A Dreadful Chain of Causation


I want to reproduce a message I just received from my first cousin, Audrey Aardvark. (Unlike my daughter Pollyanna, Audrey is a real person, though that is not her real name.) Audrey, who is a few years younger than me, took her degree in nursing from the state university, worked in various nursing capacities, and now helps hospitals appeal insurance denials.

Audrey describes this trend emerging as the pandemic continues:

Nurses get sick, which means that,
Registered nurses working as utilization review specialists get called upon to abandon their usual jobs and to fill in as bedside nurses, which means that,
Because new admissions are not being reviewed for insurance and Medicare precertification, insurance coverage for entire hospital stays is being denied, arbitrarily, by operation of certain insurance requirements, which means that
Grievous harm is being inflicted on ordinary people and on hospitals.

My cousin Audrey—emphatically not a person prone to exaggeration or extremism—writes, “I believ that insurance denials during this pandemic wil be a catalyst for a healthcare crisis of tsunamic proportions.”

In Her Own Words

Her message, in her own words, follows:

I have a grave concern and am asking that you use any political influence you may have to bring this matter to the attention of those in a position to intervene. 

Most commercial insurance companies, (Humana, Aetna, UCH, Anthem, etc.) require a precertification (precert) for all hospital admissions. The precert is mandatory and must be obtained within 24-48 hours of the admission.  If this requirement is not met, the entire admission is DENIED for payment.  Registered Nurses, work as Utilization Review specialists and are responsible for obtaining precerts. 

In addition, Medicare (CMS) has a 2 midnight rule (2MNR) that is similar to a precertification, but focuses on level of care.  Ensuring adherence to the 2 MNR is also the responsibility of the Utilization Review RN.

With the COVID-19 crisis, and imposed quarantine on exposed bedside RNs, the Utilization RNs are being pulled to the bedside to care for patients.  This means there will be no / limited staff available to do precerts and 2MNR reviews.  

Hospitals are already struggling financially, in part due to insurance and Medicare denials, and this will decimate them.  The potential for more hospitals being forced to close is exponential.   I believe that insurance denials during this pandemic will be a catalyst for a healthcare crisis of tsunamic proportions.

We need our elected officials  to compel commercial and Medicare insurance providers nationwide to WAIVE precert requirements and suspend CMS’ 2MNR until the CDC determines that the COVID-19 pandemic has been mitigated. 

If you review the year end reports of carriers- Aetna, Anthem, Humana, Molina, UHC, etc. you will see the obscene profits they are making.  It’s telling when the profits are huge despite lower memberships.  The bulk of that profit is from denying payment to hospitals.  I have been working with hospitals now for about 7 years doing denial appeals and it’s very frustrating.  However, this has passed frustration and heading for a crisis.

I would be interested in your opinion- I have been in discussion with the Senior Policy Advisor for Gov Ivey of Alabama so will see where that leads.  I appreciate any advice or assistance you can provide.  THANK YOU

Audrey Aardvark, RN, CCM, BSHCS, LNC

Clinical Denial Analyst