UPJ INSIGHT: Leaving No Stone Unturned: Factors Associated With Overturning Insurance Claim Denials for Urological Conditions in New York State

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UPJ INSIGHT: Leaving No Stone Unturned: Factors Associated With Overturning Insurance Claim Denials for Urological Conditions in New York State

By: Lulu Wei, BS; Ping Ping Zeng, BS; Isabelle Kaplan, MS; Ryan Kong, BS; Aaron Huang, MD; Andrew Winer, MD, FACS | Posted on: 01 Dec 2022

Wei L, Zeng PP, Kaplan I, Kong R, Huang A, Winer A. Leaving no stone unturned: factors associated with overturning insurance claim denials for urological conditions in New York state. Urol Pract. 2022;9(6):568-573.

Study Need and Importance

Members and providers in managed care plans have the right to file for external review, in which a third-party evaluates the merit of an appeal for a denied insurance claim. Despite the policy attention on and importance of external review for preserving patient rights, there is a scarcity of research on external review as it pertains to the field of urology. Denials cause frustration and burnout, and require additional administrative time from urologists, practice managers, allied providers, and urological patients alike. Thus, research into the landscape of external appeals for urological services is warranted.

What We Found

We found that appeal volumes have nearly doubled since 2019 for urological care and rates of successful appeal increased 244% between 2019 to 2021. There was a 39.5% rate of successful appeal within urology, which is lower than the overall 43.4% in New York State. Only 15.2% of reviewers cited AUA guidelines to justify medical management decisions and referencing the AUA guidelines was associated with a 70% reduced odds of overturning denials (OR: 0.30; 95%CI: 0.11-0.79; P = .016; see Table).

Table. Multivariate Logistic Regression of Overturned Urological Service Denials

Parameters	OR (95%CI)	OR P value
Gender, No. (%)		.131
Male	Reference	Reference
Female	1.48 (0.89–2.44)	.131
Age group (years), No. (%)		.043
0–19	Reference	Reference
20–39	0.23 (0.09–0.60)	.003
40–59	0.34 (0.14–0.79)	.012
60–79	0.42 (0.17–1.05)	.064
80+	0.41 (0.11–1.50)	.178
Appeal reason		.659
Medical necessity	Reference	Reference
Formulary exception	1.36 (0.22–8.47)	.744
Experimental/investigational	0.44 (0.07–2.92)	.395
Treatment, No. (%)		< .001
Inpatient hospitalization	Reference	Reference
Home health care	11.29 (4.09–31.19)	< .001
Medications	11.90 (2.39–59.31)	.003
Surgical services	28.26 (5.69–140.33)	< .001
Other	1.99 (0.70–5.65)	.195
Comorbidities		.255
No	Reference	Reference
Yes	1.38 (0.79–2.40)	.255
Referenced AUA		.016
No	Reference	Reference
Yes	0.30 (0.11–0.79)	.016

Limitations

This study only captures the cases that were successfully filed according to New York State external review regulations. We could not draw statistically meaningful conclusions about the characteristics of appeals related to different urological cancers or elevated PSA because of low case counts and insufficient power.

Interpretation for Patient Care

These findings will help serve as a reference point for future external appeals research and for urology advocacy groups engaging with insurance company decisions. External reviews should be utilized more often to minimize out-of-pocket costs because nearly 40% of appeals were successful. Utilizing AUA guidelines may prevent overtreatment or mistreatment, but they are potentially overly constricting if used as benchmark for some cases of experimental services and other claim types.