Ronnie Sasser needed a larger "shower table" to bathe her growing teenage son, a quadriplegic who has cerebral palsy, severe mental retardation, cortical blindness and a history of seizures.
The $1,250 table would better stabilize Perry Monroe Sasser while he was being washed, his mother said. She said it was medically necessary because "if Perry Monroe starts to have a seizure on the shower table, at least he's in a controlled environment so you can keep him safe."
Sasser filed a claim with her family's longtime health insurer, Kaiser Permanente. The HMO's mid-Atlantic operation, based in Rockville, rejected the claim, calling the table a "convenience item for the caregiver," not covered by the Sassers' plan.
The rejection letter set in motion a ritual familiar to many Americans: the tedious, at times grueling, back and forth between health insurers and their members over denied claims for prescription drugs, hospital and physician services, and specialized medical equipment.
This week, after the Sassers battled Kaiser for almost two years, the Maryland Insurance Administration took action against the HMO, ordering it to provide the shower table. "Kaiser did not present any evidence to show that a shower table was not medically necessary" for Perry Monroe, the order said.
Most claims sought from health insurers across the nation are processed and paid without a hitch. And insurance commissioners, including Maryland's Alfred W. Redmer Jr., often agree with insurers that they acted appropriately in denying claims. When they side with the patients, regulators usually resolve disputes within a few months.
Redmer has issued more than 100 disciplinary orders during the past two years against Kaiser Permamente, Aetna Inc., Mid Atlantic Medical Services Inc., CareFirst BlueCross BlueShield and other insurers that violated state law by denying claims that should have been paid, a review by The Washington Post has found. Some of the state regulator's orders carried fines of up to $2,500 per offense.
Redmer said the state's five-year-old appeals and grievance law puts health insurers on notice that they are being watched. The law makes Maryland one of the most aggressive states in protecting consumers against wrongly denied claims.
"I am confident that there are a significant number of health care services that are being delivered in 2004 that would have been denied years ago," Redmer said.
Ronnie Sasser said the shower table was one of more than a dozen items Kaiser has denied Perry Monroe in recent years.
Many of the Sassers' claims, including one for a wheelchair, were paid only after the Maryland Insurance Administration took disciplinary action against Kaiser. In November, the state regulatory agency ordered Kaiser to pay for the shower table. The HMO appealed the order.
"I have been put through the gates of hell and back by Kaiser," Ronnie Sasser wrote in an e-mail to The Post.
Kaiser spokeswoman Amy Goodwin said in an e-mail that since 2000 the HMO has paid more than $440,000 in claims for Perry Monroe Sasser's medical care. Denied claims have totaled less than $14,000, she wrote. These claims were denied because the services or supplies were medically unnecessary or were not covered by the Sassers' plan, she wrote.
Kaiser declined to elaborate even though Ronnie Sasser signed a waiver giving the HMO permission to fully discuss her 15-year-old son's case with a Post reporter.
Unlike most HMOs, Kaiser Permanente acts both as an insurer and health care provider: It has 29 medical centers that employ about 900 doctors in the Washington-Baltimore region.
"The care Perry Sasser has received as a Kaiser Permanente member since birth reflects our commitment to both Perry and the Sasser family," Goodwin wrote.
Health insurers argue that claims must be denied at times because patients seek reimbursements for drugs, services and equipment that are not medically necessary or covered under the policies they bought. If these claims were paid, premiums would have to be raised, they say.
Denied claims, said Philip S. Carney Jr., the top medical official in Kaiser's mid-Atlantic operation, make health care affordable for those who follow coverage rules.
Often, though, insurers must grapple with "gray areas" in deciding what is -- and isn't -- medically necessary, Carney added. And often it's left to insurance commissioners to turn the gray into black and white.
"Typically, the problems revolve around poor communication" between insurers and their members, Redmer said. "But there are also genuine disagreements" over medical necessity.
Under Maryland law, patients must first appeal denied claims to their insurers. If the denial is upheld by the insurer, a patient can file a complaint with the Maryland Insurance Administration, which hires independent reviewers -- usually doctors with specialized training in the areas of dispute -- to investigate. Decisions ultimately are made by the regulator with help from the state attorney general's office. Insurers can appeal decisions.
Patients who can establish with the regulator that they have pressing medical needs can appeal directly to the insurance administration without filing an appeal to their insurer.
It's clear that patients often can get their way if they appeal denied claims to insurers, then, if necessary, to state regulators.
A recent study of two large health insurance plans in California reported that 90 percent of all denied claims for hospital emergency room visits were paid after patients filed appeals. The study by the Rand Corp. and Harvard School of Public Health said the average cost of the denied ER visits it examined was $1,107.
In Maryland, just over half of the denied claims the regulator investigated in fiscal 2003 -- from July 1, 2002, through June 30, 2003 -- eventually were paid, according to preliminary data obtained by The Post. (The agency will release fiscal 2004 data later this year.)
In 69 cases, the insurance administration reversed -- fully or partially -- insurers' decisions to deny claims. In 74 more cases, insurers reversed their own denials -- agreeing to pay the claims -- after the regulator opened an investigation.
In 137 cases, the agency agreed with insurers that claims should not be paid.
Insurers deny claims for a wide range of reasons, a review of disciplinary orders found. Copies of the orders were obtained under Maryland's Public Information Act.
On June 27, 2003, for example, Aetna denied coverage of a weight-loss procedure to a 30-year-old, 6-foot, 300-pound man who had diabetes, hypertension, coronary artery disease and other conditions.
The patient appealed the denial to Aetna. On Sept. 10, 2003, Aetna upheld its decision, saying the patient had not documented a five-year history of morbid obesity -- a requirement for paying the claim, the insurer said.
After the patient filed a complaint with Redmer's office, the case was reviewed by a surgeon with a subspecialty in gastric surgery. The reviewer concluded the patient had various "life-threatening" conditions and was "at extremely high risk of death within ten years."
Redmer ordered Aetna to pay for the surgery.
Also last summer, Mid Atlantic Medical Services refused to pay for a three-night hospital stay for a 36-year-old woman who had metastatic breast cancer. She was admitted to Gettysburg Hospital in Pennsylvania with severe back and leg pain. In denying coverage, Mid Atlantic Medical said her condition didn't require treatment at an acute care facility such as Gettysburg.
The woman appealed to the insurer and the claim was again denied. A state reviewer concluded that the hospitalization was appropriate for a cancer patient who needed "aggressive treatment," the reviewer wrote. The patient has since died.
The Sassers' claim for a larger shower table was first made in 2002. After Kaiser denied the claim in January 2003 and upheld its denial on appeal, Sasser filed a complaint with the insurance administration.
The state reviewer, a pediatrician with a subspecialty in neuro-developmental disabilities, concluded that the shower table should be provided. "A child with this degree of involvement needs a safe system for personal hygiene maintenance, particularly as increased size and weight preclude lifting into and out of a tub," the reviewer wrote.
On Nov. 25, the agency ordered Kaiser to provide the table. Kaiser requested a hearing to contest the order. On May 4, Ronnie Sasser and Kaiser officials met at the insurance administration offices in Baltimore. Kaiser's appeal was denied on Monday.