Insurers’ dirty tricks that deprive patients of care

Insurers’ Dirty Tricks: 5 Tactics That Deprive Patients of Care

The healthcare system in the United States is a complex web of providers, payers, and patients. While it’s designed to ensure that those who need care receive it, there are several tactics employed by health insurers that can create additional barriers to access and even deprive patients of necessary care. In this article, we’ll explore five frustrating health insurer tactics that have been making headlines in recent years.

Claim Denials: The Unwelcome Surprise

Claim denials are a significant issue in the United States, with nearly 20% of Americans having a claim denied in 2021. This can be due to various reasons, including lack of coverage for specific services or failure to provide adequate documentation. However, what’s concerning is that the majority of claims (77%) were not listed as being denied due to any specific reason. This means that patients are left without a clear understanding of why their claim was denied, leaving them to navigate a complex system to appeal the decision.

The consequences of claim denials can be severe. Patients may have to pay out-of-pocket for services they thought were covered, or they may be forced to delay treatment due to financial constraints. In some cases, claim denials can even lead to death, particularly if patients are denied coverage for life-saving treatments. The lack of transparency in claim denials is a significant concern, as it undermines trust in the healthcare system and creates unnecessary barriers to access.

Prior Authorization: The Delays and Denials

Prior authorization is another tactic used by insurers to ensure that care is medically necessary and cost-effective. While this may seem like a reasonable practice, it can lead to delays in care and even death. Insurers often use prior authorization as a tool to ration care, particularly for expensive treatments or procedures. However, the process of obtaining prior authorization can be lengthy and bureaucratic, leading to delays that can have serious consequences.

The use of artificial intelligence to streamline prior authorizations has also come under scrutiny, with a class-action lawsuit filed against UnitedHealthcare for algorithmic denials of rehabilitative care. The lawsuit alleges that the insurer’s algorithms denied coverage for patients who needed rehabilitation services, despite meeting the medical criteria for such treatment. This highlights the need for greater transparency and accountability in the use of artificial intelligence in healthcare.

Small Networks: The Inconvenient Truth

Smaller networks are another issue, as patients may struggle to find doctors who take their insurance or have to wait longer for an appointment. Inaccurate provider directories can exacerbate this problem, leading patients to choose a plan based on incorrect information and then face difficulties in accessing care. This can be particularly problematic for those with chronic conditions or complex medical needs, who require regular access to specialist services.

The consequences of small networks can be severe, particularly for those living in rural or underserved areas where access to healthcare is already limited. Patients may have to travel long distances to receive necessary care, which can lead to increased costs and decreased health outcomes. The lack of transparency in provider directories is a significant concern, as it undermines trust in the healthcare system and creates unnecessary barriers to access.

Surprise Billing: The Unwelcome Shock

Surprise billing is also a significant concern, with nearly 30% of emergency transports and 26% of non-emergency transports resulting in surprise bills between 2014 and 2017. This can occur when patients receive care from out-of-network providers without their knowledge or consent. While the No Surprises Act has helped address this issue to some extent, it does not apply to ambulance services.

The consequences of surprise billing can be severe, particularly for those who are uninsured or underinsured. Patients may have to pay thousands of dollars in out-of-pocket costs for emergency care, which can lead to financial ruin and decreased health outcomes. The lack of transparency in billing practices is a significant concern, as it undermines trust in the healthcare system and creates unnecessary barriers to access.

Pharmacy Benefit Managers: The Hidden Costs

Pharmacy benefit managers (PBMs) are another tactic used by insurers to control costs. However, PBMs can inflate drug costs to overpay their own vertically integrated pharmacies, leading to higher out-of-pocket costs for patients. They also prevent drug manufacturer co-pay assistance programs from counting toward patients’ cost sharing, prolonging how long patients have to pay out of pocket.

The consequences of PBMs can be severe, particularly for those who rely on prescription medications to manage chronic conditions or maintain health. Patients may have to pay thousands of dollars in out-of-pocket costs for necessary medications, which can lead to decreased adherence and increased health outcomes. The lack of transparency in PBM practices is a significant concern, as it undermines trust in the healthcare system and creates unnecessary barriers to access.

Conclusion: Time for Change

These insurer tactics can negatively affect patients’ health and trust in the healthcare system, creating unthinkably difficult circumstances for those who need care. It’s essential that we address these issues to ensure that patients receive the necessary care and medications without facing unnecessary barriers. This requires greater transparency and accountability from insurers, as well as a commitment to improving access to care.

In conclusion, the five frustrating health insurer tactics explored in this article highlight the need for reform in the healthcare system. By addressing these issues, we can create a more equitable and accessible system that prioritizes patients’ needs above profits. It’s time for change, and it starts with holding insurers accountable for their actions.