One New York City doctor has tips on how to deal with health insurance companies "without becoming a fugitive."
The killing of the CEO of one of the largest healthcare insurance in the U.S. has highlighted Americans' intense dissatisfaction with the cost and complexity of getting medical care, and healthcare providers like Dr. Dan Ginader are typically the first to communicate with insurance companies.
As a physical therapist and medical content creator in New York City, Dr. Ginader says dealing with healthcare insurance is "genuinely the worst part" of his job.
Following the deadly shooting of UnitedHealthcare CEO Brian Thompson, the doctor who often works with Broadway dancers posted a video to his social media to spread the message about what patients can do to advocate for themselves if their health insurance company denies their claims.
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"As a healthcare provider that fights against insurance companies in order to get coverage for my patients on a weekly basis, here are four ways that you can fight against your insurance company that don't involve you becoming a fugitive," Dr. Ginader said at the start of his video, referencing what authorities say was a targeted attack on Thompson.
Here are some of the things Ginader says you and your healthcare provider can do to appeal a claim denial:
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Use AI against them
In a ProPublica report published last year, health insurer Cigna was found to have denied over 300,000 requests for payments using an automated algorithm that spent an average of 1.2 seconds on each case. The company and other insurers, including UnitedHealthcare and Humana, are now facing lawsuits over the use of similar algorithmic software used to process claims.
Denial rates for private insurance can range widely from 5.7%. to 41.9%, according to a 2023 analysis by KKF, but patients can use the same technology against their health insurance companies, Dr. Ginader said.
Most people are unaware that they have a legal right to appeal if their health insurance company denied their claim, a survey by the Commondwealth Fund found. When they do, the appeal process is often complex but the outcome typically goes in the patient's favor.
To make the appeal process more accessible, software companies like Claimable and Anamoly are using AI to analyze data to help payers in their appeal and help providers to get reimbursed.
Claimable says that it can help you overturn unjust denials and prevent care delays, touting more than 80% success rate within 10 days or less.
Anamoly was built specifically for healthcare providers to help predict what health insurance companies will cover. Its CEO, Mike Desjadon, sat down with NBC 4 Washington and explained how his company can help streamline the process for providers.
"Our goal is to make sure that your doctor's office has all the information that they need so that they can do everything right in advance. So you go and you get your care, your insurance company pays for your care, or you get a transparent bill," Mike Desjadon said.
Request a peer-to-peer review
Another way that patients can work with providers to get coverage is to request a peer-to-peer (P2P) review.
"That is when somebody like me gets on the phone with an actual human being to discuss your care," Dr. Ginader said.
A P2P review is typical between the healthcare provider and a medical professional employed by the health insurance company to obtain prior authorization approval for certain procedures or drugs, but it can also be requested to appeal a previously denied prior authorization.
While P2P can be helpful in the appeal process, its requirement to determine if certain services are covered can often delay serious care for patients, according to the American Medical Association (AMA), which advocates for physicians.
An AMA survey found that 24% of physicians report that prior authorization has led to a serious adverse event for a patient in their care. In addition, 94% of physicians report that prior authorization somewhat or significantly increases physician burnout.
Hire an insurance lawyer
The appeal process can be time-consuming and complex, and an attorney can help take some of the stress off your mind.
"It's unfortunate but I've had a few patients who had to resort to hiring an insurance lawyer. But when they do, they really do make a difference," Dr. Ginader added.
Oftentimes, you can get a consultation for a very low free, or even for free if you utilize local services like the ones listed below.
Request a fair hearing
People in New York pay some of the highest health insurance premiums in the country, but the state also has a number of social services aimed to help you navigate the field.
Those with public health insurance can request a fair hearing with the New York State Office of Temporary and Disability Assistance, appeal their case with an administrative law judge. Medicare allows you to appoint a representative, like an attorney or a friend, to handle the appeal for you, according to nonprofit Consumer Action.
"It basically gives you the chance to state your case in front of a third party and they get to make the decision," Dr. Ginader said. A fun note is that insurances hate these, and even the threat of one can bring them down on their knees and in your favor."
Medicare recipients also get help from the State Health Insurance Assistance Program. Every state also has a Consumer Assistance Program that offers services for free. Although New York New York no longer operates a CAP under the Affordable Care Act, the Community Service Society of New York continues the service for residents and you can call them at 1-888-614-5400.
