From Dan Nagle, MD, Practice Division Director:
Dr. Bob Terrill in his ASSH Listserv posting of September 10, 2009 highlighted the problem of arbitrary and unfounded coverage denials by insurance companies. His posting is included below.
“Colleagues – especially those in Massachusetts – I have just been told by my practice manager that Tufts health plan has now unilaterally decided that 64708 is now an “experimental” procedure and as such will not longer be a covered procedure. I have attempted to contact the medical director without success. This has been done unilaterally without any evidence to back it up, etc. I do not know about any of you, but I do these procedures. This includes proximal median nerve decompression, radial tunnel decompression, suprascapular nerve decompression, peroneal nerve decompression, tibial tunnel decompression, etc. It floors me that the insurance company can just do this. Here in Massachusetts, BCBS and Medicare decided that iontophoresis is experimental and have now denied its coverage. This is even though there is at least 20 years of PT published data noting its effectiveness. This now has the potential to hurt our patients. Have you seen this? Do you have any suggestions? I have considered contacting the Insurance Commissioner, but do not know what good that will do. If everything we do is under scrutiny, and the effectiveness of procedures needs to be documented, don’t we also need data that denying needed care will also harm patients?”
Many concerned and well informed ASSH members chimed in and provided Dr. Terrill with suggestions regarding how to deal with this issue. Proposed avenues of response included legal action and intervention through legislative initiatives. Dr. Andy Gurman, a long time ASSH member and Vice Speaker of the American Medical Association (AMA) House of Delegates provided contact information for the Massachusetts Medical Association.
Dr. Desirae McKee suggested a large-scale survey of surgeons could be helpful in assessing the magnitude of the problem and possibly provide data that could be used in future efforts to curtail inappropriate insurance coverage denials. Stimulated by Dr. McKee’s suggestion, our President Dr. Robert Szabo along with Dr. Dan Nagle created a survey probing our members’ inappropriate insurance denial experience. The survey results are summarized below: (view complete survey results)
Thirty six percent of those who responded (121/332) indicated they had experienced a denial for payment because the insurer had arbitrarily designated a well-established procedure as being “experimental.” The denials concerned a wide variety of procedures. One respondent reported 186 such denials!
Blue Cross and Blue Shield was the most frequently cited offending company with Aetna, United Health Care and Cigna not far behind.
Only 31 members answered the question regarding avenues of appeal. (Three hundred seventeen members skipped this question.) Twenty-three (74%) indicated they did not pursue an appeal.
Members from all over the country responded to the survey. Members in 30 different states responded saying they had experienced a denial for payment because the insurer has arbitrarily designated a well established procedure as being experimental. It appears the issue is prevalent in all areas of the country.
Our members provided many “pearls of wisdom” regarding how to deal with inappropriate denials. Hopefully, these “pearls” will help others as they deal with inappropriate insurance denials.