Currently, Congress is working on a bipartisan solution for “surprise” medical bills, a move that has the potential to tilt the balance of power away from insurers and back into the hands of patients. It’s a necessary fix, but it’s not the only one we should implement if we want to really support patients. Lawmakers must look beyond emergency rooms and operating tables to another tool insurers are using to take advantage of patients — surprise denials.
Just how prevalent are surprise denials? According to a recent Kaiser Family Foundation analysis of the healthcare.gov marketplace, “Insurers denied nearly one out of every five claims submitted for in-network services in 2017, and enrollees only appeal a tiny share (0.5 percent) of those denied claims.”
Among cancer patients prescribed proton therapy, the rate is even higher. My organization often hears the gut-wrenching stories of patients pitted in a David versus Goliath battle against their insurers over the baffling denial of a doctor-recommended treatment.
Last May, we released a report showing that private insurers deny proton radiation treatment six out of 10 times for patients age 18-64. While those denials are reversed a third of the time, appeals take an average of five weeks. That’s time patients don’t have as they fight an aggressive disease.
Proton radiation therapy is routinely approved for pediatric patients and by Medicare. The absurdity of the current “surprise denial” system is, if you’re between the ages of 18 and 64 getting insurance approval for the treatment can be a tremendous struggle.
In the face of insurers’ claim denials, some cancer patients opt to take on the “surprise” financial burden of paying for proton therapy themselves. Those without such means are forced to settle for other forms of treatment that may be less effective and/or cause unnecessary side effects. Ron Cunningham fell into the former camp when his late wife, Orrana, was diagnosed with stage IV nasopharyngeal cancer.
MD Anderson oncologists recommended proton therapy for Orrana because they were concerned about the tumor’s proximity to her brain stem and other critical structures. Proton therapy could precisely target the tumor while preventing potential side effects, ranging from loss of taste and memory to blindness and death. In Orrana’s case, she fell into that 18 to 64 age gap that insurers incomprehensibly exploit.
When Aetna blindsided the couple with a rubber-stamped denial, they were forced to mortgage their dream home in order to pay for the FDA-cleared treatment. Ron later filed suit against Aetna and a jury found that the company acted in reckless disregard of their duty to Orrana.
Ron’s case demonstrates the power imbalance between patients and insurers and validates why unplanned medical bills top the list of financial worries for one in four Americans. The alarming costs of a cancer diagnosis are only compounded by an insurance system run amok. Nearly 42 percent of patients diagnosed with cancer between 2000 and 2012 drained their entire life’s savings within two years. The financial burden patients experience while fighting cancer makes them 2.65 times more likely to file for bankruptcy compared to those without cancer.
Protecting patients from surprising and overwhelming costs associated with unfair health insurance company policies and practices is a commendable, overdue goal. Congress should be aware, however, that putting power back in the hands of patients requires fixing more than one facet of our broken healthcare system. It must include addressing a broken review and appeals process that results in surprise denials.
As Congress works to balance the scales between patients and insurers, I encourage members to adopt the principles of a Cancer Patients’ Timely Treatment Bill of Rights into legislation to ensure patients have a fair and prompt review process when they are facing life-threatening illness, rather than the bureaucratic insurance company run-arounds that too many cancer patients are encountering today. Doing so will allow cancer patients and their families and doctors to focus on fighting the disease with the best-available treatment, free from unfair financial and emotional distress.