When Colleen Henderson's daughter, 3 years old, complained of pain when using the bathroom, the doctors pushed him as an infection or constipation of urinary tract, common diseases in the training years.
Henderson, however, suspected it could be something worse and asked for an ultrasound. The doctor and the ultrasound technician told him that his insurer, Unitedhealthcare, would not cover him, but Henderson decided to do so anyway, invoicing the $ 6,000 procedure on his credit card. Then came the news: there was a tumor the size of a grapefruit in his bladder for toddlers.
It was in 2008. The next five years, Henderson said, became a prolonged battle against Unitedhealthcare to pay the specialists who finally diagnosed and treated the rare state of his daughter, Inflammatory pseudotumor. She called on the refusal of coverage for hospital stays, surgeries and medicines to the insurer and state regulators, in vain. The family of the Sacramento region has accumulated more than a million dollars of medical debt, she said, as Unitedhealthcare had decided that the treatments recommended by doctors were not necessary. The family said bankruptcy.
“If I had not fought tooth and nails at each stage of the process, my daughter would have died,” said Henderson, whose daughter has finally recovered and is now a 20 -year -old flourishing junior at Oregon State University. “You pay a lot of money to have health insurance, and you hope your health insurance will have your well-being at the forefront, but that does not happen at all.”
While insurance refusals are upward,, surveys Show some Americans call them. Various analyzes have found that many of those who degenerate complaints government regulators succeed Reversed refusals (Unlike Hendersons). Consumer defenders and decision -makers say that signs insurance companies are regularly only care should not be. Now, a proposal in the California Legislative Assembly seeks to penalize insurers who make the bad call on several occasions.
While the measurement, Senate bill 363, Only about, about, about a third of insured Californians whose health plans are regulated by the State, experts say that this could be one of the most daring attempts in the country to slow down the refusals of health insurers – before and after care. And California could become one of the rare states that oblige insurers to disclose denial rates and reasoning, the data that industry often considers proprietary information.
The measure also aims to force insurers to be more judicious with refusals, bringing them up to 1 million dollars per case if more than half of the calls filed with regulators are canceled in one year.
In 2023, State data show, About 72% of calls were launched in the managed health care department, which regulate the vast majority of health plans, led to the inversion of initial refusal of an insurer.
“When you have health insurance, you should have confidence that this will cover your health care needs,” said Senator Scott Wiener, the Democrat of San Francisco who presented the bill. “They can simply delay, deny, obstruct and, in many cases, avoid having to cover medically necessary care, and it is unacceptable.”
A spokesperson for California Assn. Health plans refused to comment, saying that the group still examined the language of the bill. Governor’s spokesman Governor Gavin Newsom, Elana Ross, said her office is not generally commenting on current legislation.
Concerned by the spiral of consumer health costs, States legislators across the country have increasingly sought ways to verify that insurers pay the complaints fairly.
In 2024, 17 states promulgated The legislation dealing with the prior authorization of care by private insurers, according to the National Conference of States Legislatures. For example, Connecticut, which has one of the most robust denial rate disclosure laws, publishes a annual The report detailing the number and percentage of complaints that each insurer has refused, as well as the part which ends up being reversed. Oregon has published similar information Until recently, When state disclosure requirements have destroyed.
In California, there is no way to know how often insurers deny care, which, according to health experts, is particularly disturbing as mental health needs reach crisis levels Among children and young adults. According to Keith Humphreys, professor of health policy at the University of Stanford, it is easier to deny mental health care because a diagnosis, say, depression can be more subjective than that of a broken member or cancer.
“We believe that it is unacceptable that the state has absolutely no idea of the size of a problem,” said Lishaun Francis, principal Director of Behavioral Health for the Defense Group of Children Now, a sponsor of the bill.
Under Wiener's proposal, private insurers regulated by the State Department of Health Care of the State or the Ministry of Insurance, or both, would be required to submit detailed data on refusals and calls. They should also explain these refusals and report the results of the calls.
For calls that go to the state independent medical examination process, or IMR, insurers whose refusals are canceled more than half of the time would face narcotic penalties. The first case which brings a company above the 50% threshold would trigger a fine of $ 50,000, with a penalty varying from $ 100,000 to $ 400,000 for a second. Each after that would cost $ 1 million to the company.
If adopted, the measure would apply to around 12.8 million Californians on private insurance. He would not apply to patients on Medi-Cal, on the statement program of the State or Medicare, and he would exclude the self-assured plans offered by major employers, who are regulated by the US Labor Ministry and covered around 5.6 million Californians.
The expression “deny and delay” continues to repercussions in the health care industry after the murder From the director general of Unitedhealthcare, Brian Thompson, in December. In a investigation By the NORC research organization at the University of Chicago, directed shortly after the attack, 7 in 10 respondents said that they thought that the refusals of health coverage and the benefits of health insurance companies had a lot or moderate responsibility for the death of Thompson.
After the death of Thompson, Unitedhealthcare said in statements that “Very inaccurate and roughly misleading information” had been broadcast on the way the company deals with complaints and insurers, which are highly regulated, “generally have Low margins half shift. “”
Wiener called Thompson's murder of the murder of a “cold blood assassination” and said that his measure had grown up from a closer This failed last year aimed at improving mental coverage for children and adults under the age of 26. But he recognized that the public reaction to the murder highlighted the long-standing anger that many Americans have felt the practices of the health insurers and the urgent need for reform.
Humphreys, Stanford Professor, said the American health system creates solid financial incentives for insurers to refuse care. And, he added, the state and federal penalties are dispected enough to be radiated as a working cost.
“The more they deny care, the more they earn money,” he said.
Increasingly, large employers are starting to include the language in contracts with complaint administrators who would penalize insurers for having approved too much or too few complaints, said Shawn Gremminger, president of the National Alliance of Healthcare Buy Coalitions.
Gremminger mainly represents major employers who finance their own insurance, are regulated by the federal government and would be excluded from the Wiener bill. But even for so-called self-funded plans, it may be almost impossible to determine denial rates for insurance companies hired simply to administer complaints, he said.
Although the bill can be too late for many families, Sandra Maturino de Rialto said that she hoped that the legislators attack the refusals of insurance so that the other Californians can avoid the saga that she endured to obtain her niece treatment.
She adopted the 13 -year -old girl after the death of her sister. His niece had long fought against self -harm and violent behavior, but when the therapists recommended hospital psychiatric care, his insurer, Anthem Blue Cross, would only cover him for 30 days.
For more than a year, Maturino said, his niece has traveled and outside the facilities and advice because his insurance would not cover a long -term stay. Doctors have tested a list of prescription drugs and doses. None of them worked.
Anthem refused to comment on this story.
Unlike so many others in similar situations, Maturino was finally able to obtain external help to remedy the situation. She asked for help from her adoption agency, and that ended up covering the cost of the stay of her niece in a residential program of Utah, where she was diagnosed with bipolar disorder and has been under treatment for a year.
Maturino said that she did not have the energy to call on Anthem.
“I was not going to wait for the insurance to kill her, or for her to hurt someone,” said Maturino.
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