In 2013, before Affordable Care Act regulations kicked in, insurers denied roughly 1.5% of claims, according to the American Medical Association. But under ACA rules, denials increased tenfold. Now nearly 15% of claims are denied, reports Premier, an insurance consultant firm. Some insurers deny a third or more of claims, according to Kaiser Family Foundation research.
Your doctor has to call the insurer before beginning treatment or ordering a medication - and seldom is the person on the other end of the phone a specialist in the disease or treatment in question. It could be an ob/gyn overriding your neurosurgeon's recommendation, warns the AMA.
Dr. Debra Patt, an oncologist in Austin, Texas, told the AMA she prescribed a drug combination for a patient with metastatic breast cancer, but had to wait weeks for pre-authorization. In the meantime, she had to settle for ordinary chemotherapy, a substandard treatment for the case. Her patient died.
80% of preapprovals that Cigna denied for Medicare Advantage customers were overturned on appeal - a sign that legitimate claims are being denied due to bureaucracy rather than medical necessity.
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