13 things your health insurer doesn

Since Hippocrates wrote "Do no harm," countless patients have put their trust in physicians who have taken his oath. But somewhere along the line, medicine became a business — a $1.3 trillion a year business, according to the United States government — run by insurance companies that have taken no such oath.

Do you ever feel that when it comes to your health plan the deck is stacked against you? That's because there are many things your health insurer doesn't want you to know. Here are just 13 of them.

1. It is sometimes cheaper to let you die rather than to treat you for a serious condition.

Health insurers don't deny care, they deny payment which usually amounts to the same thing. Denying payment saves them money, but sometimes cause patients' deaths. Sound outrageous? Consider the statement below. It's an excerpt from the May 30, 1996, testimony given before the United States House of Representatives by Dr. Linda Peeno, a former HMO medical director and medical claims reviewer for Humana and Blue Cross and Blue Shield of Kentucky. Peeno is now a medical-ethics consultant and managed care whistleblower.

"I wish to begin by making a public confession: In the spring of 1987, as a physician, I caused the death of a man. Although this was known to many people, I have not been taken before any court of law or called to account for this in any professional or public forum. In fact, just the opposite occurred: I was "rewarded" for this. It bought me an improved reputation in my job, and contributed to my advancement afterwards. Not only did I demonstrate I could indeed do what was expected of me, I exemplified the "good" company doctor: I saved a half million dollars!

Whether it was nonprofit or for-profit, whether it was a health plan or hospital, I had a common task: using my medical expertise for the financial benefit of the organization, often at great harm and potentially death, to some patients. . . . I am the evidence that managed care is inherently unethical, in the areas of both medicine and business. Had my experiences been the result of merely local aberrations, I would not have had anything to do for the past six years. On the contrary, I discovered that my experiences are standard practice and quite ordinary for the managed care business."

But the Health Insurance Association of America (HIAA) says doctors are "actually more likely to face financial incentives encouraging them to provide high-quality care and high productivity rather than those that might be expected to reduce the amount of care they provide."

2. Health insurers routinely hide benefit exclusions.

Health insurers make their covered benefits as narrow as the market allows and routinely redesign benefits to control their highest costs, according to Peeno. They also use deceitful policy language to hide exclusions.

Some dental plans, for example, cover accidental injury to teeth. If you bite down on a hard candy and your tooth partially crumbles, you believe the insurer will pay to fix it. But when you submit your claim, it's denied weeks later. That's when you discover the policy's "definition of terms" section states in fine print: "Injury to the teeth while eating is not considered an accidental injury."

The HIAA says that while health plans and insurance regulators make every effort to ensure that insurance contracts are clear, "understanding them does require a significant degree of effort" on the part of the consumer.

3. Health insurers don't really want you to understand how your health plan works.

Health insurers use marketing that enhances the attractive elements of a plan, but they don't disclose potential plan problems. Most group health insurance members have no idea of their exact coverage limits or a plan's rules until they received a benefit booklet after the open enrollment period.

Even then, the benefit booklets don't fully reflect the contract between the members' employer and the health insurer. The seeds of some of the most common claims problems are sown when employers purchase health insurance for their employees, according to Maria K. Todd, president and CEO of HealthPro Consulting Consortium Inc., a private managed care consulting firm in Aurora, CO. Todd says most employers use health insurance brokers to whom they give a list of desired benefits. The broker, in turn, identifies insurers that offer affordable plans with those benefits. After the employer selects an insurer, the broker hands the employer a contract to review and sign.

"But the average human resources director really isn't aware he or she is being given a boilerplate contract that favors the health plan," Todd says. They may not realize that every element of the plan is potentially negotiable, and that they could hammer out improvements for the plan members.

According to the HIAA, "all the disclosure in the world won't help if people don't take the time necessary to be careful shoppers." The association urges "health insurance purchasers" (including consumers and insurance brokers for employers) to make sure they know what they are buying before they make any major health insurance purchase.

4. Health insurers employ "phantom networks."

Did you ever try to switch primary care physicians within your plan's provider network only to find out that many of the doctors named on the provider list are not accepting new patients? Then you have fallen prey to a health insurer that uses a "phantom network," a directory filled with doctors who are no longer with the plan or who are not taking new patients. Health insurers leave the names on the list to make it look as if they have a large number of available doctors.

HIAA says the problem is that printed booklets that list a plan's participating doctors can quickly become out of date. Instead of relying on printed materials, visit your plan's web site where there is usually a more up-to-date listing. "Health plans are interested in serving their members in order to keep them — not in antagonizing them," says HIAA.

5. Health insurers purposefully delay paying claims in order to maximize their profits.

Although 46 states have prompt-pay laws, those laws apply only to "clean claims," or claims submitted to them without any missing or wrong information. The problem is, according to Peeno, health insurers create a maze of payment-submission rules that guarantee there will be many "technical" denials for missing information or failure to follow the convoluted claims-submission procedures.

Why do insurers drag their feet on paying claims? When you pay your insurance premium, it is invested in interest-bearing accounts. An insurer delays your claim payment until the interest in these accounts is sufficient to pay the company's accumulated claims without cutting into its profit margin. Medical ethicists such as Peeno say "growing" the money isn't a questionable business practice, but the deliberate denial and/or slow payment of claims is. The problem is widespread. For example, Texas Insurance Commissioner Jose Montemayor slapped 17 health insurers with fines totaling $9.2 million for violating the state's prompt-pay law and lawsuits have been filed across the country by doctors charging slow payment of claims by health insurers.

The HIAA disputes Peeno's allegations: "Each time a claim has to be handled, the administrative costs for that claim increase, and these increased costs would quickly outweigh any benefit to be realized by 'growing' the money as alleged by Ms. Peeno."

6. Your doctor isn't calling the shots.

Do you know whose guidelines your health insurer follows when approving the length of your hospital stay? Your doctor, right? Wrong. Your insurer is most likely using guidelines developed by an actuarial consulting firm such as Milliman & Robertson. The problem is: Many doctors complain that Milliman & Robertson's recommended hospital stays are dangerously brief.

For example, Milliman & Robertson data state that the "target" hospital stay for meningitis (an infection of the covering of the brain and the spinal cord) is three days. Many physicians say this is outrageously short and that the average length of hospital stay for meningitis is a week or more. The use of Milliman & Robertson data to limit patients' care (and increase revenue) is just one of the allegations brought forth in a lawsuit filed by the state medical associations of California, Georgia, and Texas in U.S. District Court in Miami that accuses a nine health plans (Aetna Inc. and its Prudential unit, CIGNA Corp., Coventry Health Care Inc., Foundation Health Systems, Humana Inc., PacifiCare Health Systems, United Health Group, and WellPoint Health Networks) of violating federal racketeering laws.

The HIAA says that the Milliman & Robertson guidelines are adjusted on a case-by-case basis depending upon the condition of the patient, and when problems arise "it is often the result of doctors not adequately explaining the special circumstances that make a longer stay necessary."

7. Health insurers make a fine distinction between "emergency" and "urgent" care.

Your health insurance policy probably contains a clause stating you will not be billed for emergency room services if those services are eligible under "The Prudent Layperson Standard" for emergency room visits. These visits have been defined as medical, maternity, or psychiatric emergencies that would lead a "prudent layperson" (an average person) to believe that a serious medical condition exists or the absence of immediate medical attention would result in a threat to the person's life, limb, or sight. This includes situations where an individual is in severe pain.

But in some health plans, conditions such as a broken hip are not classified as conditions that require emergency care. They are classified as "urgent" conditions and you must call your primary care physician to get authorization to visit the emergency room.

"The devil is in the details," says Robert D. Finney, a former manager for health-care cost containment at the Hewlett-Packard Co. and author of HMO Hardball, a consumer self-help book. "HMOs hide the details in incomprehensible self-serving contracts written by HMO lawyers to take advantage of sick and disabled patients."

8. Health insurers don't want you to know how they come up with their prices.

Would you shop at a grocery store where none of the merchandise had price labels? Of course not, but many health insurers use a pricing practice known as "UCR," which stands for "usual, customary, and reasonable," to determine how much of a claim they will pay. As the name says, these charges are supposedly the "going rate" health care providers in your area charge.

But a consumer can't get UCR prices to dispute a claim payment or to compare plans. Even court orders have done little to force insurers to supply the formulas that they say they use to devise UCR rates, claiming it's proprietary (or secret) business information.

"Publishing this type of information would lead to providers gaming the system to raise fees, thus eliminating any competitive market forces that may influence providers' fees," according to the HIAA. "This would result in even higher costs for health care services."

9. Health insurers don't want you to take your grievance outside the health plan.

Every health plan has an internal grievance process, but insiders say many are reluctant to let you know that many states have also implemented laws governing external appeals that in certain cases give you the right to a review by an independent board of qualified experts. If the appeal is determined in your favor, your insurance company cannot deny your claim.

Additionally, insiders say few health insurers let you know that if you file a grievance with your state insurance department, insurance regulators are bound by law to investigate all consumer complaints that fall under their jurisdiction. Insurers do not want you to file a complaint with the United States Department of Labor, the agency that oversees health plans that are governed by ERISA, the Employee Retirement Income Security Act. ERISA governs self-insured health plans, meaning the employer assumes the risk for plan members.

According to the HIAA, the insurance industry voluntarily developed the external review process (subjecting claims determinations made by a health plan to review by external experts) in an effort to address the concerns of health plans, consumers, and doctors regarding the appropriateness of experimental and investigational procedures.

10. Health insurers don't want you to know that some of their practices violate laws.

Although 46 states have prompt-pay laws, insurers still violate them flagrantly enough to set off lawsuits and insurance department investigations that often lead to fines. The majority of these are settled quietly. And then the cycle begins again.

Insiders say what health insurers really fear are the massive class action lawsuits that ask the courts to force the insurers to repay all the money they have gained from these practices.

Contact Information

Christopher E. M. Maldonado - Director

    Telephone         602 308-1862

    Address            5045 North 12th Street Suite 136

                               Phoenix, Arizona 85014