Health insurance companies employ individuals whose full-time job consists of finding reasons to deny claims for medical treatment even when necessary. Whether a doctor ordered surgery, a procedure or medication, 25% of patients surveyed revealed that their health insurance provider denied coverage, as reported by the Texas Medical Association.
Accordingly, 30% of the patients surveyed admitted that they paid for the necessary medical services themselves. Ten percent of individuals surveyed stated that either they or a relative became “a lot sicker” after the insurance company denied a physician’s order.
Because of a large volume of denials, the Lone Star State passed legislation requiring health insurance companies to disclose how they determine a patient’s eligibility to receive treatment coverage. Insurance companies must now provide greater transparency regarding the review process.
New legislation may eliminate some denials and waiting times
Reforms passed by the Texas Legislature eliminate the need for a review when a physician orders a routine treatment or procedure. Patients no longer need to receive prior authorization from an insurance company for common services.
Some health insurance plans may also begin to offer an automated authorization process to help reduce patients’ waiting times. With a speedy and automated approval process, more patients may find themselves gaining quicker access to the medical care they need.
The need to appeal denials remains
Patients may not, however, find all denials eliminated by an automated process. When the need for an appeal arises, the process may easily become a detailed and lengthy affair when a human being must review the application.
In certain cases, patients facing a life-or-death emergency may receive a boilerplate form denying a common medical service even when it goes against industry standards. While patients have the right to appeal a denial, many do not understand the process for doing so. An insurance company must, however, provide its policy for appealing a decision. When it fails to do so or makes the process difficult, a policyholder may require a legal action to resolve the issue.
