Letter to HELP Committee asking for Claims Denials Hearing

September 18, 2023

 

The Honorable Bernie Sanders
Chairman
U.S. Senate Committee on Health, Education, Labor and Pensions
428 Senate Dirksen Office Building
Washington, DC 20510

The Honorable Bill Cassidy
Ranking Member
U.S. Senate Committee on Health, Education, Labor and Pensions
455 Dirksen Senate Office Building
Washington, DC 20510

 

Dear Chairman Sanders and Ranking Member Cassidy,

People’s Action’s Care Over Cost campaign and the undersigned organizations write to respectfully request the Health, Education, Labor and Pensions (HELP) Committee hold a hearing to investigate the pattern and practice of care denials by private health insurance corporations, and the impact these denials have on people in need of care, including prolonged illness or injury, suffering, and medical debt.

Everyone should have access to the care they need, when they need it. Too often, private insurance corporations refuse to pay for health insurance claims submitted by health care providers in order to increase their profits. These care denials cause medical debt, bankruptcy, worse health outcomes, and in some cases even premature death due to care not received. 

People’s Action’s Care Over Cost campaign is made up of grassroots groups organizing nationwide to address the systemic problem of care denials by private insurance corporations. Everyone is affected by care denials, whether that looks like a prior authorization denial that prevents someone from getting the treatment they need or insurance’s refusal to pay for treatment someone has already received via a claim denial. Insurance companies offer a process through which policyholders can appeal denials, but the processes are confusing, opaque, and time consuming. And they are designed and managed by the private insurers themselves, who stand to profit by denying the appeal. The Care Over Cost campaign is organizing people experiencing care denials and helping them file appeals and run public pressure campaigns on the insurance corporations to overturn the denials, and elevating the peoples’ stories in traditional and digital media. Through fighting individual claims, we publicly expose the injustice and build power and expertise as we build towards policy campaigns to reduce claims denials and profiteering and build public support for Medicare for All as we are campaigning. 

Available data indicates high denial rates. In 2021, 17% of claims submitted under health insurance plans purchased through the ACA marketplace were denied, with some plans having denial rates as high as 49%. A recent report by the Department of Health and Human Services Office of the Inspector General found that in 2019 Medicaid managed care organizations (“MCOs”) fully or partially denied 1 out of 8 prior authorization requests or 12.5%. Twelve of the 115 MCOs in the study had prior authorization denial rates above 25%. 6% of prior authorization requests for care for people on Medicare Advantage plans were partially or fully denied. While only 11% of these denials were appealed, 82% of those appealed resulted in the full or partially overturning of the denials. 

Despite the authority to do so, the federal government does not collect and publish uniform and comprehensive data on insurance claims denials by claim type and demographics across types of insurance plans. We recommend that the Senate HELP Committee invite people to testify about their experiences with private insurance refusing to pay for their care and identify solutions to advance public transparency and accountability in our healthcare system. 

Over the past several months, the Care Over Cost campaign helped fight and win claims denial cases throughout the country. The examples below illustrate the problem and severity of claims denials.

• A subsidiary of Elevance Health denied People’s Action/Iowa Citizens for Community Improvement member Bri Moss a new insulin pump, forcing her into a stay in an emergency room. The New York Times included her story in an article on the Inspector General report on privatized Medicaid (Managed Care) claims denials noted above. After Bri’s hospital stay, Care Over Cost helped her appeal and got her a new insulin pump. Elevance Health (the former Anthem BCBS) reported $8.5 billion in profits in 2022, while buying back $2.3 billion in shares. 
• United Healthcare denied Carly Morton life-saving surgery that would allow her to eat again. Care Over Cost waged a public campaign and with assistance from Senator Bob Casey, we won Carly’s care and she had her surgery in late July 2023. Carly is on a Medicare Advantage (privatized Medicare) plan. UnitedHealth Group reported $20.1 Billion in profits in 2022 alone.
• After two rounds of cancer treatment, side effects from a mastectomy and breast reconstruction surgery put former State Representative (R-NH) and emergency medical technician Jenn Coffey in bed for years. United Healthcare refused to pay for her treatments, forcing Jenn to sell her car and fundraise to pay for treatments. Care Over Cost campaigned to win Jenn approval for her first round of treatment, but Jenn is now navigating repeated prior-authorization processes that hinder her care. Care Over Cost and New Hampshire Senators Shaheen and Hassan continue to work with Jenn to help remove these and other obstacles to her life-saving care. United Health Group is the largest provider of Medicare Advantage plans (27.1% market share) and is accused of fraud and overbilling by the federal government.

Thank you for your leadership and consideration of this request. We hope to have the opportunity to support you in conducting a hearing. We would be happy to help you identify people who have been denied claims and can speak to the physical, emotional, and financial hardships suffered at the hands of private health insurance corporations.

 

Sincerely,

People’s Action 

Care Over Cost Campaign Member Organizations

[see full list of 100+ signatories in below PDF]

 

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