Denial of Hospital’s COVID Claim Shows Why Patients Must Support Providers

You might think that a health insurance company would not possibly contest the hospital treatment of an insured patient severely ill with COVID-19.

Think again.

COVID-19, also known as coronavirus, has created a global pandemic. More than 230,000 Americans have died from the illness. Coronavirus poses a serious threat to people with underlying medical conditions. Unfortunately, this demographic constitutes an immense portion of the U.S. population.

COVID-19 Denials During the Pandemic

Even during a global pandemic, health insurance companies continue to look for ways to deny portions of a hospital’s claim, including for patients suffering from the COVID-19 virus. 

In one glaring denial recently appealed by our office, a 32-year-old nursing home employee was treated as an inpatient for coronavirus and related complications for 26 days. After being placed in an acute inpatient bed (a medical/surgical unit), the patient was elevated to the Intensive Care Unit (ICU) on the twelfth day of admission when her condition worsened. The patient’s condition steadily declined and tragically she died after 26 days of treatment.

In denying the hospital’s claim, the insurance company stated the ICU level of care was too high for the last five days of this critically ill woman’s life. A physician, who works for a managed care health plan, stated this patient’s level of care should have been downgraded while her condition declined.

This is a common example of the types of claims denials our hospital clients receive.

The Managed Care Disconnect

This heartbreaking example makes clear that there is a disconnect between physicians serving in hospitals and those who conduct managed care for insurance companies. Medical professionals employed by hospitals and insurance companies should be on the same page when it comes to treating patients—especially during this pandemic.

Why should a critically ill person whose condition is declining be moved to a less intensive level of care? Even without the benefit of hindsight, it should be crystal clear to all that the health plan’s physician is making a harmful and wrong determination.

How Patients Can Help Healthcare Providers

During these financially challenging times, healthcare providers must engage patients to ensure they advocate for payment from managed care plans. As consumers of care, patients have a powerful say in advocating for appropriate payment. Often, the patient’s say carries greater weight than healthcare providers contracted by managed care plans.

In framing this issue for patient-consumers, I would urge them to consider the following scenario: their own hospital stay. Imagine, dear consumer, you spend a week in the hospital where the doctor renders thoughtful treatment and the nurses provide compassionate care. After being discharged you receive an “Explanation of Benefits” notice that indicates your insurance will pay for your treatment. However, the hospital that treated you with such care will receive zero or severely curtailed compensation.

Now multiply this scenario by hundreds of similar cases and you can see why hospitals are facing financial crisis just when they are needed most. This is precisely why hospitals require help from patients and their families.

Consumers have the right to contact their insurance company through written appeal, or voice dissatisfaction at a denial via a phone call. Insurance companies are inclined to listen because members are essential to their purpose. In the case of the nursing home employee, the hospital could look to the patient’s family and our law office for help in overturning the denial.

Hospitals are essential institutions that must be reimbursed in order to stay in operations. The team at Anderson & Quinn works diligently to overturn denials such as this.

We call on patients to join us.