Mar142019

State Regulators Overturn more than 60 Percent of Health Plan Denials

Posted by Kassy Perry

California Chronic Care Coalition releases report highlighting serious nature of wrongful health plan denials and calls for increased awareness of state’s appeal process

(SACRAMENTO) The California Chronic Care Coalition (CCCC) today sounded the alarm on the health insurance industry’s practice of inappropriately denying patients the medicines, treatments and testing prescribed by their doctors. In their research study, “Standing Up For Your Rights Creates Results,” the California-based nonprofit found that the California Department of Managed Health Care (DMHC) reversed or overturned more than 60 percent of health plan decisions as part of the Independent Medical Review (IMR) process in 2017.

“The high percentage of cases that the DMHC reversed or overturned should raise red flags with consumers and policymakers alike,” said Liz Helms, president and CEO of CCCC. “It’s unacceptable that more than 60 percent of patients were inappropriately denied care because the health plan industry is trying to minimize costs.”

After a patient receives a denial for a service, medicine or treatment from their health plan, they can appeal the decision with their plan directly. Should the health plan deny the service a second time, patients have the right to request an IMR through the DMHC. An IMR is an independent review of a denied, delayed or modified health care service that the health plan has deemed to be not medically necessary, experimental/investigational or non-emergent/urgent.

“If these denials were only overturned because of the IMR process, think of the hundreds of thousands of Californians denied necessary care who never appealed the decision because they didn’t even know it was an option,” said Joan Werblun, RN, chair of CCCC. “It’s imperative that people living with chronic diseases and conditions, and all patients for that matter, know that they have the right to an appeal and they are not alone in their struggle to get the care they need.”

In 2017, the DMHC assessed $8,907,000i in fines and penalties against health plans, with Anthem Blue Cross being one of the major violators. In November 2017, DMHC took enforcement action against Anthem Blue Cross for its systemic violations of the grievance system, fining it $5 million for failing to identify, process and resolve consumer grievances in a timely manner. The $5 million fine was the result of 245 specific grievance system violations that occurred from 2013 through 2016. In each of these cases, Anthem deprived patients of their right to medical care.

While compiling the data necessary for “Standing Up For Your Rights Creates Results,” CCCC was alarmed at the number of individual denials requesting authorization or reimbursement of medications, procedures and testing. To evaluate the types and patterns of denials, CCCC took a closer look at 1,011 of more than 4,000 IMR cases, focusing on chronic conditions and serious illnesses such as cancer, mental health, musculoskeletal, cardiovascular and hepatitis. Those within these categories were denied requests which were vital for the effective treatment and management of their conditions. Although more than 50 percent of health plan decisions from this specific subset were reversed or overturned, it’s important to note the specific diseases and services that had higher counts of denials as it highlights the health plan industry’s routine practice of inappropriately denying care to patients in need.

In one such case, a young patient with juvenile spondyloarthritis was denied coverage of intravenous Remicade infusions as their health plan didn’t find it medically necessary. Before requesting Remicade, the patient had tried three other medications that failed to treat her inflammatory arthritis. To prevent long-term damage from leaving it untreated, the patient’s physician recommended Remicade infusions as the treatment is safe in the pediatric population and demonstrated significant improvement in arthritis, inflammatory markers, pain and physical function for juvenile spondyloarthritis. The independent reviewer determined the requested services were medically necessary and overturned the health plan’s denial.

Patients who need assistance navigating the complex health care system should visit My Patient Rights, a one-stop–shop created by CCCC to help patients receive the care they need and deserve. My Patient Rights provides information on how to file a complaint with a patient’s health plan, as well as the appropriate state agency. In addition, the website offers patients an avenue to learn about their rights and specific barriers put in place by health plans that may jeopardize their care.

To access CCCC’s “Standing Up for Your Rights Creates Results” report and the related infographic, visit www.CaliforniaChronicCare.org.


About the California Chronic Care Coalition
The California Chronic Care Coalition (CCCC) is a unique alliance of more than 30 leading health organizations and provider groups that promote the collaborative work of policy makers, industry leaders, providers and consumers to improve the health of Californians with chronic conditions. We envision a system of care that is accessible, affordable and of a high quality that emphasizes prevention, coordinated care, and the patient’s wellness and longevity. http://www.californiachroniccare.org

i California Department of Managed Health Care. (2017). Annual Report (Page 16). Retrieved from: https://www.dmhc.ca.gov/Portals/0/Docs/DO/2017-Annual-Report-web.pdf