You have the right to know why a health insurance company denied your claim — ProPublica

If you would like to request your own claim documents, please go to our Claim Document Assistant.If you are having difficulty retrieving your claim documents, please let us know what happened [email protected].

Out of public view, algorithms, employees and executives in the U.S. health insurance industry are processing tens of millions of claims for people seeking medical care.

Sometimes, as ProPublica reports, insurance companies make decisions based on what’s good for the company’s bottom line, rather than what’s good for patients’ health. Sometimes insurance companies make mistakes. In one case we learned of, a company refused to treat children because its judgment was based on adult guidelines rather than pediatric guidelines. In another case, an internal reviewer misread the type of surgery a patient was seeking and denied coverage based on that error.

At first, these patients had no idea why they were being denied treatment. But in every incident, insurance company employees left a written record — in the form of notes, emails or recorded phone calls — explaining what happened. Patients and advocates use what they find in these records to file appeals and ultimately get the care they need.

Federal law and regulations require insurance companies to provide this information accurately upon written request. And they have to do it quickly: Most people who get coverage through their employer should get a record (called a claim file) within 30 days.

There’s just one problem: Some insurance companies don’t turn over documents like they should. We followed ProPublica readers through the process at five different insurance companies. Several companies shared files with patients only after we contacted them.

Our team discovered how helpful claims documentation can be after patients shared internal notes and calculations made by health insurance companies on their cases. But few health insurance companies advertise the service or provide clear instructions for obtaining these records. To help fill this gap, we have published a guide explaining how to submit a claim document request. We are also sharing resources, including request letter templates, with healthcare providers and patient advocates nationwide.

More than 120 people told us they have requested or plan to request documents for their claims. While a handful said the information they received helped them understand why their health insurance company denied coverage, many more encountered challenges. They told us that insurance companies exceeded deadlines, mistakenly requested subpoenas, and in some cases completely misunderstood their requests.

We shared a summary of these examples with Deputy Assistant Secretary of Labor Tim Hauser. His office oversees claims filing laws covering more than 131 million people. He said insurance companies that fail to provide records are violating the law. “Claimants really need to be able to see the relevant evidence so they can respond,” he said.

We presented our findings to five insurance companies. We provided them with details of the requests made by patients and how the company responded, and asked them to explain what happened in each case.

All insurance companies recognize that patients have the right to receive the materials they request. After we asked, the four began sending documents. A spokesperson told us two of them are updating their policies to handle future requests. Anthem Blue Cross Blue Shield spokesman Michael Bowman said the company needs to better train employees on the rules “to close any gaps and prevent this from happening again in the future.” Cigna spokesperson Justine Sessions acknowledged that patients do not need a subpoena to access their records, contrary to what insurance companies tell members. She said the company would update its “policies and communications to reflect future requirements.” We regret not making these updates sooner and apologize for any frustration or confusion this may cause our customers. “

By crowdsourcing people’s experiences, we identified some behavioral patterns among health insurance companies. Here are some of the most common questions people encounter, and what to note when submitting your own request:

Insurance company requests unnecessary subpoena or court order

Cigna and Anthem told members they would need to obtain a court order or subpoena to access their claims file records.

“That’s completely unheard of,” said Wells Wilkinson, a senior staff attorney at Public Health Advocates, a nonprofit legal group that regularly makes these requests. “It also sounds completely illegal. Consumers have a right to any information a health plan uses in the event of a denial.”

On July 12, Maryland resident Lisa Kays asked Cigna for phone records related to the decision to deny coverage for speech therapy for her 4-year-old son. “We can’t just give up,” Case said.

In September, Cigna sent her a letter saying she would need to submit a subpoena to obtain any transcripts or recordings.

After ProPublica inquired, the company sent Kay a portion of the call transcript. It also reimbursed her for some coverage she had previously been denied. She is still waiting for the recording.

We asked Anthem about similar cases. On July 19, a call center agent told Pamela Tsigdinos that she needed a subpoena to receive her claim file. Tsigdinos submitted the request 50 days ago.

Anthem spokesperson Bowman told us the response was a mistake and apologized. The company compiled claim documents and sent them to Tsigdinos.

Insurers confuse claim document requests with appeals

At least five people told ProPublica that after submitting requests for claim documents, their health insurance companies mistook the requests for appeals.

We submitted three cases to UnitedHealthcare. SJ Farris requested claim documents from the company on May 10. Five days later, she received a response saying her appeal request had been received. Farris sent a letter of clarification but received a call from Ireland’s appellate attorney. “I asked her to send her claim documents,” Farris said. “She had no idea what I was talking about.”

Farris received a call from UnitedHealth in October after ProPublica raised questions with the company. They told her the insurance company was processing her claim file and she should receive results soon. “We take our responsibility to provide members access to their records seriously and have processes in place to comply with the law,” UnitedHealth spokesperson Maria Gordon Shydlo said in a statement to ProPublica. “We deeply apologize for the inconvenience.”

After Beth Tolley sent a request for claim documents to Anthem on behalf of her granddaughter, she received a letter from the health insurance company that read, “We have received Beth Tolley’s request for appeal.” This confused Tolley because on In that communication, Anthem said it had exhausted all avenues of appeal to its office.

In early October, Anthem sent the Tolleys a check for the same amount they initially refused to pay. Bowman told ProPublica the company will send the records soon.

The insurance company has passed its 30-day deadline

Under federal law, for most people who get coverage through their employer, the insurance company must return claim documents within 30 days.

Twelve people whose requests ProPublica tracked did not receive their records within that time frame, despite having such plans. Five of the companies had waited more than 70 days to hear back from their insurance companies before ProPublica contacted them with questions.

Isabella Gonzalez submitted a request for claim documents by certified mail on August 8. When she called Aetna to get the latest information, a representative told her they didn’t see the information in their system and suggested she upload it to the insurance company’s online portal, where she found it . Did. She called back a few days later. Another customer service employee told her Aetna would respond within 45 days.

Alex Kepnes, executive director of communications for Aetna, said the company was initially unaware of Gonzalez’s request and did not respond.

Kepnis declined to answer follow-up questions about why the employee failed to correctly identify the request and whether the company would take action to ensure this never happens again.

Other companies that failed to comply with the 30-day timeline include UnitedHealth, Anthem and Cigna.

“It’s important to have these responses in a timely manner,” said Hauser, the Labor Department official. “If that didn’t happen, that would really be a breach of the rules.”

If you are facing a health insurance denial and want to obtain your claim documents, check out ProPublica’s Claims Document Assistant.

If your health insurance company blocks your access to your claims files, you can contact the agency that regulates your health insurance company. Use our free tool to learn more.If you would like to tell our team about your experience, you can send an email to [email protected].

Leave a Comment

Your email address will not be published. Required fields are marked *

%d bloggers like this: