ailments, such as the common cold. Ideally, patients would choose to visit a less costly care site such as a retail clinic or an urgent care clinic.

But payers interpret that law too stringently, expecting too much of patients who are facing what patients may believe is an emergency, DPRP contended.

Under payers’ own definitions of “avoidable” and “unavoidable” ED visits, only about 3.3 percent of all ED visits would be covered by insurance.

Payers primarily deny claims through a retroactive denial process during which the payer looks at the final care diagnosis and determines a need that was not emergent.

For example, an individual visiting the ED for shortness of breath and trouble breathing may be concerned that he is having a heart attack. If the diagnosis is not a heart attack but instead something less urgent, that visit may not be covered.

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This puts an unreasonable onus on a layperson patient, DPRP argued, especially when that patient was experiencing what could be interpreted as life-threatening symptoms.

“By retroactively denying coverage for emergency visits based on a patients’ diagnosis and not his or her symptoms, insurers are expecting patients to play doctor and diagnose themselves when they’re potentially facing a life-threatening medical event,” Vidor Friedman, MD FACEP, president of the American College of Emergency Physicians (ACEP) said in a statement.

“If someone is experiencing chest pain, it could be severe heartburn, or they might be having a heart attack,” Friedman continued. “A patient shouldn’t second guess going to the emergency room and put their life at risk just because their insurer might send them a large bill if their diagnosis isn’t deemed serious after the fact.”

About 52 percent of retroactive claims denials appeals turn over the original payer decision, DPRP reported.

Going forward, overhauls to the health payer industry must discourage extensive claims denials processes, DPRP asserted. In doing so, payers can enable patients to access care.

“Based on the full analysis in both Access Denied reports, the Doctor Patient Rights Project finds patients are being impacted by denials at every phase of care—preventive, and emergency medical treatment,” the group concluded. “This is a problem that effects patients across demographics, but as is so often the case, impacts high-needs populations the most. It is a problem that must be addressed to truly empower patients and their doctors to make decisions about their care.

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