Portland resident Ronan Aubrey, 30, has a family history of cancer. When his doctor found two masses in his body in April of 2022, the doctor recommended a diagnostic ultrasound.
However, the ultrasound was not fully covered by his insurance provider, Community Health Options, leaving him with roughly $1,000 to pay out of pocket. Aubrey is currently in the process of setting up a payment plan to do so.
“My insurer shouldn’t be deciding whether I should be getting a medical procedure,” Aubrey said. “My doctor should.”
Physicians and supporters joined Aubrey outside Aetna Health Insurance, a CVS Health company, in Portland on Wednesday to demand that the provider and other private insurers stop denying insurance claims. The rally of about 10 people brought together by Maine People’s Alliance, a community action organization, was one of 14 organized across the country for the Care Over Cost campaign run by People’s Action, of which MPA is a member.
The Care Over Cost campaign demands private insurers overturn denial claims for treatments recommended by medical professionals, be more transparent in why claims are denied as well as the monetary value of denials, and reimburse governments for public money diverted because of denials, among other asks.
MPA intended to deliver in person a letter to the Aetna office addressed to Duncan Stewart, who leads its Northeast Region, detailing their demands. However, the office was closed so MPA sent the letter virtually after the event, said Nora Flaherty-Stanford, media and public affairs director for MPA.
Aetna did not respond to Maine Morning Star’s question about why the Portland office was closed Wednesday but did provide a general response to the rally.
My insurer shouldn’t be deciding whether I should be getting a medical procedure. My doctor should.
“We believe that every American should have access to affordable, high quality health coverage,” Alex Kepnes, executive director of communications for Aetna wrote to Maine Morning Star. “The basic premise of making health care more affordable and simpler is at the core of CVS Health’s transformation.”
For Aetna, being part of the solution means preserving and strengthening Medicare and Medicaid programs, building on the employment-based insurance system, and supporting efforts to make individual health insurance more affordable to serve those who do not have access to employer-sponsored coverage, Kepnes wrote.
According to a report issued by the U.S. Health and Human Services’ Office of Inspector General in July, one in eight requests for prior authorization of health services to Medicaid Managed Care in 2019 were denied, a denial rate of 12.5%.
Aetna’s denial rate was just below at 12.1%, a figure cited in the letter. The OIG report did not include data from Maine, as the state did not have comprehensive, risk-based Medicaid managed care organizations. Overall, the report concluded that the wide variation in denial rates among insurers emphasized the need for targeted state oversight of prior authorization denials in order to make sure that enrolled residents are not inappropriately denied care.
Wednesday’s speakers zeroed in on denial of care in privatized programs, such as managed care within Medicaid and Medicare Advantage. These plans provide Medicare-approved private company health insurance.
“This is really about the principle of claims denial rather than any specific case or set of cases,” Flaherty-Stanford told Maine Morning Star. “This is about private insurers having the power in our system to deny people care that has been recommended by their medical providers. Because when claims are denied, what it comes down to often is that people just don’t get that care.”
“It sort of doesn’t matter where it is, or what form the claims denial is taking, whether it’s something where they’re just straight up saying ‘no,’ or whether it’s a deductible thing, or whether it’s something else,” she added. “What it is fundamentally is a private insurer saying that you can’t get that care.”
For Aubrey, it was a matter of his deductible not being met, so he was responsible to pay for the services received.
Psychiatrist Julie Pease said claim denials were not as common when she began practicing in Maine in 1987. In the mid 1990s, guiding patients through claims denials started to become a regular part of her day-to-day work.
“The first question people get asked is not ‘What brings you here today?’ or ‘Why are you here?’” Pease said. “But, ‘What insurance do you have?’”
Pease now regularly practices in New Zealand, a change she made due to the flexibility of semi-retirement but also because of the country’s universal healthcare model, she said. Research shows cost is a barrier to healthcare in the U.S. On a national scale, 1 in 11 adults reported that they delayed or went without care because of the cost, according to the 2021 National Health Interview Survey.
With private insurance and privatized Medicare like Medicare Advantage, patients have to confirm each year that their doctor’s office accepts their insurance, Pease said, adding that the same is true for coverage of specific medications.
This year, Maine’s largest hospital, Maine Medical Center, dropped the state’s largest insurance carrier, Anthem Blue Cross and Blue Shield. The decision came after MaineHealth, which runs MMC, rejected several mid-contract policy changes from Anthem that impacted reimbursement.
“Anthem is not paying its bills,” Andy Mueller, chief executive officer of MaineHealth, testified to the Joint Standing Committee on Health Coverage, Insurance and Financial Services in 2022. “They owe us $70 million in unpaid claims that date back to 2019.”
In its letter, MPA asked Aetna for an in-person meeting to discuss its demands and to reverse specific care and claim denials, as well as for Aetna to more generally have monthly open microphone meetings with policyholders in each state the insurer operates.
The letter also instructed private insurers not to use Artificial Intelligence to deny claims in bulk, although no specific accusations were made against Aetna or other insurers. Separately, an investigation by ProPublica earlier this year found that the insurance company Cigna used an automated system to assess and deny claims in bulk.
MPA located Wednesday’s event at an Aetna office for visibility, Flaherty-Stanford said, however the rally targeted all private insurers.
Other rallies occurred on Wednesday in Denver, Colorado; Hartford, Connecticut; Chicago, Illinois; Detroit, Michigan; The Bronx, New York; Rochester, New York, Manchester, New Hampshire; Charleston, West Virginia; Milwaukee, Wisconsin; Randallstown/Pikesville, Maryland; Saint Louis; Missouri; and Louisville, Kentucky. The 14th rally is scheduled to occur tomorrow in Cedar Rapids, Iowa.
