Persius

Wrongful health insurance denials have dire consequences for peoples’ physical, mental, and financial well being.

By all indications, the scale of the problem is massive, and the implications for people are devastating and unjust.

We were formed to help address this problem.

When appeals are filed, they are often overturned, suggesting that many denials were never justified in the first place. Appeals work, but are difficult to access, and poorly understood. Individually they don't address root cause, but they hold collective power.

In reviewing first level appeals of health insurance denials, reviewers are supposed to engage with the specific medical details and context of the individual for whom the appeal was filed.

Instead, we see failure to address details, and blind application of one-size-fits-all medical policies.

Each year, there are over 290,000 denials administered in state-regulated commercial health insurance plans in New York for alleged 'lack of medical necessity'.

Many are necessary.

Our mission is to help people in America access healthcare by working with patients and physicians to reverse wrongful health insurance denials and build evidence for accountability and systemic change.

We are a 501(c)(3) nonprofit building technology in the public interest.

When mandated contact numbers put on thousands of denial letters lead to representatives who are invariably incapable of addressing the matter for which the contact number is purportedly supplied, maybe it's time to end the honor system and start aggressive enforcement.

We reached out to DOL after an insurer wrongly prevented someone from appealing.

They said the insurer "can't do that". They seemed to think we thus had nothing to worry about.

Regulators saying something is illegal, but providing no help, is insane.

We know it's illegal. We need you to regulate

In collaboration with those we serve, we are building a scalable evidence base to shine a light on the systemic harms and injustice caused by wrongful health insurance denials.

We aim to use individual victories to drive systemic change.

Filing external appeals of health insurance denials with patients is a critical part of our work.

These appeals are important because unlike other appeals they force (more) independent third parties to review the denials. They are also monitored by regulatory agencies, and can lead to penalties.

Indeed. It can be a full time, unpaid, and miserable job, year in and year out. Harmful, infuriating, and unjust.

So sorry to hear you are facing this, and hope you are doing alright. If you could use support with your prior authorizations, please feel free to reach out. Wishing you all the best and quick access to the medication you need.

In California, 54% of external appeals for denials of Crohn's Disease related care are overturned when reviewed by third party physicians.

The problem is it's wildly profitable to wrongly deny care. The solution (within our system) is aggressive penalties. Money is the only language insurers speak.

New York Data Suggest Coverage Denials Put Most Vulnerable Patients At Risk People’s Action Executive Director Sulma Arias condemns Trump’s Senate budget as a violent attack on working families—cutting Medicaid, housing, and food to fund tax breaks for billionaires. The…

New report on the role of harmful role of prior authorization and claim denials from our friends at @pplsaction, with contributions from us. Findings suggest denials are widespread, and pose disproportionate harms to the most vulnerable.

Read the report here:

No time like the present to push for the removal of all corporate interests from US healthcare.

13% of prior authorization denials in Medicare Advantage meet Medicare coverage rules and are supposed to be covered.

Health insurers go to great lengths to defend the indefensible, because they count on us giving up.

According to the medical records, the patient is a child with a past medical history of spastic quadriplegic cerebral palsy, prematurity, hydrocephalus with shunt, bronchopulmonary dysplasia, and developmental delay. The patient underwent selective dorsal rhizotomies of lower nerve roots (lumbar [L]4-sacral [S]1) for spasticity treatment and recently completed a course of inpatient rehabilitation. The patient is now doing outpatient physical therapy. Ambulation was originally being performed with a KidWalk gait trainer but the patient has made progress in therapy and can now ambulate for 100-200' with a posterior rolling walker. A Nimbo posterior rolling walker has been requested for home use. The previous request was denied due to not being medically necessary/insufficient information in the medical record. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The patient has made progress in their walking abilities and

Actual insurance denial. Overturned on independent medical review:

In California, 6 in 10 external appeals for denials of ALS care are overturned when reviewed by third party physicians.

The problem is it's wildly profitable to wrongly deny. The solution (within our system) is to aggressively penalize wrongful denials. Money is the only language insurers speak.

Any reasonable and wealthy society should provide equitable, affordable access to healthcare for all people.

Insurance denial reviewed by a third party. The review reads: "Diagnosis: Seizure Treatment: inpatient stay The insurer denied the inpatient stay The health plan's determination is overturned. The patient is a young boy who presented with a first time seizure. He was well until naptime at school, when he began to flatten his back, foam at the mouths, and his eyes rolled back. He was unresponsive during the episode and it lasted from several seconds to a few minutes. An ambulance was called and he was noted to be 'spaced out' with a 'dead stare' for 10 minutes during transport. There were no other associated symptoms. He had no fever or recent trauma. He did have a runny nose for the past few days with a cough. He has a history of speech delay and is receiving speech therapy. His family history is significant for a seizure disorder in his sister. Inpatient Hospital Admission was medically necessary for this patient."

Actual insurance denial. Overturned after review by an independent third party.

Health insurers rely on patients and physicians being too unwell or burnt out to seek appeals.

Attrition is critical to making wrongful denials profitable.

The Data Liberation Project — Medicare "Level 2" Appeals We’re requesting database records tracking the circumstances and outcomes of patients’ appeals of Medicare insurance decisions.

We requested Medicare appeal outcomes. CMS had delayed indefinitely.

This data is more important than ever, as MA is being pushed, and trad Medicare is using AI.

This data belongs to the public. Please help us in making this request visible.

Due to influence, power, and minimal enforcement, we continue to see insurers get away with illegal practices with palatable consequences.

This is unacceptable.

In collaboration with the patients we work with we are building an evidence base to document bad faith, illegal, and deadly behaviors.

The call center racket is a key part of the health insurance racket.

We help patients fight health insurance denials for free. Reach out if you need help.

info@persius.org

Rarely discussed is the rate of denials for purported lack of 'medical necessity'.

Many of the most harmful denials are made on this basis. Useful to track them specifically, who administers them the most, and which patient populations face them the most. Overall denial rates don't tell this story.

13% of prior authorization denials in Medicare Advantage meet Medicare coverage rules and are supposed to be covered.

Insurer representatives who can help with appeals are often unreachable. We make calls daily.

Call the number on your denial? "Wrong number."

Transfer me? "Can't do that."

They'll call back? They won't.

Attrition by design. We document this, and intend to hold those responsible accountable.

New York Data Suggest Coverage Denials Put Most Vulnerable Patients At Risk People’s Action Executive Director Sulma Arias condemns Trump’s Senate budget as a violent attack on working families—cutting Medicaid, housing, and food to fund tax breaks for billionaires. The…

External appeal overturn rates are supposed to be low. High rates mean internal appeal processes are not working.

The external appeal overturn rate among people with cancer on Managed Long Term Care plans in New York is 85%.

Read the report here:

Health insurers go to great lengths to defend the indefensible, because they count on us giving up.