Insurance Claim Denials: The Impact on Patients

Insurance claim denials have become a growing concern in the healthcare industry, particularly when it comes to procedures aimed at treating peripheral artery disease (PAD) and critical limb ischemia (CLI). These denials not only frustrate physicians like Interventional Cardiologist Dr. Barry Tedder in Jonesboro, Arkansas but also inflict unimaginable suffering on patients. In this week’s The Heart of Innovation, we will delve into the alarming trend of insurance claim denials for minimally invasive procedures and explore the detrimental effects they have on patients’ lives.

The Prevalence and Severity of Peripheral Artery Disease

Peripheral artery disease, characterized by the narrowing or blockage of blood vessels outside the heart and brain, affects millions of individuals worldwide. It is deadlier than all cancers combined, excluding lung cancer. Patients with PAD experience severe leg pain during physical activity and may even have their sleep disrupted due to restricted blood flow caused by plaque buildup in the arteries.

For patients in early stages of PAD who experience intermittent claudication, a regimented walking program is the best medicine. If medication and lifestyle modifications are not enough to relieve symptoms of leg pain and leg cramps, and they progress, then a physician may try a minimally invasive approach to opening up the arteries to attain more blood flow. For advanced stage of PAD, known as CLI, physicians know that time is of the essence to get vessels opened up as “time is tissue”, especially if a patient has a wound that won’t heal and/or gangrene has developed on their toe or foot.

The Importance of Minimally Invasive Procedures

Interventional cardiologists like Dr. Tedder have been advocating for the use of minimally invasive procedures to treat PAD and CLI. These procedures offer a potentially life and limb-saving alternative to traditional surgery, providing relief to patients suffering from excruciating pain and preventing limb loss. Minimally invasive methods can effectively open up the blocked arteries, restoring blood flow and improving the overall quality of life for patients.

Insurance Claim Denials: A Disturbing Trend

Despite the demonstrated efficacy of minimally invasive procedures for PAD, insurance companies are consistently denying reimbursement requests from physicians. This trend has left both medical professionals and patients frustrated and desperate for a resolution. One of Dr. Tedder’s patients, spent the summer suffering without a much needed intervention to relieve her lifestyle limiting claudication, because her insurance denied coverage. He shares the story on this week’s show, of having to fight for approval over the course of nearly three months until it finally was to go before a judge. Insurance finally came through, but it was literally moments before the hearing was scheduled to begin.

” It’s a game of who will blink first!”

Dr. Barry Tedder

The Human Cost of Insurance Claim Denials

Insurance companies often prioritize cost-cutting measures over patient well-being. Patients suffering from lifestyle limiting claudication due to PAD and especially CLI where they are awakened by what patients describe as the worst Charlie Horse you could ever imagine, and wounds that won’t heal, find themselves trapped in a cycle of excruciating pain and limited options for relief. Delayed or denied claims ultimately prolongs patient suffering and jeopardizes their overall health. Insurance providers must recognize the human cost of these claim delays and denials and take steps to prioritize patient care.

The Impact on Physicians

Insurance claim denials not only affect patients but also place an immense burden on physicians. Doctors, who are in direct contact with their patients and understand their medical needs, often find themselves second-guessed by insurance providers who prioritize financial considerations over patient care. This constant battle with insurance companies can lead to frustration and burnout among healthcare professionals. And it’s simply not fair to second-guess them when the vast majority are truly trying to do what’s best for the patient to improve their quality of life and a timely, effective manner.

Factors Contributing to Insurance Claim Denials

Multiple factors contribute to the denial of insurance claims. One of the most contentious issues is the misuse of atherectomy devices (devices used for removing plaque) by a small number of doctors. As a result, insurance companies either reject procedures altogether or require physicians to perform a diagnostic angiogram first and provide a detailed plan outlining the tools they intend to use before the vessel opening procedure. The Way To My Heart, a patient advocacy organization, has encountered cases where limb salvage procedures have been denied by pediatricians or obstetricians serving as case review physicians for insurance claims. Additionally, if a patient presents with critical limb ischemia in an office-based laboratory, they are not considered an emergency, leading to many denials or a mandatory 14-day waiting period before undergoing the limb salvage procedure to restore blood flow and alleviate symptoms. However, if a patient goes to the Emergency Room, amputation is covered without question. In certain instances, The Way To My Heart has also witnessed insurance providers denying limb salvage procedures for patients who have not consulted a certified vascular surgeon, instead opting for intervention by a limb salvage trained Interventional Radiologist or Interventional Cardiologist. Additionally, algorithms used by insurance companies to review claims often result in mass denials without proper examination of individual cases. And in the case of Dr. Tedder, the insurance company denied his request for coverage of a patient because their ‘guidelines’ indicate a minimally invasive procedure is not appropriate for a lesion longer than five centimeters. The guidelines don’t consider a patient’s overall health, in which in this case, the patient was not an appropriate surgical candidate due to other comorbidities.

The Legal Landscape and Class-Action Lawsuits

There is no consistency to the guidelines insurance companies set for their coverage. Each chooses its own set of evidence-based methods based on cherry-picked studies that best support cost-efficiency. Those standards should be made to be transparent not only for physicians but also patients so it’s clear as to the policies that impact their care and they can ultimately choose the policies that best align with their needs. What is consisent, however, are the laws in many States such as in California, which require insurers to conduct thorough and objective investigations into each patient claim. But that’s not always followed, and it’s especially a concern with more companies turning to AI and automated systems to review claims. A class-action lawsuit has been filed against Cigna, shedding light on the problem this is causing for patients being denied treatments based on an algorithm, without a more thoughtful review. The outcome of that class-action lawsuit is almost certain to set the stage for claim reviews going forward.

Seeking Solutions: Collaboration and Advocacy

Meantime, to address the issue of insurance claim denials, collaboration between healthcare professionals, patient advocacy groups, and insurance companies is crucial. Vascular specialists are urging insurance providers to cover the necessary procedures for PAD and CLI, emphasizing the impact these denials have on patients’ lives. By working together, it is possible to find solutions that prioritize patient well-being while also considering the financial concerns of insurance companies.

If a physician is not providing care in a way that the insurance companies support, they can always choose to not renew their managed care contract. In terms of State and Federal Insurance, the authorities do crackdown on those physicians who are not aligned with guidelines. The majority of doctors who are doing the right thing for their patients and in-line with guidelines, should not have to be second-guessed for their decisions to treat a patient in the best way they determine is right for their patient.

It can’t be reiterated enough, that insurance claim denials for minimally invasive procedures to treat peripheral artery disease and critical limb ischemia have devastating consequences for patients. The denial of coverage prolongs their suffering and limits their access to life-saving treatments. It is essential for insurance companies to prioritize patient care and work collaboratively with healthcare professionals to find solutions. By doing so, we can ensure that patients receive the treatment they desperately need, alleviating their suffering and improving their quality of life.