My Turn: Fight for a better health insurance system

For the Monitor
Published: 1/25/2022 6:01:28 AM
Modified: 1/25/2022 6:00:11 AM

A study conducted by the Kaiser Family Foundation last year found that an average of 15 to 20% of in-network health insurance claims were denied in 2019, depending on the type of plan. While rates vary from state to state New Hampshire insurance providers deny a whopping 31.9% of in-network claims.

Given this, perhaps I shouldn’t have been surprised that a nearly $6,000 claim for my husband’s surgery to regain the use of his dominant arm in 2020 was denied by a major healthcare provider to a New Hampshire hospital. This is not an amount our family can easily afford and it wasn’t part of our budgeted expenses. We had already reached our limits for deductibles and out-of-pocket expenses for the year.

We were confused.

Why was it the patients’ responsibility to have the correct codes in pre-authorization forms from the hospital for surgery? This should be the responsibility of the doctors’ offices and hospitals in charge of their patients’ care. Many denials are for treatments deemed “experimental,” “unnecessary,” or “investigational.” My husband’s doctor told him that he has done thousands of these surgeries and never had a problem before.

And then his doctor asked, “Why is your insurance provider harassing you?” My husband did not have an answer to that question.

During the year, we made multiple phone calls to the hospital, our insurance company, and the doctor’s office. We spent well over 40 hours trying to resolve this issue, and it caused us immense anxiety. We’d call one and they’d refer us to the other. At many points, we thought that maybe they weren’t even communicating with each other.

At the end of the summer, we came home from a relaxing trip and discovered that the hospital had referred our account to a collection agency because they thought we’d been denied, even though we had called to tell them we had appealed the denial. From the beginning, this seemed like something that the insurance company and the hospital should negotiate between themselves, without our involvement. We were informed a few weeks later that the denial had been dropped and we were free from accruing medical debt for the time being.

I realized how unlikely it is that folks are as stubborn or as persistent as we were and perhaps they would not continue pursuing an appeal after being denied once. Less than two-tenths of one percent of patients appeal their denials in the first place and insurance providers rarely overturn their decision. In total, over $40 million in claims denials generally get upheld and end up in the insurance providers’ bank account, while we, the people, get to pay for it.

In the United States, millions of people are still struggling with medical debt. They report many sacrifices as a result, including delaying vacations or major household purchases, spending less on food and clothing, using up most or all their savings, taking an extra job or working more hours, increasing their credit card debt, borrowing money from family or friends, changing their living situation, and seeking the aid of a charity.  75% of those insured say they pay more than they can afford for their insurance copays, deductibles, or coinsurance.

In 2020, GoFundMe announced that one-third of all donations on the popular crowdfunding site had gone toward health care costs. This amounts to over 250,000 campaigns raising $650 million. It is painful to think about the folks who may not meet their fundraising goals and cannot get the care they need.

In 2010, when the Affordable Care Act was signed into law, the cost of healthcare was causing a bankruptcy every 30 seconds and it was expected that 1.5 million Americans would lose their homes during that year alone. While this reform has helped decrease this number, we are still seeing more than 500,000 personal bankruptcies due to medical costs every year. Since that time, the cost of insurance premiums has risen significantly and out-of-pocket spending continues to increase, leaving patients with higher bills to pay.

Naturally, in my own case, I feel extremely lucky that we were able to push the burden of this bill back to the providers and get the care my family needed. Still, I can’t help but think about all of the people who don’t try because they don’t have the time or they believe that insurance companies are too powerful. There has to be a better system. Let’s fight for it together.

(Heather Stockwell is the NH Statewide Healthcare Organizer at Rights & Democracy. She lives in Dublin. If you’ve experienced a recent denial of a health care claim, you can contact her at heather@radnh.org.)




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