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MONDAY, JULY 03-JULY 09, 2023
VISIT RIVERSIDEINDEPENDENT.COM
VOLUME 9,
NO. 127
How often do health insurers say no to patients? No one knows.
Detectives seek other potential victims of alleged sexual assailant
By Robin Fields, ProPublica
By City News Service
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This story was originally published by ProPublica. ProPublica is a Pulitzer Prize-winning investigative newsroom. Sign up for The Big Story newsletter to receive stories like this one in your inbox. Series: Uncovered ow the Insurance Industry Denies Coverage to Patients It’s one of the most crucial questions people have when deciding which health plan to choose: If my doctor orders a test or treatment, will my insurer refuse to pay for it? After all, an insurance company that routinely rejects recommended care could damage both your health and your finances. The question becomes ever more pressing as many working Americans see their premiums rise as their benefits shrink. Yet, how often insurance companies say no is a closely held secret. There’s nowhere that a consumer or an employer can go to look up all insurers’ denial rates — let alone whether a particular company is likely to decline to pay for procedures or drugs that its plans appear to cover. The lack of transparency is especially galling because state and federal regulators have the power to fix it, but haven’t. ProPublica,in collaboration with The Capitol Forum, has been examining the hidden world of insurance denials. A previous story detailed how one of the nation’s largest insurers flagged expensive claims for special scrutiny; a second story showed how a different top insurer used a computer program to bulk-deny claims for some common procedures with
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A picture of a piggy bank, a stethoscope and a stack of US $1 bills.| Photo by 401(K) 2012 (CC BY-SA 2.0)
little or no review. The findings revealed how little consumers know about the way their claims are reviewed — and denied — by the insurers they pay to cover their medical costs. When ProPublica set out to find information on insurers’ denial rates, we hit a confounding series of roadblocks. In 2010, federal regulators were granted expansive authority through the Affordable Care Act to require that insurers provide information on their denials. This data could have meant a sea change in transparency for consumers. But more than a decade later, the federal government has collected only a fraction of what it’s entitled to. And what information it has released, experts say, is so crude, inconsistent and confusing that it’s essentially meaningless.
The national group for state insurance commissioners gathers a more detailed, reliable trove of information. Yet, even though commissioners’ primary duty is to protect consumers, they withhold nearly all of these details from the public. ProPublica requested the data from every state’s insurance department, but none provided it. Two states collect their own information on denials and make it public, but their data covers only a tiny subset of health plans serving a small number of people. The minuscule amount of details available about denials robs consumers of a vital tool for comparing health plans. “This is life and death for people: If your insurance won’t cover the care you need, you could die,” said Karen Pollitz, a senior
fellow at KFF (formerly known as the Kaiser Family Foundation) who has written repeatedly about the issue. “It’s all knowable. It’s known to the insurers, but it is not known to us.” The main trade groups for health insurance companies, AHIP (formerly known as America’s Health Insurance Plans) and the Blue Cross Blue Shield Association, say the industry supports transparency and complies with government disclosure requirements. Yet the groups have often argued against expanding this reporting, saying the burdens it would impose on insurance companies would outweigh the benefits for consumers. “Denial rates are not directly comparable from one health plan to another and could lead consumers to See Health insurers Page 14
iverside County sheriff’s investigators Wednesday were continuing to try to identify additional victims of sexual abuse allegedly at the hands of a Coronita man already charged with assaulting two female relatives, who are now adults. Abimael Hernandez Saldana, 70, was arrested in May following a sheriff’s investigation that authorities said was prompted by one of the defendant’s family members. Saldana is charged with lewd acts on a child under 14 years old and sexual penetration of a child under 10 years old. He pleaded not guilty in May and is slated to appear for a felony settlement conference before Superior Court Judge Mark Johnson at the Riverside Hall of Justice on Aug. 2. Saldana is being held in lieu of $1 million bail at the Smith Correctional Facility in Banning. According to sheriff’s Sgt. Brandon Mullins, in early April, deputies were contacted by law enforcement officials in Orange County, Florida, who had received information from a woman alleging she was sexually abused by Saldana as a child. “The victim stated she had been sexually assaulted multiple times ... while she slept,” Mullins said. According to the District Attorney’s Office, along
See Sexual assailant Page 27
Police: Alleged thief already in custody linked to Riverside burglaries By Staff
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nvestigators believe a probationer currently in jail on robbery charges is responsible for at least seven burglaries in Riverside, officials said Friday. Michael Aria Javdani, 27, of Riverside, is facing additional burglary charges and a weapons charge after police served a search warrant at his residence last Tuesday in the 4000 block of Sedgwick Avenue. Officers recovered an unregistered handgun and evidence linking the suspect to the additional burglaries. “Late last month, the Riverside Police Department’s Property Crimes Unit began following up on a commercial burglary that occurred in the 2000 block of Iowa Avenue,” Riverside officials said in a statement. “Several thousand dollars was stolen from an ATM machine inside the See Burglaries Page 28