An 18-year veteran of the corporate insurance industry takes aim at the practice of denying care.
RALEIGH, NC / ACCESSWIRE / August 16, 2023 / Ron Howrigon worked for nearly two decades at some of the largest insurance companies in the U.S. A rising star in the industry, he left his executive track when he became disillusioned by the contracting tactics used toward independent medical providers and the insurance industry focus on increasing profits at the cost of members' care. So, in 2004 he took his negotiating skills to the other side of the table and began to represent physicians in their negotiations with medical insurance companies.
As an economist and insurance insider, Howrigon is uniquely qualified to speak on every aspect of the business of healthcare. Once again, his conscious has motivated him to act, this time speaking out about the health insurance industry's denial process. A process that has become increasingly automated and less transparent to the detriment of patients, the frustrations of their physicians, and profitable for payers.
Last spring Howrigon provided his perspective to ProPublica's in-depth reporting on the insurance industry's medical denial process. Afterward, he was contacted by Dr. Dan Hurley who was going through a similar struggle with his insurer. Dr. Hurley wanted to share his story in hopes that he could help others facing the challenge of battling an insurance company while simultaneously fighting a disease. Dr. Hurley was no stranger to this process, he had faced this hurdle as a physician, a father, and now a patient.
Dr. Hurley was diagnosed with a rare and aggressive form of cancer. At 48 years old, the formally active Otolaryngologist, commonly known as an Ear, Nose, and Throat (ENT) physician, was able to secure a top cancer doctor to treat the tumor in his hip. Dr. Hurley first had surgery to remove the tumor. After discovering that the cancer was not completely eradicated, his oncologist started him on a treatment plan and ordered a PET scan to establish a baseline level of cancer cells in his body. That's when Dr. Hurley and his oncologist learned that his insurance company's medical director denied the scan deeming it "not medically necessary." This was the first of many frustrating denials that ultimately led Dr. Hurley to choose between starting his chemotherapy or getting the long-delayed baseline scan.
According to Howrigon, denials occur because the insurance industry is focused on profits and not patient care, and two specific areas of the process are aligned to support this goal. The first is the automated process that determines if requests received from physicians fall outside of insurance company established guidelines. It has been reported by ProPublica that insurance company medical directors are signing off on thousands of denials a day and most patients don't appeal. The second is in the qualification and accountability of the insurance company's medical directors. Howrigon and Dr. Hurley point out that the insurance company medical directors signing off on these denials are often not in the same specialty as the patient's physician and often have not practiced medicine for years. Frequently, the insurance companies put up barriers that keep the treating physician from discussing the case directly with the medical director that is denying the care they requested. All these factors contribute to patients not getting care and increased profits for insurance companies.
Health insurance leaders say they are not stopping someone from getting care, they just won't pay for it. Howrigon recalls how he responded as an insurance exec, "I would say 'We are not denying care we are only making coverage decisions.' that is simply wrong. People have insurance because they can't afford to pay for care without it. Withholding payment for care is the same thing as withholding the very care they need."
According to Dr. Hurley, everyone needs to be involved in fixing this problem and he says it will likely require making tough decisions from legislators, attorneys, and most importantly healthcare leaders on the insurance side. He says the solution is all about transparency and accountability. "Initially it [the insurance company] is a wall, as a patient you can't talk to them, you get denials, you talk to people that don't even know why you got denied." he said. Hurley continues "Patients deserve the same level of accountability and transparency from their insurance physician that we have assigned to practicing physicians through medical boards and medical legal liability."
Howrigon elaborates on how these areas can be fixed. "First, we need to give patients the same kind of protections we give people in our justice system. We do this because we have decided that it's worse to jail an innocent person than it is to let someone who is guilty go free. Isn't it worse to deny care to someone who needs it than to approve care that isn't totally necessary?" He said this approach turns the table on the current system, instead of a patient's physician trying to prove to a marginally qualified insurance company medical director the need for a test or treatment, the burden of proof should be on the insurance company to prove the patient really doesn't need it.
Elaborating on Dr. Hurley's comments about the accountability of insurance company doctors, Howrigon suggests expanding the definition of "practicing medicine" to include the act of denying a service as "not medically necessary". This would mean that doctors signing these denials would be required to have a license in good standing, practicing in their field or specialty and they could be held responsible for malpractice if the denial was not clinically reasonable and resulted in a bad outcome. According to Dr. Hurley putting the kind of accountability he and Howrigon are talking about on insurance company physicians, will greatly reduce denials, "This will disappear." he said.
Howrigon was so impressed with Dr. Hurley's outreach to him on this topic, he began to share Dr. Hurley's story with everyone, "Here I was talking to a doctor while he was getting chemotherapy for his cancer, and instead of being angry or wanting vengeance, was concerned only about future patients. Patients that he would never know or treat. Patients who wouldn't even know of his efforts to help them and patients that he would never receive any payment from." Howrigon hosted Dr. Hurley on his podcast, and the two continued to communicate over the summer. Dr. Hurley shared his hopes to see his daughter graduate and take his wife on one more trip to Paris. He was able to see his daughter graduate, but on August 3rd, Dr. Dan Hurly lost his battle with cancer leaving behind a wife and three children.
The practice of denying medical procedures or treatments by insurance companies has begun to gain attention thanks to in-depth reporting like ProPublica, but Congress is also now looking into the practice, the House Energy and Commerce Committee requested from Cigna information on their practices, a new lawsuit was filed last month in California and long-time health care professionals, like Howrigon are following Dr. Dan Hurley's lead and are speaking out. If you would like to see a change in the prior authorization and medical denials process, contact your state and federal representatives, medical boards, or patient advocacy groups and share Dr. Hurley's message of transparency and accountability of healthcare providers inside the health insurance industry.
About Fulcrum Strategies:
Fulcrum Strategies is a medical provider advocacy consulting firm, providing contract negotiation, public relations, and strategic planning services to medical provider groups in 18 states.
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SOURCE: Fulcrum Strategies
View source version on accesswire.com:https://www.accesswire.com/774747/Fulcrum-Strategies-CEO-Speaks-out-on-Medical-Denials
