It is infuriating to see a publication that presents itself as being a defender of ordinary consumers sell bogus advice and refuse ever to consider, let alone promote, sound policy options. The object lesson today is a recent article, Doctors and Patients Try to Shame Insurers Online to Reverse Prior Authorization Denials. It would be one thing if KFF were to highlight this tendency to call for reforms. But no, the story advocates this approach as a strategy…using KFF itself picking up one of these cases and getting a $36.000 payout.
But since this KFF story was picked up by NBC, we are sure to see energy diverted into social media campaigns rather than reform…which the article indicates in a well buried paragraph was already happening. On top of that, the claim that a social media strategy works is based on source the story mislabels as the National Consumer Rage Survey, which is actually the National Customer Rage Survey. It’s done annually with about 1000 households. There is no indication of what proportion of these complaints (74% of respondents stated they had a problem with a product or service) related to health insurance claim denials, so we have no ideas how large that share was and if it could be considered representative
Moreover, the article also misrepresented the significance of social media efforts. This is what the article said:
This is the 2022 study finding, according to KFF Health News:
Customers are increasingly using social media to air their complaints across all industries, and companies are paying attention. Nearly two-thirds of complainants reported receiving some sort of response to their online post, according to the 2023 “National Consumer Rage Survey,” conducted by Customer Care Measurement & Consulting in collaboration with Arizona State University.
This is the actual finding from the study, as reported by Hubspot:
50% of customer complaints were made using digital channels including email, chat, and social media…..
63% of businesses are doing a better job of monitoring and responding to social media complaints. However, many of the consumers who complain via social media say they’re only “somewhat satisfied” with the resolution.
Even though it seems logical that consumers might be using social media more, that is not what the study found. It reported a shift away from complaining by phone to complaining by e-mail, chat and social media, with social media listed last, presumably to signal it is the least important. And given the way most companies have cut call center hours and staffing and have been aggressively trying to shift consumers to using less labor-intensive channels, it is hard to see the shift as mainly a result of customer preference, as opposed to companies making it more painful to complain via phone by inserting phone trees and long hold times between customers and human agents.
Let us step back and depict this particular insurer scam, which is the abuse of prior authorization. This requirement applies not just to scheduled surgeries but other treatments. From the article:
Prior authorization is a common cost-cutting tool used by health insurers that requires patients and doctors to secure approval before moving forward with many tests, procedures, and prescription medications. Insurers say the process helps them control costs by preventing medically unnecessary care. But patients say the often time-consuming and frustrating rules create hurdles that delay or deny access to the treatments they need. In some cases, delays and denials equal death, doctors say….
The 2010 Patient Protection and Affordable Care Act prohibits health insurance plans from denying or canceling coverage to patients due to their preexisting conditions…
But some patient advocates and health policy experts question whether insurers are using prior authorization as “a possible loophole” to this prohibition, as a way of denying care to patients with the highest health care costs, explained Kaye Pestaina, a KFF vice president and the co-director of its Program on Patient and Consumer Protections.
The story then recites denial horrorshows, one of a denial of a $13,000 a month intravenous immunoglobulin treatment for an autoimmune disorder after all else had failed, another for $450 worth of daily meds to shrink a pediatric brain tumor, and a third of an ugly skin rash due to the failed to approve a biologic for Chron’s disease.
KFF Health News points to the IV treatment as an apparent social media success, because KFF Health News contacted the insurer, Blue Cross of Illinois, and the patient soon found that $36,000 of outstanding treatments had been redesignated as paid with no notice or explanation from the insurer. KFF Health News does not indicate how that patient, Sally Nix, got to KFF Health News. Even though the article says Nix vented on Facebook and Instagram, for all we know, she came to KFF Health News’ attention via a more old-fashioned means, like writing editors at KFF Health News who were on the insurer denial beat, or getting people in her personal network to do.so. In the other showcased story, mother appear to have navigated the approval system to get 90 days of medications approved; she then posted online out of the hope that that would prevent the insurer from denying the next 90 day approval. The mother seems convinced social media made a big difference but there is no evidence of that; in fact, her daughter could have been caught up in sadly routine requirements for additional documentation.
The one case that is looks the strongest as a social media win is the doctor who tweeted a nasty photo of the skin rash. His case was reportedly escalated to a review the next day and approved.
In fact, the article concedes that social media may make no difference:
But many patients and doctors believe venting online is an effective strategy, though it remains unclear how often this tactic works in reversing prior authorization denials.
The problem with these misleadingly-told tales is any successes are almost certainly follow a power curve, particularly since the ability to get attention on social media depends on one’s social capital to begin with. Would a parent tweeting the ugly skin rash photo have been taken as seriously as an upset parent?
And how many cases will be amplified by the likes of a KFF Health News? This seems way too much like a lottery (see at 0:50):
And that is before getting to the fact that big corps can and do suppress bad press. Companies called reputation defenders are skilled at planting stories, tweets, and posts so as to drown out negative coverage. I’ve seen this happen with our extensive work on private equity fees and CalPERS. If consumer complaints become enough of a nuisance, the insurers may devote more energy to diluting their visibility rather than solving the problem.
The article further concedes insurers are starting to clean their acts up, albeit slowly:
But there’s reason to hope things may get marginally better. Some major insurers are voluntarily revamping their prior authorization rules to ease preapproval mandates for doctors and patients. And many states are passing laws to rein in the use of prior authorization.
But nowhere does this account mention that there’s already an effective way to crack down on insurer denials, and it’s well road tested too. New York has had an external appeal process for decades. I’ve used it and it works. I’ve gotten denials reversed on routine care, and the mere warning to reps that I will avail myself of the appeals process if I have to seems to help as well. There is also an expedited process for pending procedures, where the state delivers a response in 72 hours.
Some details from the New York Department of Financial Services website:
If your insurer or HMO denies health care services as not medically necessary, experimental/investigational or out-of-network, you have the right to appeal to the Department of Financial Services (DFS). This appeal is known as an External Appeal. Health care providers also have the right to an external appeal when health care services are denied (concurrently or retrospectively)….
Health plans may charge a $25.00 fee to patients or their designees, not to exceed $75.00 in a single plan year. The fee is waived for patients who are covered under Medicaid, Child Health Plus, Family Health Plus, or if the fee will pose a hardship. Health plans may charge providers a $50.00 fee …
For an external appeal to be expedited, the denial must concern an admission, availability of care, continued stay, or health care service for which the patient received emergency services and remains hospitalized; or the patient’s physician must attest that the patient has not received the treatment and a 30-day timeframe would seriously jeopardize the patient’s life, health, or ability to regain maximum function, or a delay will pose an imminent or serious threat to the patient’s health. Or the patient is suffering from a health condition that may seriously jeopardize his or her life, health, or ability to regain maximum function, or is undergoing a current course of treatment using a non-formulary drug. A patient may request an expedited internal and external appeal at the same time. A decision on an expedited external appeal will be made within 72 hours (or 24 hours for a non-formulary drug), even if all of the patient’s medical information has not yet been submitted.
When I asked for a review, my case was read by an MD, and I believe this is still the standard. MDs are not very keen about insurers second-guessing doctors on medical care.
There needs to be far more activist and press demands for external appeal, as opposed to at best tiny bandaids of individual consumers trying to make enough noise to be heard.