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Your Pain,
Their Gain

How health insurers profit off denying care

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1.

Meet
Susan

Susan is 52 and was healthy until recently. One day, she stood up from her work desk and fainted.

At the emergency room, a doctor diagnosed Susan with a heart arrhythmia (irregular heart rhythm). Susan’s cardiologist prescribed medication. Then Susan underwent a non-invasive procedure to shock her heart back into its normal rhythm.

But Susan still has symptoms. Her cardiologist said she’s at risk of stroke if she doesn’t get a procedure that stops the electrical impulses causing her irregular heart rhythm. Susan’s cardiology office sent a pre-authorization request to her health insurance company. The response came back almost immediately.

DENIED.

Susan’s scared. The surgery costs between $20,000 and $26,000 and she doesn’t have the money to pay for it out of pocket. She’s taking an unpaid medical leave from her job, and her family’s savings are nearly depleted.

Susan’s cardiologist will appeal the denial, but it’s a lengthy, resource-consuming process with no guarantee.*

*Susan is a fictional person, and this narrative is a fictional account inspired by real patient stories.

 
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2.

Barriers
To Care

Do you know who gets the final say on what treatments are covered?

While physicians take an oath to prescribe beneficial treatments for their patients, it’s the commercial insurance companies who get the final say on what treatments are covered — sometimes to the detriment of patient health.

According to 1,000 doctors of the American Medical Association:

94%

94% said prior authorization (PA) — insurance companies’ requirement for pre-approval before treatment — delayed access to necessary care

80%

80% said PA led patients to abandon recommended care

25%

25% said PA had led to a patient’s hospitalization

Adding more barriers to care, commercial insurers have raised premiums 14.5% over the past 5 years.

3.

Treatment
Denied

In 2021, the private health insurers in the HealthCare.gov marketplace denied 17% of in-network claims. According to Change Healthcare, a healthcare analytics platform, average denial rates increased by 23% between 2016 and 2020.

Did you know that it may not be a person denying treatment coverage, but an algorithm?

Using an automated system, Cigna spent an average of 1.2 seconds per case to deny more than 300,000 claims.

And your commercial insurance company may also be using an algorithm to make inflexible treatment decisions. For example, NaviHealth, a UnitedHealth Group subsidiary, is being investigated for taking measures to align the length of rehab stays of their Medicare Advantage patients to within 1% of the days projected by an algorithm.

Other commercial insurers have not been complying with patients’ written requests for documentation about claims denials, even though they’re required to do so by law.

Adding insult to injury, commercial insurers often delay or deny claims for treatment already undergone, potentially leaving the patient on the hook for the cost.

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?

Has your health insurer denied your claim?
Click here to find out why.

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4.

Your Health,
Their Profit

Commercial health insurance companies add to their bottom line and pay shareholder profits by denying people healthcare. And their profits have been soaring for years.

In 2021, large commercial health insurers reported profit increases ranging from 14% – 30%.

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In 2022, profits from several major carriers went up 7% – 70%.

  • United Health Group’s profits up 28%+
  • Cigna’s profits up 70%+
  • Elevance Health’s profits up 7%+
  • Centene’s profits up 26%+
  • Molina’s up 60%+

However, there is hope and it’s found in the local hospitals serving those who need care the most.

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5.

Beacons
of Hope

Investing in healthcare here
Rooted in the places and people they serve, local hospitals may not turn away anyone seeking emergency medical care.

Covering unpaid costs
The IRS requires hospitals to have a written financial assistance policy to explain how patients in need can access free and discounted care.

For example, on average, not-for-profit hospitals provide free care to individuals and families who are under 200% of the federal poverty level guidelines. That means a family of four making less than $60,000 a year would likely be eligible for free care.*

In addition, these hospitals provide discounted care for individuals and families making up to 350% of the federal poverty level guidelines. That means a family of four making $105,000 would still be eligible for financial assistance.*

*Source: FY2020 IRS Form 990, Schedule-H filings

Contributing Their Fair Share
In 2019, nonprofit hospitals’ tax-exempt status resulted in a loss of $12.4 billion federal tax revenue dollars. But the same year, nonprofit hospitals dispersed more than $110+ billion to community health programs. This investment in community benefit is NINE TIMES what nonprofit hospitals would pay in taxes if they were for-profit entities.

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6.

Under
Attack

Local hospitals are here, but for how long?
At the same time as insurance companies pocket record breaking profits, many local hospitals are experiencing financial distress.

1.3%

Hospitals’ median operating margin , the proportion of revenue remaining after costs, is 1.3%.

30%

More than 30% of our nation’s rural hospitals are at risk of closure.

20.1%

Between 2019 and 2021, per-patient hospital expenses (for labor, drugs, supplies, etc.) increased 20.1 percent.

2x

Over the past decade, annual commercial health insurance premiums have increased at twice the rate as the annual rise in hospital prices.


How much longer can we allow this to go on?

What About Susan?

Fortunately, Susan qualifies for financial assistance from her local hospital so she can get the procedure. Susan can also take part in her hospital’s free education seminars on heart-healthy living, weekly exercise classes, and monthly heart health support group.

Millions of Americans aren’t as fortunate as Susan. And this number will continue to grow as hundreds of city and rural hospitals across the United States are teetering on the edge of closure.







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A Call to Action

1.

Stay Informed

Read and share information happening in your healthcare community or choose from articles below.

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When ‘Prior Authorization’ Becomes a Medical Roadblock

The New York Times

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Denied by AI…The Dangerous Use of AI in Medicine

STAT News

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A Doctor at Cigna Said Her Bosses Pressured Her to Review Patients’ Cases Too Quickly. Cigna Threatened to Fire Her.

ProPublica.org

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‘What’s My Life Worth?’ The Big Business of Denying Medical Care

New York Times

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Find out why your health insurer denied your claim.

ProPublica.org

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Are insurers using tech to automate claims denials?

ModernHealthcare.com

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Corporate Insurance Companies are Denying Health Care, Driving Up Costs

ProtectHealthcare.org

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Hospitals and Profits:
Should They Co-exist?

The New York Times

2.

Find out why

Have you been denied by your health insurer?
Get to the bottom of it.

3.

Share your voice

Contact your elected state and federal representatives to express your support for your local hospital.

Find your local representatives
Enter your zip code here:


Don’t know what to say?
To help you get started, below are some helpful talking points you can personalize to express your concern.

Dear [Elected Official’s Name],

My local hospital [name] plays a vital role in providing essential medical services to our local neighborhoods. It is the primary healthcare resource for me and my family. I’m concerned [hospital name] faces significant challenges that threaten its sustainability and the health and well-being of our community.

As your constituent, I urge you to support and protect [hospital name] and other local hospitals and ensure accessible healthcare for all Americans.

I’m confident your leadership and dedication to the well-being of our constituents will drive positive change on this critical issue. I hope you will prioritize this matter and work toward enacting legislation and policies to safeguard local hospitals and prevent healthcare deserts.

Thank you for your attention to this urgent matter.

Sincerely,
[Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number]

Brought to you by the
Alliance for Access to Care

The Alliance for Access to Care supports healthcare professionals who provide essential medical services 24/7 to patients in our local communities. Alliance members include the American Hospital Association, Association of American Medical Colleges, Catholic Health Association, Healthcare Financial Management Association, and other health care providers and patient advocacy groups.


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