Ticked Off Over Preauthorization: Walk-in Patient Avoided Lyme Disease But Not A Surprise Bill

Leah Kovitch was pulling invasive plants successful nan meadow adjacent her location 1 play successful precocious April erstwhile a tick latched onto her leg.

She didn’t announcement nan mini bug until Monday, erstwhile her calf musculus began to consciousness sore. She made an assignment that greeting pinch a telehealth expert — 1 recommended by her wellness security scheme — who prescribed a 10-day people of doxycycline to forestall Lyme illness and powerfully suggested she beryllium seen successful person. So, later that day, she went to a walk-in session adjacent her location successful Brunswick, Maine.

And it's a bully point she did. Clinic staffers recovered different tick connected her assemblage during nan aforesaid visit. Not only that, 1 of nan ticks tested affirmative for Lyme, a bacterial infection that, if untreated, can cause superior conditions affecting nan nervous system, heart, and joints. Clinicians prescribed a stronger, azygous dose of nan medicine medication.

"I could person gotten really ill," Kovitch said.

But Kovitch's insurer denied sum for nan walk-in visit. Its reason? She hadn't obtained a referral aliases preapproval for it. "Your scheme doesn't screen this type of attraction without it, truthful we denied this charge," a archive from her security institution explained.

Health insurers person agelong based on that anterior authorization — erstwhile wellness plans require support from an insurer earlier personification receives curen — reduces discarded and fraud, arsenic good arsenic imaginable harm to patients. And while security denials are often associated pinch high-cost care, specified arsenic crab treatment, Kovitch's mini tick wound exposes really anterior authorization policies tin use to treatments that are considered inexpensive and medically necessary.

Pledging to hole nan process

The Trump management announced this summertime that dozens of backstage wellness insurers agreed to make sweeping changes to nan anterior authorization process. The promise includes releasing definite aesculapian services from anterior authorization requirements altogether. Insurers besides agreed to widen a grace play to patients who move wellness plans, truthful they won't instantly brushwood caller preapproval rules that disrupt ongoing treatment.

Mehmet Oz, administrator of nan Centers for Medicare & Medicaid Services, said during a June property convention that immoderate of nan changes would beryllium successful spot by January. But, truthful far, nan national authorities has offered fewer specifics astir which diagnostic codes tagged to aesculapian services for billing purposes will beryllium exempt from anterior authorization — aliases really backstage companies will beryllium held accountable. It's not clear whether Lyme illness cases for illustration Kovitch's would beryllium exempt from preauthorization.

Chris Bond, a spokesperson for AHIP, nan wellness security industry's main waste and acquisition group, said that insurers person committed to implementing immoderate changes by Jan. 1. Other parts of nan promise will return longer. For example, insurers agreed to reply 80% of anterior authorization approvals successful "real time," but not until 2027.

Andrew Nixon, a spokesperson for nan U.S. Department of Health and Human Services, told KFF Health News that nan changes promised by backstage insurers are intended to "cut reddish tape, accelerate attraction decisions, and promote transparency," but they will "take clip to execute their afloat effect."

Meanwhile, immoderate wellness argumentation experts are skeptical that backstage insurers will make bully connected nan pledge. This isn't nan first clip awesome wellness insurers person vowed to betterment anterior authorization.

Bobby Mukkamala, president of nan American Medical Association, wrote successful July that nan promises made by wellness insurers successful June to hole nan strategy are "nearly identical" to those nan security manufacture put distant successful 2018.

"I deliberation this is simply a scam," said Neal Shah, writer of nan book "Insured to Death: How Health Insurance Screws Over Americans — And How We Take It Back."

Insurers signed connected to President Donald Trump's promise to easiness nationalist pressure, Shah said. Collective outrage directed astatine security companies was peculiarly aggravated pursuing nan sidesplitting of UnitedHealthcare CEO Brian Thompson successful December. Oz specifically said that nan promise by wellness insurers was made successful consequence to "violence successful nan streets."

Shah, for one, doesn't judge companies will travel done successful a meaningful way.

"The denials problem is getting worse," said Shah, who co-founded Counterforce Health, a institution that helps patients entreaty security denials by utilizing artificial intelligence. "There's nary accountability."

Cracking nan case

Kovitch's measure for her session assignment was $238, and she paid for it out-of-pocket aft learning that her security company, Anthem, didn't scheme to screen a cent. First, she tried appealing nan denial. She moreover obtained a retroactive referral from her superior attraction expert supporting nan necessity of nan session visit.

It didn't work. Anthem again denied sum for nan visit. When Kovitch called to study why, she said she was near pinch nan belief that nan Anthem typical she said to couldn't fig it out.

"It was for illustration complete their heads aliases something," Kovitch said. "This was each they would say, complete and complete again: that it lacked anterior authorization."

Jim Turner, a spokesperson for Anthem, later attributed Kovitch's denials to "a billing error" made by MaineHealth, nan wellness strategy that operates nan walk-in session wherever she sought care. MaineHealth's correction "resulted successful nan declare being processed arsenic a master sojourn alternatively of a walk-in center/urgent attraction visit," Turner told KFF Health News.

He did not supply archiving demonstrating really nan billing correction occurred. Medical records supplied by Kovitch show MaineHealth coded her walk-in sojourn arsenic "tick wound of near little leg, first encounter," and it's not clear why Anthem interpreted that arsenic a master visit.

After KFF Health News contacted Anthem pinch questions astir Kovitch's bill, Turner said that nan institution "should person identified nan billing correction sooner successful nan process than we did and we apologize for nan disorder this caused Ms. Kovitch."

Caroline Cornish, a spokesperson for MaineHealth, said this isn't nan only clip Anthem has denied sum for patients seeking walk-in aliases urgent attraction astatine MaineHealth. She said Anthem's processing rules are sometimes misapplied to walk-in visits, starring to "inappropriate denials."

She said these visits should not require anterior authorization and Kovitch's lawsuit illustrates really security companies often usage administrative denials arsenic a first response.

"MaineHealth believes insurers should attraction connected paying for nan attraction their members need, alternatively than creating obstacles that hold sum and consequence discouraging patients from seeking care," she said. "The strategy is excessively often tilted against nan very group it is meant to serve."

Meanwhile, successful October, Anthem sent Kovitch an updated mentation of benefits showing that a operation of security institution payments and discounts would screen nan full costs of nan appointment. She said a institution typical called her and apologized. In early November, she received her $238 refund.

But she precocious recovered retired that her yearly oculus assignment now requires a referral from her superior attraction provider, according to caller rules laid retired by Anthem.

"The inclination continues," she said. "Now I americium much savvy to their ways."