When the girl of Colleen Henderson, three years old, complained of pain when using the bathroom, the doctors pushed her as an infection or constipation of urinary tract, common diseases in the years of training.
Henderson, however, suspected it could be something worse and asked for an ultrasound. The doctor and the ultrasound technician told him that his insurer, Unitedhealthcare, would not cover him, but Henderson decided to do so anyway, invoicing the $ 6,000 procedure on his credit card. Then came the news: there was a tumor the size of a grapefruit in his bladder for toddlers.
It was in 2008. The following five years, Henderson said, became an prolonged battle against Unitedhealthcare to pay the specialists who finally diagnosed and treated the rare state of his daughter, inflammatory pseudotumor. She called on hospital stays, surgeries and drugs to the insurer and state regulators in vain. The family of the Sacramento region has accumulated more than a million dollars of medical debt, she said, because Unitedhealthcare said that her treatments recommended by doctors were not necessary. The family said bankruptcy.
“If I had not fought tooth and nails at each stage of the process, my daughter would have died,” said Henderson, whose daughter has finally recovered and is now a 20 -year -old flourishing junior at Oregon State University. “You pay a lot of money to have health insurance, and you hope your health insurance will have your well-being at the forefront, but that does not happen at all.”
Although refusal of insurance is increasing, investigations show that few Americans call them. Various analyzes have found that many of those who degenerate complaints from government regulators have managed to overthrow denials (unlike the Hendersons). Consumer defenders and decision -makers say that signs insurance companies are regularly only care should not be. Now, a proposal in the California Legislative Assembly seeks to penalize insurers who make the wrong call repeatedly.
While the measure, SB 363, would only cover approximately a third of insured Californians whose health plans are regulated by the State, experts say that this could be one of the most daring attempts of the nation to brake the Refusal of health insurers – before and after care is given. And California could become one of the rare states that oblige insurers to disclose denial rates and reasoning, the data that industry often considers proprietary information.
The measure also aims to force insurers to be more judicious with refusals, bringing them up to 1 million dollars per case if more than half of the calls filed with regulators are canceled in one year.
In 2023, showing state data, approximately 72% of calls were launched at the Ministry of Health Care Managed, which regulated the vast majority of health plans, led to the initial refusal of an insurer.
“When you have health insurance, you should have confidence that this will cover your health care needs,” said Senator Scott Wiener, the Democrat of San Francisco who presented the bill. “They can simply delay, deny, obstruct and, in many cases, avoid having to cover medically necessary care, and it is unacceptable.”
A spokesman for California Association of Health Plans refused to comment, saying that the group was still examining the language of the bill. Governor’s spokesman Governor Gavin Newsom, Elana Ross, said her office is not generally commenting on current legislation.
Concerned about the spiral of consumer health costs, state legislators across the country have increasingly sought means to verify that insurers pay complaints fairly.
In 2024, 17 states promulgated legislation dealing with the prior authorization of care by private insurers, according to the National Conference of States Legislatures. For example, Connecticut, which has one of the most robust denial rates of denial rates, publishes an annual bulletin detailing the number and percentage of complaints that each insurer has refused, as well as the part that ends up being reversed. Oregon has published similar information until recently, when state disclosure requirements have escaped.
In California, there is no way to know how often insurers deny care, which, according to health experts, is particularly disturbing, because mental health care is reaching crisis levels in children and young adults. According to Keith Humphreys, professor of health policy at the University of Stanford, it is easier to deny mental health care because a diagnosis, let’s say, depression can be more subjective than that of a broken member or Cancer.
“We think it is unacceptable that the state has absolutely no idea of the size of a problem,” said Lishaun Francis, principal director of behavioral health for the children’s defense group Now, a sponsor of the bill.
Under Wiener’s proposal, private insurers regulated by the State Department of Health Care and / or the Ministry of Insurance would be required to submit detailed data on refusals and calls. They should also explain these refusals and report the results of the calls.
For calls that go to the state independent medical examination process, known as IMR, insurers whose refusals are canceled more than half of the time would face astounding penalties. The first case which brings a company above the 50% threshold would trigger a fine of $ 50,000, with a penalty varying from $ 100,000 to $ 400,000 for a second. Each after that would cost $ 1 million.
If it is adopted, the measure would cover approximately 12.8 million Californians on private insurance. He would not apply to patients on Medi-Cal, on the statement program of the State or Medicare, and he would exclude the self-assured plans offered by major employers, who are regulated by the US Labor Ministry and covered approximately 5.6 million Californians.
The expression “nier and delay” continues to resonate in the health care industry after the murder of the CEO of Unitedhealthcare, Brian Thompson, in December. In a NORC survey at the University of Chicago, shortly after the attack, 7 out of 10 said they thought that the refusals of health coverage and the benefits of health insurance companies had a lot or responsibility Moderate for the death of Thompson.
After the death of Thompson, Unitedhealthcare said in statements that “very inaccurate and roughly misleading information” had been disseminated on the way the company deals with claims and that insurers, which are highly regulated, “generally have margins at low digit to medium to midfield ”.
Wiener described Thompson’s murder a “cold blood assassination”, but said that his bill was born from a closer proposal that failed last year to improve the mental coverage of children and adults under 26. But he recognized the reaction of the country to death underline the underlining underline, underline the underlines of the end of long-standing collar that many Americans have felt the practices of the health insurers and the urgent need for reform.
Humphreys, Stanford Professor, said the American health system creates solid financial incentives for insurers to refuse care. And, he added that state and federal sanctions are sufficiently derisory to be canceled as a working cost.
“The more they deny care, the more they earn money,” he said.
Increasingly, large employers are starting to include the language in contracts with complaint administrators who would penalize insurers for having approved too much or too few complaints, said Shawn Gremminger, president of the National Alliance of Healthcare Buy Coalitions.
Gremminger represents most major employers who finance their own insurance, are regulated by the federal government and are excluded from the Wiener bill. But even for such supposedly self-funded plans, it may be almost impossible to determine denial rates for insurance companies committed simply to administer complaints, he said.
Although the bill can be too late for many families, Sandra Maturino, from Rialto, said that she hoped that the legislators attack the refusals of insurance so that other Californians can avoid the saga that she endured to obtain his niece treatment.
She adopted the 13 -year -old girl after the death of her sister. His niece had long fought against self -harm and violent behavior, but when the therapists recommended hospital psychiatric care, his insurer, Anthem Blue Cross, would only cover him for 30 days.
For more than a year, Maturino said, his niece has traveled and outside the facilities and advice because his insurance would not cover a long -term stay. Doctors have tested a list of prescription drugs and doses. None of this worked.
Anthem refused to comment on this story.
Unlike so many others in similar situations, Maturino was finally able to obtain external help to remedy the situation. She asked for help from the adoption agency, and it ended up covering the cost of the stay of her niece in a residential program of Utah, where she was diagnosed with a bipolar disorder and undergoes treatment For a year.
Maturino said that she did not have the energy to call on Anthem. “I was not going to wait for the insurance to kill her, or for her to hurt someone,” said Maturino.
Kff Health News is a national editorial room that produces in -depth journalism on health problems and is one of the main operating programs in Kff – The independent source of research on health policies, survey and journalism.
California Daily Newspapers
