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When Colleen Henderson’s 3-year-old daughter complained of pain while using the bathroom, doctors brushed it off as a common illness in the age of urinary tract infection or constipation, a toilet training experience.
However, Henderson suspected it could be even worse and sought ultrasound. The doctor and ultrasound technician told her that her insurance provider, UnitedHealthcare, wouldn’t cover it, but Henderson decided to do it anyway and charged her credit card for the $6,000 process. did. Then the news came: her infant’s bladder had a grapefruit-sized tumor.
It was 2008. The next five years have been a prolonged battle with UnitedHealthcare over the payment of the experts who ultimately diagnosed and treated their daughter’s rare condition, an inflammatory pseudotumor. She appealed to the insurance company and state regulators to refuse coverage for hospital stays, surgery and drug therapy, but to no avail. She said Sacramento-area families have acquired more than $1 million in medical debt as UnitedHealthcare determined that doctors recommend treatments were not needed. The family declared bankruptcy.
“If I hadn’t nailed my teeth and nails at every stage of the road, my daughter would be dead,” Henderson said. Henderson’s daughter eventually recovered and is now a 20-year-old junior at Oregon State University. “You’re paying a lot to get health insurance. I hope your health insurance has your happiness at the forefront, but that’s not happening at all.”
Insurance refusals are on the rise, but studies show that few Americans appeal to them. Various analyses have shown that many of those escalating complaints to government regulators (unlike the Hendersons) have their denial overturned. Consumer advocates and policy makers say it is a clear sign company. Now, the California Legislature proposal is trying to punish insurers who repeatedly make incorrect calls.
The measure, Senate Bill 363, covers only about a third of insured Californians whose health plans are regulated by the state, but experts should curb health insurance companies’ denials He says that doing so could be one of the nation’s most audacious attempts. It is given. And California could be one of only a handful of states that require insurance companies to disclose their rejection rates and inferences.
The measure also seeks to force insurers to be more wise against denial if more than half of the appeals filed with the regulator are overturned in one year.
In 2023, state data shows that about 72% of appeals made to the Department of Managed Health Care, which regulates most of the health plans, insurers’ initial denials were reversed.
“Once you have health insurance, you should be confident that it covers your healthcare needs,” said Sen. Scott Winner, a San Francisco Democrat who introduced the bill. “They can just delay, deny, and interfere, and often don’t need to cover medically necessary care, and that’s not acceptable.”
A spokesman for Asun, California. He declined to comment on the health plan, saying the group is still reviewing the bill’s language. Elana Ross, a spokesman for Gov. Gavin Newsom, said his office had not commented on the pending laws to the public.
Concerned about the swirl of consumer health costs, lawmakers across the country are increasingly looking for ways to ensure that insurance companies are paying their claims fairly.
In 2024, 17 states enacted laws dealing with advance approval of care by private insurance companies, according to a national meeting of the state legislature. For example, Connecticut, which has one of the most robust rejection rate disclosure laws, has published an annual report card detailing the number and percentage of claims each insured company has rejected, as well as the stock that is reversed. I’m doing it. Oregon released similar information until recently, when state disclosure requirements expired.
In California, there is no way to know how often an insurance company will refuse care. Health experts are particularly troubling as mental health needs are reaching crisis levels among children and young adults. Denying mental health care is easy, as diagnosis of depression can be more subjective than fragments or cancer diagnosis, according to Keith Humphreys, a professor of health policy at Stanford University.
“We’ve seen a lot of people who are hoping to do this,” said Lishaun Francis, senior director of behavioral health at Advocacy Group Children Now, a sponsor of the bill.
Under Wiener’s proposal, private insurance companies regulated by the state’s Department of Control or Insurance, or both, must submit detailed data on denials and appeals. They must also explain their rejections and report the outcome of the appeal.
Over half of the insurers whose denials have been reversed due to the state’s independent medical review process, or due to appeals reaching the IMR, will face astounding penalties. The first case of exceeding the 50% threshold will result in a fine of $50,000, with penalties ranging from $100,000 to $400,000. Each then costs the company $1 million.
If successful, the measure applies to approximately 12.8 million Californians under private insurance. It covers roughly 5.6 million Californians, excludes large employer-provided self-insurance plans that do not apply to state Medicaid programs or Medicare patients and are regulated by the U.S. Department of Labor.
The phrase “deny and delay” continues to echo across the healthcare industry after killing United Healthcare CEO Brian Thompson in December. A survey conducted immediately after the attack by the University of Chicago research institute NORC found that seven in 10 respondents were heavily responsible for Thompson’s death due to health insurance companies’ denial of health insurance and benefits. He said he was thinking. .
After Thompson’s death, UnitedHealthcare said in a statement that “very inaccurate and grossly misleading information” has been circulating about the way the company claims, and highly regulated insurance companies have “usually the same as one-sided fingers.” There’s a small margin.”
Wiener called Thompson’s murder a “cold blooded assassination,” and said his measure grew from a narrower proposal last year aimed at improving mental health compensation for children and adults under the age of 26. . The killing underscored the rage that many Americans have long attacked over health insurance companies’ practices and the urgent need for reform.
Stanford Professor Humphries said the US health system creates strong financial incentives for insurers to deny care. He added that state and federal penalties are small enough to be amortized as an expense for doing business.
“The more they deny care, the more money they make,” he said.
According to Shawn Gremminger, national president of the Healthcare Alliance of Healthcare’s Buyers Union, large employers are in a language to contract with claim managers who fine them for approving too many or too few claims for insurance providers. I’m starting to include:
Gremminger represents a large employer who funds his insurance, is federally regulated and excludes him from Wiener’s bill. But even so-called self-funded plans could make it nearly impossible to determine the rejection rate for insurance companies hired to simply manage their claims.
The bill may be too late for many families, but Rialto’s Sandra Machurino has said that lawmakers will be insured to help other Californians avoid the saga they endured to receive her nie’s treatment. He said he hopes to tackle the denial of.
She adopted a now 13-year-old girl after her younger sister passed away. Her nie has long struggled with self-harm and violent behavior, but when the therapist recommended psychiatric care for hospitalized patients, her insurance company Anthem Blue Cross has been working to just 30 days. I’ll cover that.
Matrino said her nie had repeated facilities and counseling sessions and repeated consultations because her insurance doesn’t cover long-term stays. The doctor tested the laundry list for prescription medications and doses. None of them worked.
Anthem declined to comment on the story.
Unlike many others in similar situations, Machurino was ultimately able to get outside support to improve the situation. She sought help from the adoption agency, but ended up covering the costs of Nie’s stay in the Utah Housing Program. She was diagnosed with bipolar disorder and has been undergoing treatment for a year.
Matrino said she had no energy to appeal to the national anthem.
“I wasn’t going to wait for the insurance to kill her, and I wasn’t going to wait for her to hurt anyone,” Matrino said.
KFF Health News is a national newsroom that produces detailed journalism on health issues and an independent source of health policy research, voting and journalism, one of KFF’s core operating programs.
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