We are about to embark on the work of a state health insurance exchange and a healthcare cabinet designed to look for comprehensive solutions to the healthcare crisis. We need to ask whether there are additional ways to lower health insurance costs and improve access to and the quality of healthcare besides reining in over-utilization of services, cutting back on covered services and increasing patient responsibility—the most common reform suggestions. 

There is another option, however. I believe that the insurance industry is vital to Connecticut’s economy and future, but it is now time to scrutinize health insurance practices to find additional savings and ensure accountability to the policyholders that make the health insurance industry the success that it is. While we’re beginning the work of these new boards, we must not duplicate the flawed insurance practices that have kept some consumers from getting needed care or led to providers from dropping out of networks.

Insurers have made many statements in the last few years about the need to find savings in and improving access to high quality healthcare. I am expecting them at the exchange board and healthcare cabinet to contribute some ideas on producing some administrative savings and reforming practices within their own companies.

Valuing health insurance as an important business sector in Connecticut also means valuing customers and policyholders. The current insurance system needs some internal reforms before it can be expanded to Connecticut’s uninsured residents. Over time we have allowed administrative burdens to prevent access to care, make it complicated to appeal a denial, and force providers to have to argue sometimes for days, to justify treatment that they, more than any medical director of an insurance company, know is the best treatment. Stagnated provider fee schedules over which providers have little or no bargaining power contribute to lack of access and five minute office visits. Obtaining coverage for residential stays for mental health and substance abuse disorders is a perpetual battle. Every day I hear from providers whose requests for services are routinely denied by a provider of an unrelated specialty at an insurer, only to be overturned after going through the burden of appealing by disrupting their patient schedules and speaking with a true peer provider at the insurer. Each insurer has its own provider manuals and medical necessity criteria; one plan’s guidelines or practice requirements may completely contradict another’s. These burdens only serve to impede access to care and strike at providers’ and consumers’ resolve to fight through an appeal. 

This is not hypothetical.  In the last fiscal year, the State of Connecticut’s Office of the Healthcare Advocate (OHA) recovered $11 million for consumers. That’s $11 million recovered for wrongfully denied claims based on medical necessity, coding disputes, and billing mistakes. That $11 million represents many people who went without needed cancer treatments or mental health services because an insurance company denied the care initially.  Whether one attributes the $11 million to mistakes by insurers, incomplete information supplied by providers or deliberate denials by the companies, the $11 million would likely have forestalled additional, catastrophic healthcare costs down the road. Further, a significant portion of that $11 million was saved after review on external appeal—by reviewers independent of the insurance companies—another sign that requests for services are improperly denied by insurers. Most importantly, that’s $11 million of state residents’ insurance premiums that without our intervention would have stayed in the pockets of the insurers.  And finally, that $11 million is a fraction of what could be recovered if all consumers appealed denials successfully. (Only five percent of Connecticut insured residents appealed denials related to medical necessity last year.) These denials mean that a substantial sum of our premium dollars are going unspent on needed medical services that, if received, might actually lower future healthcare costs. 

As we move toward the healthcare reform, we need to revisit our mindset.  What are our goals?  Healthy individuals, cost containment, efficiencies, health information technology? Surely all of these things are important, and surely, the insurance industry is vital to providing insurance coverage, but insurers now must come to the table with their own solutions for streamlining processes, reducing burdens and preventing improper denials of coverage. The premium dollar must not be used to thwart legitimate access to services through burdensome and inconsistent processes. 

I don’t fault the insurers for holding their partners accountable by imposing logical requirements that control over-utilization and prevent unnecessary use of services, and ensure solvency of the companies, but we must hold the insurers accountable too.  We need a strong insurance industry in Connecticut that provides coverage for the services it promises to provide, but without excess burdens for consumers and providers. That means we must be willing to reform insurance company practices as well as insurance coverage.  We do that by holding all the partners in healthcare accountable—consumers, providers, subcontractors, administrators, and insurers.

Accountability is not anathema to a strong insurance industry in Connecticut. It is essential to it.

Vicki Veltri is the state Healthcare Advocate.