05 April 2006


I did some work for an insurance company this year, and learned a number of interesting things. It turns out that most of the time, when patients think their insurer is trying to screw them, they aren't—it's actually that the insurer is trying to screw the doctors and other providers. When a doctor joins an insurer's network, they sign a long and complicated compensation rules package saying what they will get paid for each proceedure. The rules are deliberately obfuscated, so that the insurer can later say, "well, because that surgery is covered under both paragraph 324 section 78 subsection B and paragraph 187 section 32, you only get paid the cost of the oxygen plus $280, instead of the $1500 you thought ...." This why what's covered is so confusing.

Of course, I wouldn't put it past folks doing stuff like that to do other "cost controls." Via Ezra Klein, I learn of a lawsuit against Blue Cross for trying to screw customers.

They allege that Blue Cross scours years of medical records after expensive claims have been submitted, looking for innocent misstatements and omissions to use as pretext to rescind coverage and escape expensive bills.

The suits also accuse Blue Cross of using a vague, confusing and ambiguous medical history questionnaire in an effort to trick applicants into making mistakes that the company can use later to dump them.

It's a good thing we're keeping health insurance in the efficient private sector, eh?


Reya Mellicker said...

Saddest of all - of course - is that none of this seems to have anything to do with healing.

Kate said...

Interesting you should post this today. Did you see this article? I know Stu Altman well; he was the architect for Nixon's universal healthcare package. Unfortunately that died since it was introduced to Congress as Watergate was emerging. Anyway..........take a gander.


Jonathan Korman said...

The Massachusetts plan is interesting. I have mixed feelings about it.

On the one hand, anything which gets universal heath coverage happening is good. On the other hand, much of the cost of health care in the US comes from the paperwork of different players in the process trying to evade paying for things. So if you leave the insurers standing, as that plan does, it doesn't seem like it would lead to cost control.

Kate said...

There is always the need for cost controls, my dear. But this has the backing of most participants in the debate and as a result more insured, particularly children, will benefit. And for that I say, Huzzah!

There is no PERFECT solution. If you have one, I would love to hear it certainly. But this certainly comes close.

Anyway I will watch to see how it all unfolds.

Kate said...

too many certainly(s) in that last post.........I certainly apologize.