Dr Jeffrey Sippel: Medicare Advantage NIV Denials Take Time From Patients With ALS

In an interview with the American Journal of Managed Care^Ⓡ (AJMC^Ⓡ), Jeffrey Sippel, MD, MPH, the associate director of Inpatient Clinical Services and associate professor of Clinical Medicine in the Pulmonary Sciences and Critical Care Medicine Division at the University of Colorado School of Medicine, discussed a pattern of denied insurance claims for non-invasive ventilators (NIVs) in Medicare Advantage plans and the way these denials affect individuals with amyotrophic lateral sclerosis (ALS).

Transcript

From your perspective, are there any solutions to amend the issue of these medicare denials?

I think we could do a lot of things to amend this issue. The first is that if a patient has a neuromuscular diagnosis, assume that they need the support that the clinician ordered. And then the insurance companies can follow up and audit that, but when the opening bid is to deny, that really puts us back several steps. So I think that the opening bid for these patients needs to be approval, not deny, it can be approve and verify, as opposed to deny and appeal.

So really, what's happening is this, the time crunch is thrown completely on the patient—the patient's doing poorly, by the way, and they don't have time—as opposed to the insurance company owning the time component of this. I think the humanistic side of this is completely underappreciated by the insurance companies. I have had a few verbal appeals, where I've been able to talk to somebody on the phone. I've had—my opinion only—relatively unprofessional discussions that I just think communicate the insurance industry's lack of appreciation. It doesn't matter if I've spoken with the pulmonary physician or any other physician who is in their appeals channel. It's, relatively speaking, the backhand. And it's super frustrating, if I'm going to take 15 minutes to an hour to appeal something, and make a phone call and wait and wait and be on hold and then finally talk to somebody, I would expect professional behavior, which is just not always there.

It's an important topic because I feel that this vulnerable patient population, the ALS patients, are in the line of fire for purely financial reasons. And I think that there's such a great opportunity to improve their quality of life, even just a little bit, for somebody who has a pretty short timeline. They have a short timeline to be with their loved ones and with their family and with their friends, and we should do what we can to improve their quality of life. And this is a tool in the toolbox that is summarily being denied.