San Francisco Chronicle examines health insurance claim denials

The San Francisco Chronicle on Monday examined how "[e]ach year, thousands of Californians find themselves at odds with their health insurers over whether they, as patients, should get the treatment their doctors prescribed."

Insurers say that physicians do not always prescribe the most cost-effective treatments. Anthem Blue Cross says it follows strict protocols in denying care and relies on medical evidence to determine what care is appropriate. Michael Belman, Anthem's medical director, said, "Even in a dire situation, it is ethically appropriate to withhold treatment if it's not effective." Alan Sokolow, chief medical officer for Blue Shield of California, said, "We think that is our job -- to help patients and providers apply the benefit package the patient has, the dollars they put for insurance coverage and health care, in the most appropriate and effective way," adding that patients should appeal denials if they disagree.

According to the Chronicle, in 2007, the state's HMO Help Center received about 90,000 calls from individuals with health insurance disputes. The majority of disputes involved whether treatment or procedures prescribed by physicians were "medically necessary" or considered "experimental" or "investigational." The state Department of Insurance, which regulates a smaller number of insurance plans, received 35,280 complaints and resolved 262 independent medical review cases in 2007. The Department of Managed Health Care since 2001 has offered third-party medical reviews and has resolved 1,716 IMRs since 2007. According to DMHC, roughly 40% of decisions are settled in favor of the patient.

Jerry Flanagan, health advocate for Consumer Watchdog, said that issues arise because health insurers "are going back to the old strategies of the '90s, when they interrupted care on the front end by denying or delaying treatment offered by a doctor." He said insurers hope patients will not dispute the decisions or settle for less, in order to save money -- a statement that insurers dispute.

The Chronicle also profiled the cases of three individuals whose claims were denied by insurers (Colliver, San Francisco Chronicle, 6/23).