Can the internet bear one more commentary on the murder of United Healthcare (UHC) executive Brian Thompson? Can the crime that launched 10,000 news articles and millions of social media posts be scrutinized in any fashion that hasn’t already been done by perhaps hundreds of others? I ask because my perspective—which I’m certain is not completely unique—is one that I’ve not seen or read among the multitude of online reporting and musing on the subject. You see, I was both employed by the health insurance industry and its victim, though not in that order.
For years I had the good fortune
to have a job that provided fully employer-paid health insurance with a carrier
that had a robust network of hospitals and other providers. Coverage and in-network availability of care
was never an issue. But within a few
months of leaving that employer I suffered a health episode that required an
emergency room visit and follow-up procedure.
Without much thought I went to the nearest hospital, only to learn that
it was out of network for my new insurance coverage. Being in severe pain and in no state of mind
to go looking for an in-network hospital (if there was even one in town, which
I don’t think there was) I chose to continue treatment where I was. The insurer paid a miniscule amount, and I
ended up with a bill of several thousand dollars. The insurer was UHC.
Interestingly, that underpaid
claim years later entitled me to participate in a class-action lawsuit against
UHC that netted me some money, but it was a small fraction of what I had to pay
out of pocket.
Skip ahead ten years. I accepted a job offer from a regional health
plan (read: insurance company), working with the state’s Medicaid program. If you’re not acquainted with that program,
it is the state-paid health coverage for needy families. One feature of that program is that
participating providers cannot bill patients for services covered by Medicaid;
they are wholly dependent on the insurance carriers for reimbursement for care
rendered to Medicaid beneficiaries. My
role as a Provider Relations Representative was to assist providers in getting
their claims paid. And I was
instrumental in recovering literally millions of dollars for the providers in
my territory. They only came to me when
there was a claim problem to resolve—and I was constantly busy, so that should
say something about the medical claims process.
Why were there so many claims
problems? I would chalk it up to
1) The insanely complex process of coding claims, in which different insurance companies have different requirements in how to submit a claim for the identical service; even a single misplaced decimal in the procedure code can get the claim denied
2) The correspondingly complex system of adjudicating those claims on the insurer’s side; not just any off-the-shelf software can handle the task adequately
3) Deliberate efforts by insurance companies’ “cost containment” units to actively search for past supposed errors that their claims department had missed and then taking back from the providers the money paid in those claims; the most egregious example I encountered was a pediatric practice who had money deducted from their current claims’ payment for a 13-year-old error (You read that right: NOT an error on a 13-year-old’s medical claim but a claim that was itself 13 years old; I got their money back, in case you’re wondering)
4) Insurance company incompetence. Oh, ALL. THE. TIME.
But what about patients NOT
enrolled in Medicaid who have their claims denied. They ARE on the hook for the unpaid balance. And they have no billing department, no
denied claims appeal team to help them fight the denial. They are pretty much on their own. (I’ve addressed in previous posts how best to
file an appeal in these cases.)
Can I say anything in defense of
insurance companies? Certainly. Can you find anyone else who for a few
thousand dollars a year would carry the risk you could become a million-dollar
cost for them if you become very sick, as well as cover the many other routine costs
of keeping you healthy? Can you find
anyone else that would take the risk your house could be lost to some
unforeseen hazard and cost them hundreds of thousands of dollars to replace it
for you?
And of course no one would think
of cheating the insurance company, right?
So do we really need the False Claims Act that Congress passed? Or do the state police really need to run
that ad on the radio offering rewards for those who turn in people committing
insurance fraud? The attitude of “They
[the insurance companies] have plenty of money” is a dishonest excuse for a
criminal act that hurts everyone.
Dishonesty in even a small matter is still dishonesty.
We can lament the fact that for
all our advanced care our health outcomes are not on par with other countries
that spend much less on health care for their citizens, but there is no
question we have top-tier medical technology and specialty care in the U.S. But at what cost? I came across a news item about a Reddit post
sharing a picture of a hospital bill for the delivery of a baby in Kansas in
December 1955. The total for a three-day
stay was under $60, including room & board and nursing service charges of
$27.
So hospitals and doctors must be
to blame for the hyper-inflationary price spiral that has driven up insurance
costs. Not so fast. I’ve had occasion twice to be introduced
socially to physicians. When they ask me
what I did before I retired, I’ll play coy and say that with their being a
doctor I’m not sure I want to reveal what I used to do. Both times their response was, “You must have
been a lawyer.”
Medical professionals are wary of
lawsuits and routinely practice defensive medicine, ordering tests and exams
that are probably unnecessary, just to prevent someone suing them for
negligence, for not foreseeing and eliminating every possible
diagnosis—regardless of how unlikely it is.
And they have to pay for their health insurance like you do…AND
liability insurance to protect against YOU suing them.
So there’s plenty of blame to go
around, as they say. Is the American
health care system broken? Our opinions probably
depend on our personal experience with providers and with health insurers. But if we consider health care a right—and
given that as a country we apparently do, at least for the poor, disabled, and
elderly—entrusting it to marketplace forces, as we do for pricing commodities,
doesn’t seem to be working. What is the
answer?
Until next time,
Roger
“Let the one among you who has
never sinned throw the first stone.” John 8:7 Phillips
[Thank you to those who
have viewed my blog and website from outside the United States. I’m flattered to have an international
readership! I’ve left the Comments open for
this post because if you are so inclined, I’d love to hear your perspective and
your health care experience in your homeland and how it contrasts with the U.S.]
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