United Healthcare Denials
Preventing United Healthcare Denials of Care: A Professional Guide for Surgeons
Brad Bichey MD MPH, CEO Nemedic, Inc. December 8, 2024
Recent data highlights a troubling trend in healthcare: the denial of necessary care by insurance companies. According to ValuePenguin, United Healthcare denies 32% of all claims—a figure significantly higher than industry averages. For surgeons providing elective care, this rate can soar to 80%, with Medica following closely, scoring a 27% denial rate of all claims reviewed. These percentages are almost 50% higher than the industry standard, presenting significant challenges to patient care and practice efficiency.
https://www.valuepenguin.com/health-insurance-claim-denials-and-appeals#denial-rates
The Problem: Systematic Strategies by Insurers are Undermining Care
The root cause of these alarming statistics lies in specific systemic strategies employed by insurers like United Healthcare. These tactics not only obstruct the delivery of timely care but also place an undue burden on healthcare providers. Some of these strategies include:
- Excessive Prior Authorization Requirements: Nearly half of denied claims stem from the prior authorization process, where care is delayed or denied outright.
- AI-Driven Claim Denials: Autonomous systems often reject claims without proper contextual understanding, leaving providers to navigate complex appeals.
- Frequent Coverage Changes: Insurers modify coverage criteria frequently, often without adequate communication to providers.
- Burdensome Appeal Processes: Complicated, time-consuming appeals delay care, sometimes for months.
- Peer-to-Peer Review Challenges: Physicians are forced into discussions with insurance-employed doctors, a system rife with conflicts of interest and further delaying approvals.
- “Value-Based” Care Models: These models prioritize shareholder profits under the guise of efficiency, often delivering reduced care to patients.
These practices contribute to provider burnout, diminished trust in the healthcare system, and reduced availability of healthcare professionals as many providers are now opting out of such frustrating systems.
Addressing Denials: Practical Steps for Surgeons
When faced with a denial of care, there are actionable steps providers can take to navigate and potentially overturn these decisions:
Step 1 – Submit High-Quality Prior Authorization Documentation
Ensure initial submissions include comprehensive, clear, and criteria-compliant documentation. Notes should address all potential plan requirements, increasing the likelihood of approval by AI-based review systems.
Step 2 – Review Plan Documents Thoroughly
Examine denial letters and insurance plan documents to understand the basis of the denial. These documents often include:
- Reasons for denial
- Covered procedures and associated costs
- Deadlines for appeals
- Steps for the appeal process
Step 3 – Actively Engage with the Insurance Company
If the denial reason is unclear or disputed, contact the insurer directly to gain insight into the decision-making process. Clarify next steps for re-review and gather information on required documentation for an appeal.
Step 4 – Resubmit Corrected Claims Quickly
Address any errors in paperwork or coding and provide additional supporting documentation to strengthen your case.
Step 5 – Request the Claim File
Obtain the insurer’s claim file, which contains records of all information considered in the denial. This insight can help tailor your appeal effectively.
Step 6 – File an Internal Appeal*
Submit a formal request for reconsideration. Internal appeals typically must be filed within a designated timeframe based on the denial notice. Typical timelines for response vary:
- 30 days for prior authorization appeals
- 60 days for appeals related to completed treatment
- 72 hours for expedited appeals in urgent cases
*When you file an internal appeal it’s often appropriate to encourage patients to actively participate in the process by engaging their insurance provider to express concerns about the denial.
Step 7 – Pursue External Appeals
If internal appeals are unsuccessful, file for an external review through your state or the Department of Health and Human Services (HHS). Some expedited reviews in urgent cases can be resolved within 72 hours.
Step 8 – Utilize State Insurance Departments:
Patients can file complaints with their state’s department of insurance, a free and straightforward process that adds pressure on insurers to resolve disputes.
In Indiana the complaint process against an insurer is free.
Conclusion: Advocate for Patients and Ethical Practices
By diligently following these steps, surgeons can navigate the challenges posed by insurance denials and ensure patients receive the care they need. However, these systemic issues underscore a larger problem: the need for accountability and reform in the insurance industry.
Providers should also inform their patients about these practices and encourage them to consider alternative insurance options when possible. Ultimately, the healthcare system should prioritize patient well-being over corporate profits, a principle that seems increasingly at odds with the strategies employed by companies like United Healthcare.
Fire up!