The Uphill Battle: Addressing Insurance Denials for Essential Health Benefits Under ACA

By Norman Means, MD

Section 1302 of the Patient Protection and Affordable Care Act (“ACA” or Obamacare), codified at 42 U.S.C. § 18022, mandates that specific health plans include coverage for “Essential Health Benefits” (EHB). Within these EHBs are “preventive and wellness services,” incorporating all screening recommendations from the United States Preventive Services Task Force (USPSTF) graded with either an “A” or “B” level recommendation.

Tammy Atwood, a pseudonym, is a 54-year-old current cigarette smoker who recently had her annual check-up with her new primary care doctor. Despite being asymptomatic and seemingly in good health, her 35 pack-year history of smoking prompted her physician to recommend a low-dose CT of the chest to screen for lung cancer— a test accorded a “B” level recommendation by the USPSTF. The criteria for this screening include age between 50 to 80 years, a minimum of 20 pack-year smoking history, current smoking status (or having quit within the last 15 years), absence of health problems substantially limiting life expectancy, and willingness to undergo curative lung surgery. Meeting all requirements and her health plan being under the ACA-mandate, a low-dose lung CT was arranged.

However, Tammy’s health plan promptly denied coverage for the screening test, citing a “lack of medical necessity.” Per the carrier’s explanation, the denial arose because the office staff indicated the presence of any cancer symptoms as “unknown” in the insurer’s pre-test questionnaire. After a 30-minute phone appeal, Tammy’s physician secured approval for the test.

Such denials have become distressingly routine, contradicting the explicit statutory language of the ACA. “Insurers have used various tactics to evade covering portions or entire preventive services that ought to be covered,” states Laura Hermer, J.D., a Professor of Health Law at Mitchell Hamline School of Law in St. Paul, MN.

In Tammy’s case, the insurance carrier’s actions blatantly contradicted the ACA’s mandatory requirements and the USPSTF’s established cancer criteria. The insurer exploited a clerical staff member’s lack of knowledge of any symptoms to justify their denial, using the ambiguous criteria of “medical necessity,” rather than a confirmed statement regarding lung cancer symptoms.

Government efforts to address these abuses of the ACA’s preventive services mandate have been largely ineffective. “These practices persist, despite ongoing efforts by the federal Department of Health and Human Services to eradicate them,” remarks Professor Hermer.

Quantifying the human cost of such routine denials of cancer screening is challenging due to a lack of public data on unappealed denied tests. However, the toll on physician time is evident. Tammy’s physician, seeking anonymity to avoid repercussions, shared, “Multiply the hours wasted every week on hold with insurance companies by the number of primary care physicians and midlevel providers nationwide, and the societal burden surely surpasses any savings from avoiding covering medically unnecessary testing.”

Transparency holds the key to resolving these issues. Federal regulators should consider mandating insurers to disclose appeals data, including the rates of non-appealed initially denied cancer screenings. Moreover, insurers must be compelled to reveal the average duration of physician appeals calls and the success rates of such appeals. “These ‘peer-to-peer’ calls almost invariably result in approval by the insurance company physician,” says Tammy’s physician, “so why are we wasting time making these calls in the first place?”  Enforcing the mandates of the ACA will ensure that those who stand to benefit most from cancer screening do not encounter unnecessary roadblocks in their healthcare journey.

About the author: Norman Means, MD is a medical professional with over 30 years’ experience in rural healthcare, and currently a third-year law student.

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