A few months ago, the California Nurses Association issued a report with a shocking conclusion: the state's health insurers deny 21 percent of requests for patient coverage.
"Every claim that is denied represents a real patient enduring pain and suffering. Every denial has real, sometimes fatal consequences," CNA co-president Deborah Burger was quoted in a press release.
Deborah Burger
As a data junkie, I read this and decided to seek the raw material. But I quickly learned that the data does not reveal what the CNA claimed.
Lynne Randolph, spokeswoman for the Department of Managed Health Care, which keeps the information, said the data in question is not a record of care denied to patients at all. Rather, it's a record of how many services that doctors likely rendered – but didn’t get paid for.
“We don’t collect request [claim] rejections,” Randolph said. “We don’t look at every procedure, every claim.”
This sounded, after all, like familiar data to me. As a reporter at ProPublica working with the Chicago Tribune on articles about a psychiatrist, I requested and reviewed data on claims the state Medicaid agency denied for that physician.
Hundreds of claims were flagged for purely bureaucratic reasons: the claim was a duplicate, was submitted too late or it was for a service not approved by a primary care doctor. Virtually none of the reasons for claim denials suggested that a patient had not been cared for.
So what of this "daily, cold-hearted rejection of desperately needed medical care" that the nurses union described? I asked the CNA.
Spokesperson Shum Preston was familiar with what I discovered, noting that insurers made the same point. “To us, an insurance company saying 'us denying payment for care' instead of 'denying care' is someone playing semantic words with life or death health care,” he said.
Fair enough. But we’re talking about the doctor holding the bag, not a patient suffering, I countered. Preston held his ground. “For them to say they’re not going to pay the hospital means they’re shifting cost to others so they can keep profits. To me it’s a distinction without a difference.”
To me, it turns out, this is an entirely different story than the one I set out to explore.
And it raises another question. After the CNA issued this press release in September, the California Attorney General’s office swiftly announced that it was launching an investigation.
I called last week to see how that was going. The answer? There will be no comment on an ongoing investigation.
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