Multiple Florida patients denied coverage for doctor-recommended medical procedures, including cancer treatments and life-saving surgeries, have seen their denials reversed only after media outlets began investigating their cases, raising questions about how insurance companies make coverage decisions. Madeline Rogers of Zephyrhills was denied coverage for colon surgery three times before Investigative Reporter Kylie McGiven contacted Oscar Health about the denial.
The insurer then approved the $150,000 procedure with no explanation. Rogers said she was shocked and floored to hear from the company so quickly. Mary Barnes, a breast cancer patient in St. Pete, was forced to halt chemotherapy treatments when United Healthcare initially denied coverage, claiming the treatments did not meet national cancer guidelines.
The insurer reversed course and designated the same treatments as medically necessary only after Investigative Reporter Katie LaGrone began asking questions. Barnes later said she believed the insurer would still be denying her if not for the media investigation.
Broxley Bunt of West Palm Beach was denied coverage for surgery to remove a meningioma brain tumor because his surgeon was out of network. Florida Blue reversed the denial after LaGrone started interviewing him from his hospital room where he underwent the surgery anyway. Bunt said he did not think he could have done it on his own.
Mark Armstrong recently got his blood cancer medication covered after Oscar Health wanted him to pay thousands of dollars up front under a co-pay accumulator policy. According to a federal court ruling, Armstrong should have been exempt from this policy since the medication did not have a generic equivalent. Only after LaGrone questioned Oscar about the exemption did the insurer make his medication available at no cost. His wife Michele said she honestly believed it was because the reporter reached out and that the company was scared.
Dr. Bill Hennessey, a physician turned patient advocate who helps people appeal insurance denials, said most denials fall into three categories: cost of care is too high, a treatment is not medically necessary, or a treatment is experimental. When asked under what conditions most insurance companies reverse their denials, Hennessey said it happens when patients are correct and they complain.
He attributed the pattern of reversals following media scrutiny to insurers not wanting negative public relations, describing it as the power of the press. Federal data recently analyzed by KFF, the leading health policy organization in the United States, found most health insurance claims are ultimately approved, but the data does not show how many claims are denied first because insurers only report the final outcome. Most patients who are denied never appeal.
Hennessey advised denied patients to obtain all records and itemized bills, have their in-network physician document that care is medically necessary, appeal the denial with supporting documentation, emphasize clinical situations and worst-case scenarios, ensure peer-to-peer reviews involve doctors with the same specialty, and go public with their denial through social media and local news stations. A spokesperson for AHIP, the nation's largest health insurance trade group, responded to questions about how the industry responds to public scrutiny but provided no specific explanation for the pattern of reversals.