Consumers have a strong interest in picking a company that will reliably pay their legitimate claims when they need medical treatment. But health insurance companies don’t disclose the percentage of claims they reject and decline to pay. And inquiries by the Center for American Progress show that the nation’s insurance regulators have not asked them to do so.
CAP in recent weeks launched an investigation to determine whether data on commercial health insurers’ claim denial rates is available nationwide or in any states. The research included interviews with multiple senior officials of the National Association of Insurance Commissioners, other current and former insurance regulators and government officials in states around the country, officials at health insurance companies, academic experts, and others. All said that no such data is available. No state insurance regulators or federal agencies require insurers to disclose their claim denial rates, except in California. California’s Department of Managed Health Care requires insurers to include it in reports they file.
CAP also asked each of the nation’s seven largest for-profit health insurers—Aetna, Anthem Blue Cross Blue Shield, Cigna, Coventry, Health Net, Humana, and UnitedHealth care—if for the purposes of this report they would disclose their overall rates of claims denials and breakdowns by reason for the denials. All of the companies declined or did not give any direct response to the request. Spokesmen for the companies in general said that the insurers pay the vast majority of claims, and that denials are fair, with most occurring for routine reasons such as a patient erroneously submitting the same claim twice or a physician sending a claim to the wrong company.
But the reports from California indicate why health insurance companies may be reluctant to disclose their claim denial rates. That data shows that three of the six largest health insurance companies in the state each denied 30 percent or more of all claims filed in the first six months of 2009. It also showed wide variations in denial rates among the companies.
The most sensitive and potentially controversial claims are those based on medical criteria—such as whether a treatment is medically necessary or should not be covered because it is deemed experimental. CAP learned in interviews with former senior medical personnel at several of the largest insurers that big insurers—including Aetna, Cigna, and UnitedHealth care—made internal changes in recent years that gave business executives more direct authority over the companies’ doctors who evaluate claims based on these medical criteria.
Insurance companies had previously maintained a separation between the medical evaluation staff and the executives responsible for financial performance. The doctors and nurses reported to the companies’ chief doctor—known as the chief medical officer—who had final say on whether coverage for a particular individual’s treatment should be granted or denied based on medical criteria. But beginning about a decade ago, in a shakeup that evidently received no public attention, companies changed their policies so that the medical staff reported to regional business executives. These executives were given the authority to determine the doctors’ pay, bonuses, and promotion, and consequently they gained the power to influence the doctors’ decisions. The new systems generally kept “dotted line” reporting to the chief medical office, who would still weigh in on the most difficult claims decisions
By taking anti-AIDS medicine after a rape, Christina Turner discovered that she had made herself all but uninsurable.
Christina Turner feared that she might have been sexually assaulted after two men slipped her a knockout drug. She thought she was taking proper precautions when her doctor prescribed a month's worth of anti-AIDS medicine.
Only later did she learn that she had made herself all but uninsurable.
A House committee has voted to strip the health insurance industry of its exemption from federal antitrust laws as senators announced plans to take the same step.
The moves Wednesday signaled a growing determination by Democrats to punish the insurance industry for its criticism of President Barack Obama's health care overhaul agenda. The House Judiciary Committee voted 20 to 9 to repeal a 1940s law that exempted the health insurance industry from federal controls over certain antitrust violations including price-fixing.
Lawmakers said they wanted to include the legislation in a larger health care overhaul bill taking shape in the House. In the Senate, Majority Leader Harry Reid announced plans to repeal the antitrust exemption as part of its health care legislation.
On September 29th in New York City, the Mobilization for Health Care for All is launching a national campaign of "Patients Not Profit" sit-ins at insurance company offices to demand an end to a system that profits by denying people care. We want the real "public option": Medicare for All, a single payer plan that cuts out the profit and puts patients first.
Insurance companies are the real death panels in America. They make billions in profit and millions for their CEOs while millions of Americans have no health insurance and over 45,000 die every year because they can't get the care they need. That's more than 120 people every day. These insurance companies deny care to their members and the American people for profit.
America deserves better, and that's why we voted for change. But the insurance companies are spending millions to confuse and scare the public to keep us from ending their grip on our health and our money. With teabagger town hall protestors and the right-wing noise machine on their side, they're winning. We can't let that happen. It's time to take the fight to the real villain in the health care debate.
When the civil rights movement faced a similar challenge in the struggle to end segregation, nonviolent civil disobedience moved the nation and made reform possible. Just like the lunch counter sit-ins did for the civil rights movement, we have to make it impossible for the media and our country to ignore how outrageous the status quo of private insurance is for the American people.
It only takes a small group of people to do a sit-in in your community, but our actions can inspire every American who has been abused by the insurance companies and believes it's time for real reform to fight for it. This campaign of nonviolent civil disobedience will continue until the insurance companies no longer stand between the American people and the health care that is our right.
Already, doctors, nurses, patients, and people just like you are signing up to be one of the 100 ordinary but courageous people who will launch this nonviolent battle to end private insurance abuse and win health care for all. Join us! We can't wait any longer - every day more people die because of the insurance company death panels. Sign Up!
A doctor goes on a righteous rant about the pain of dealing with insurance companies to get his patient's the care they need. At the end, he provides a transcript of a call from his nurse to one company. Both hysterically funny and sad. You have to read it.
...the Obama administration is investigating the activities of health insurance giant Humana--a participant in Medicare Advantage that's been telling its aging consumers that the government plans to slash benefits as it reforms the U.S. health care system, and urging them to tell Congress not to touch the program.
Medicare Advantage plans are private health care plans that seniors can buy into with federal assistance in lieu of participating in traditional Medicare, and under terms the government erected, those insurers face strict limits on how they communicate to beneficiaries. The regulations exist to protect seniors from acting under the pressures of their insurers, who control their benefits. In response to a request from Sen. Max Baucus (D-MT), the Center for Medicaid and Medicare Services has demanded the lobbying effort cease, and is investigating the company to determine whether it violated those rules.
Senate Minority Leader Mitch McConnell, who represents Humana's home state of Kentucky, and has received tens of thousands of dollars from the company over the years, called the CMS actions a "gag order"--a characterization that has been echoed by House Minority Leader John Boehner and Rep. Dave Camp (R-MI)--ranking member on the House Ways and Means Committee--who fired off an angry letter to CMS acting administrator Charlene Frizzera.
U.S. health insurers whine about being "gagged" after being told not to violate marketing rules or improperly use protected Medicare mailing lists.
The Centers for Medicare & Medicaid Services (CMS), which oversees the Medicare program for the elderly and disabled as well as privately run Medicare alternatives, said on Monday it was investigating a letter Humana Inc (HUM.N) sent enrollees about efforts to overhaul the nation's healthcare system.
Humana's letter, sent in an envelope citing important plan information, told customers the Democrats' bills could hurt "millions of seniors and disabled individuals who could lose many of the important benefits and services that make Medicare Advantage health plans so valuable," according to CMS.
The agency also warned other insurers against sending potentially misleading health reform mailings to customers.
Representative Dennis Kucinich ask executives from six of the largest health insurance companies if denial of insurance claims can be fatal. Watch them answer:
A doctor presents some very interesting ideas in the article generating a great comment discussion - well worth the time to read and consider:
The point of this history lesson, of course, is to recall that if you are bogged down in a stalemate, a surprise counterattack can be an overwhelmingly successful tactic to gain the upper hand. The forces of the status quo continue their fight to prevent real health care reform from taking place, and we pro-reform advocates remain hunkered down trying to defend the public option -- our last tattered shred of hope for change -- from annihilation. This seems like a good time to see where the opportunities are to counterattack: to throw our foes off balance, hit them where they're lightly defended and cut off the main thrust of their attack.
To do this, I suggest that we focus not so much on the public option: that defensive line where little movement is occurring. As it is, health insurers have no disincentive to keep stalling and chipping away, because doing so gives them nothing but upside. The way to shut them down is to show that stalling the process could hurt them more than it helps them. We should attack other important strategic targets which have already been neutralized by the forces of the corporatist status quo: health insurance reform, and cost reductions. The following are some specific ideas about how to counterattack.
The four basic premises are:
Remove health insurers' tort immunity.
Cancel the insurers' anti-trust exemption.
Make health insurers spend our premiums on health care.
Give all government sponsored health insurance programs access to the VA drug formulary.
John Conyers and some allies on the House Judiciary Committee have come up with a fabulous way to get the insurance industry in line - by threatening to remove their anti-trust exemption.
Many people don't know that the insurance industry, under the McCarran-Ferguson Act of 1945, has a broad anti-trust exemption that facilitates regional monopolies. The Act allows states to regulate the insurance business instead of the federal government, but also allows that, as long as the state regulates the industry, federal anti-trust laws would not apply.
The point is that the concentration of the health insurance market among regional monopolies leads to higher costs for consumers, almost by definition. What the legislation by Conyers (D-MI), Hank Johnson (D-GA) and Diana DeGette (D-CO) would do is end that anti-trust exemption for health insurers, allowing for enforcement in all of these highly concentrated markets. The Senate has companion legislation from Sen. Patrick Leahy
Welcome to the American health insurance industry. Instead of helping policyholders attain the health security they need for their families, big insurance companies get rich by denying coverage to patients. Now they're sending lobbyists to Washington, DC to twist the arms of lawmakers to oppose reform of the status quo. Why? Because the status quo pays.
Insurance companies have used the excuse of "pre-existing conditions" to deny coverage to countless Americans. From cancer patients to the elderly suffering from arthritis, these organizations have padded their profit margins by limiting coverage to patients deemed "high risk" because of their medical condition.
But, in DC and nine other states, including Arkansas, Idaho, Mississippi, North Carolina, North Dakota, Oklahoma, South Carolina, South Dakota, and Wyoming, insurance companies have gone too far, claiming that "domestic violence victim" is also a pre-existing condition.
Words cannot describe the sheer inhumanity of this claim. It serves as yet further proof that our insurance system is broken, destroyed by the profit-mongering of the very companies who's sole purpose should be to provide Americans with access to care when they need it most. In 1994, an informal survey conducted by the Subcommittee on Crime and Criminal Justice of the United States Senate Judiciary Committee revealed that 8 of the 16 largest insurers in the country used domestic violence as a factor when decided whether to extend coverage and how much to charge if coverage was extended.
What’s beautiful about the Medicare Advantage program is that it has provided us with a real-life laboratory experiment which allows us to compare the functioning of highly-regulated private insurance plans as contrasted with the functioning of a public insurance program: traditional Medicare. The results are in, though that would be tough to ascertain if you simply observe the response of Congress.
What have we learned? The private plans take away the choice of health care providers that the traditional public program offers. The private plans insert intrusive interventions between the patient and the physician – interventions that are not found in the public plans. Private plans divert more resources to excessive, wasteful administrative services while increasing the administrative burden on the health care providers and on the public stewards who must provide oversight of our tax dollars that are diverted to this industry. Private plans also provide more entry points for the criminal element to cheat the taxpayers, patients, and providers. And for this we are paying far more of our tax dollars than we do in the traditional Medicare program for comparable levels of care. The obvious lesson is that we should dump the private plans.
What has Congress learned? They have decided that we should provide more subsidies to the private plans so that they can expand their markets!? And they have apparently decided that we will not even have a genuine public plan because it would provide unfair competition to the private plans because of Medicare’s greater efficiency and lower costs!?
It is true that a fragmented, multi-payer system is much more expensive and much less equitable, leaving too many exposed to suffering and financial hardship. But our Medicare Advantage experiment has demonstrated that it is the private plans that must be jettisoned, and it is Medicare that must be granted to everyone after modest, appropriate reengineering so that it works even better than it does now.
We need to send this urgent message to Congress and the administration, immediately:
For-profit health insurance giant WellPoint fired off an email blast to its customers (using its Anthem Blue Cross Blue Shield subsidiary) yesterday attacking the public option and Democratic plans for reforming health care, according to Politico’s Ben Smith. The email directs customers to its “grassroots Web site” for instructions on contacting legislators, a website ThinkProgress revealed to be run by the secretive corporate lobbying firm Democracy Data and Communications (DDC). DDC, which is operated by a former veteran of the astroturf organization now known as FreedomWorks, has helped various corporate and Republican interests shape legislation by helping to generate seemingly organic phone calls and letters to Congress.
However, I think Waxman is getting a little tired with Rahm's attempts to sideline the work of the Commerce Committee.
Because on Monday he sent out a demand for information on health insurance company's exorbitant costs--returnable in time for the health care debate in Congress in September.
He's asking for the following by September 4:
* A table listing the total compensation for every employee making more than $500,000 a year * A table listing board member compensation * A table listing off-site conferences and retreats * A table listing the company's total revenue and net income
And the following by September 14:
* Communication with the board on compensation packages * Tables listing premium revenue, claims payments, and sales expenses
And here's the list of insurance companies mean old Henry is picking on. In case you wondering, Mrs. Bayh's company, Wellpoint, is on that list. I would imagine that after these details become public--just as the debate between the House and Senate picks up--Evan Bayh might think a little differently about how he represents the interests of--as Mrs. Greenspan calls them--the conservative Democrats in Indiana. Likewise, once Waxman has the details of the retreats that some of those obstructing reform have attended, it may change their commitment to obstruction pretty quickly.
But the actual provisions in the HELP Committee bill call for numerous “community health insurance options,” not the single "Medicare-like" plan promised by "public option" advocates. That means the individual "options" will probably be as small and weak as the co-ops now under discussion in the Senate Finance Committee. More importantly, these "community options" will almost certainly be run by insurance companies.
Section 3106 is a mess, but its meaning becomes clear after several readings. Section 3106 does not create the "Medicare-like" program promised by Jacob Hacker, HCAN, Howard Dean, and other "option" advocates. Instead it proposes a program that authorizes DHHS to create numerous health insurance companies tied to geographic areas, and to contract with members of the existing insurance industry to create and possibly run those companies.
Leaders of the "public option" movement have an obligation to advertise the HELP Committee bill truthfully. It is not accurate to say the HELP Committee bill creates a "robust" or "strong" public option. It is not even accurate to say the HELP Committee bill creates one "option." The truth is the "option" is balkanized and very weak. In fact, HCAN, Andy Stern, Howard Dean and other "option" advocates who have praised the HELP Committee bill should do more than cease to praise it. They should tell Congress they oppose it.
Health insurers have forced consumers to pay billions of dollars in medical bills that the insurers themselves should have paid, according to a report released yesterday by the staff of the Senate Commerce Committee.
At a committee hearing yesterday, three health-care specialists testified that insurers go to great lengths to avoid responsibility for sick people, use deliberately incomprehensible documents to mislead consumers about their benefits, and sell "junk" policies that do not cover needed care. Rockefeller said he was exploring "why consumers get such a raw deal from their insurance companies."
The star witness at the hearing was a former public relations executive for major health insurers whose testimony boiled down to this: Don't trust the insurers.
"The industry and its backers are using fear tactics, as they did in 1994, to tar a transparent and accountable -- publicly accountable -- health-care option," said Wendell Potter, who until early last year was vice president for corporate communications at the big insurer Cigna.
Over the past five years, almost 20,000 individual insurance policyholders have had their policies rescinded by the three insurance companies who testified today: Assurant, UnitedHealth Group, and WellPoint.
As a family physician for 47 years, I totally agree with Paul Krugman’s May 22 column, “Blue Double Cross.” Health care insurers are more bureaucratic than any government agency. They often deny choice of doctor, and refuse to pay for care.
My experience with the government programs, Medicare and Medicaid, is that the reimbursement for services may be low, but there is one uniform set of rules to follow.
Each health care insurer has a different set of rules. The reimbursement for services varies widely and the doctor sometimes doesn’t know where to send the patient for laboratory or other tests. Furthermore, the physician often doesn’t know whether the prescriptions he or she writes will be covered.
As Mr. Krugman reports, insurance companies are still bad for your health.
Melvin H. Kirschner Granada Hills, Calif., May 22, 2009
•
To the Editor:
I am a dual citizen, born and raised in Canada. After attending graduate school in the United States, I returned to Canada, first of all because of its much better health system. During my time in the United States, I heard many astonishing lies about Canadian health care.
Someone said that Canadians can’t choose their own doctors. Sorry, wrong. It’s Americans whose choice is constrained, by health maintenance organizations.
Another person said Canadian-style care is more expensive. In fact, Canadians pay far less and still get a high standard of care and are healthier and live longer than Americans.
Someone else said that Canadian health insurance involves tons of paperwork. Wrong again. Canadian medical insurance and billing is a miracle of simplicity and economy. Anyone who has ever been to an American hospital knows how much paperwork — mostly financial — is involved, and how many different bills they get from how many different parties.
Americans deserve far better than their current system, because most of them can’t simply move to a country with a rational, humane vision of health care.
