Dr Jeffrey Sippel: Ventilator Claim Denials Are Driven by Cost

There has been a trend of denied insurance claims for non-invasive ventilators (NIVs) by Medicare Advantage plans, particularly affecting individuals with amyotrophic lateral sclerosis (ALS), according to 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. In an interview with the American Journal of Managed Care^Ⓡ (AJMC^Ⓡ) he emphasized the adverse impact on patient outcomes and the financial shortsightedness of the carriers' approach, as appropriate admissions could potentially save significant health care costs in the long run.

Transcript

Could you shed light on the larger trend among Medicare Advantage plans? Why do you think this trend is emerging, and what are the consequences for patients?

So there are trends here that we've observed, and I would just say that United [Healthcare], by example, is the leader of the pack here, but there are absolutely other carriers that are following. And so, when we see trends for denials, one thing we need to ask ourselves is, “Are they right? And are these services medically indicated or not?” And they're telling us that they're not—I respectfully disagree.

They have a legalistic interpretation of a written document that's just not reality based. And so I think the main driver here—in fact, I know the main driver here—is cost. Back of the napkin, NIV machines might cost $15,000 to $20,000. The RAD (respiratory assist device) devices might cost $2000 to $3000. I get it. However, here's also the rest of the story. The DME company contracts for the NIV machines allow them to appropriately provide really good in home respiratory support. The bilevel devices get supported like CPAP—they just quite literally send patients masks and say, “Hey, try these, let us know which ones you like,” that's not appropriate. And when there are troubleshooting problems, they don't have the resources, because their contracts have much lower support for the bilevel devices, the RAD devices, they just don't provide the enhanced support.

So it's driven by money. It's driven by a lack of appreciation of how dynamic these patients are, and how quickly they can change from sort of stable to doing quite poorly. And then the final thing that they don't appreciate is that when we admit these patients appropriately, the costs associated with that admission are huge. They could have saved an admission and saved themselves tens of thousands of dollars. It's a short-sighted approach to making this quarter's profit statement look better.