Health Insurance Companies: Their Abuse and Tricks, Part One

January 11, 2008 by Orville Campbell, MD.

There is little or no doubt that the Health Insurance Industry has a strangle hold on doctors and other healthcare providers and the delivery of healthcare. There may be little hope as a significant number of these health insurance companies get richer and richer; their buildings get taller and taller and they become more powerful political lobbyists. CEO’s may command six or even seven figure salaries. In a significant number of cases, bonuses grow and flourish as life-saving or health preserving medicines and care are denied.  This series of articles will focus on the abuse inflicted on healthcare providers and the healthcare system by a significant number of health Insurance companies. “The nation’s HMOs reported a $3.6 billion profit for the first three months of 2005, representing a $646 million, or 21.4 percent, increase over the $3.0 billion earned during the first quarter of 2004,” according to Weiss Ratings, Inc. (http://www.weissratings.com/News/Ins_HMO/20051024hmo.htm).

Abuse #1:  Pre-existing Condition.

Patient walks into a doctor’s office to be seen and he or she presents his or her health insurance card. The staff verifies insurance coverage and / or obtains a valid referral (permission) from the insurance company to see the patient. The patient is seen to take of the concerning health problem. The insurance company is billed. The doctor’s claim for payment is denied. Pre-existing condition is the reason given by the insurance company.  In other words this condition started before (pre-existed) the insurance coverage. However, a doctor cannot know this unless he or she first sees the patient and takes a history. The doctor or other healthcare provider may never get payment. The patient despite paying premiums may get stuck with the bill. The insurance company pockets this money. The fight is on. Guess who usually wins, the company in that 20 or 40 story plush corporate office building that has enough red tape to tie up the healthcare provider for months to come. Guess who usually gives up.

Example: I was asked to consult on a hospitalized patient because she was passing blood and in pain due to a kidney stone. Imagine my surprise when my claim for payment was denied for pre-existing condition. The insurance company claimed that the stone was pre-existing!

Abuse #2: Referral or Prior Authorization

It is my opinion that the practice of insurance companies mandating that healthcare providers get special permission (referrals or prior authorizations) should be banned. These referrals or prior authorizations may be imposed on a healthcare provider before he or she can give a patient a health preserving medicine, diagnostic test, hospitalization or even an office visit.  Referrals or prior authorizations in too many cases delay care and may place a patient’s health in jeopardy. They are barriers to care and in many cases are used as weapons to deny care in order to line the pockets of the insurance company. Isn’t it silly to think that healthcare providers who have spent many years in training and are indeed experts can’t determine on their own if a patient needs to be seen or is in need of a medicine or test.

Example: A patient presented to my office just after closing. I had seen her in consultation in the past for uncontrolled high blood pressure. She was not feeling well and she complained that her blood pressure “was up”. The insurance company was closed so we could not get a referral number. I obviously saw the patient and administered medicine to reduce her blood pressure. She felt better. I also prevented a needless emergency room visit. The next day we called the insurance company to explain our situation and they said they would deny our claim since we saw her without permission.  

Healthcare providers and patients must speak up and demand that our elected officials make health insurance industry reform a priority.

Orville Campbell, MD

http://www.ClaimWellness.com

Posted in Uncategorized | No Comments »