Brown Launches Independent Inquiry into HMOs' Handling of Health Insurance Claims

[tinrobot]

Source: California DEpt of Justice

Los Angeles - Attorney General Edmund G. Brown Jr. today announced that deputies in his office are launching an independent inquiry into how Health Maintenance Organizations review and pay insurance claims submitted by doctors, hospitals and other medical providers.

This investigation is prompted by reports that California's five largest health-insurance providers are denying insurance claims at rates of up to 39.6 percent.

"These high denial rates suggest a system that is dysfunctional, and the public is entitled to know whether wrongful business practices are involved," Brown said.

In the coming days and weeks, deputies will review records and will speak with individuals who have relevant knowledge of the issues raised.


Read more: http://ag.ca.gov/newsalerts/release.php?id=1797

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So, we're paying thousands a year for health insurance just to have 39% of our claims denied? How in the world can a government plan not be better than this ripoff?


(edit - bad math)

[cutlassmama]

1. It's just 22%

These are the real death panels!

[LeftHander]

2. SAVE HEALTH INSURANCE!! Stop Reform...!!

We need to protect the free markets and the profit!!

SAVE THE PROFIT!!!!

:sarcasm:

[wryter2000]

3. You go, Jerry

He's a good, hard-headed guy, despite the Governor Moonbeam stuff. We toughed him up in Oaktown. :evilgrin:

[pattmarty]

7. Yeah, he's an old time liberal that's been around in politics seems..............

..........like forever. Although in my opinion as he has gotten older seems like he has gotten a little more conservative, but still on our side.

[MurrayDelph]

10. Yes, he has been a much better

Attorney General than he ever was as Governor.

[David Zephyr]

22. He was a spectacular governor.

I know Jerry Brown. He took the state from Ronald Reagan's financial debt in the red and left it in the black eight years later. He started the California Conservation Corp which Americorp is a copy of. He put the first the first minorities on the Supreme Court when it wasn't "cool" to do so. He decriminalized homosexuality which let GLBT not be arrested and jailed for who they were and set the example for the other 50 states in the 1970's. He was always a steadfast defender and advocate and friend of unions and working people. He set standards for protecting the environment that are still ahead of many states all these decades later.

We've not had a Governor of his caliber since he left office.

[CountAllVotes]

24. Jerry Brown is running for governor again!

He should be in the office soon luckily.

As for the Calif. Conservation Corps - it no longer exists in the form it once did sadly. It was dumped/cut by the gropenfuhrer. :mad: AmeriCorps is a Federal program started by Clinton. and is somewhat like the CCC was.

I agree with you, Jerry Brown was a fine governor and I look forward to seeing him in that office serving the people of California once again!!! :D :D :D

:kick:

[Phoebe Loosinhouse]

4. I would think talking to the guy from Cigna who left in disgust and is singing like a canary

would be a good first step. The California Nurses Association (God bless them!) is also deeply involved in attempting to end Death by Spreadsheet. Let's start with recissions of someone newly diagnosed with cancer because they forgot about a podiatrist appointment 3 years before. I think that would qualify as a fraudulent business practice. Not to mention that the insurance company would know all about it in the first place. How do you think they know about it in the second place?

A health insurance application should be:

Your name, your address, your phone number, your birthdate and your SS.

[tinrobot]

6. Death by Spreadsheet.

Never heard of that before... it's a great phrase.

[global1]

5. The AG's Of Every State Should Do The Same.......

make the insurance companies spend their booty defending themselves versus doling out money to Congress to give them an opportunity to become more corrupt and deny more claims.

Just like the RW's are pulling their kids out of school for the President's speech - we on the other side should demand investigations of insurance companies all over this country.

The best defense is a good offense. If the Repugs can do it - we certainly can do it back!!!!!!!

[LuckyLib]

8. Deny first is their policy. Not everyone will fight back and pursue them

to pay for what they are legally committed to cover. They bank on it. Literally.

[dflprincess]

28. Exactly

in fact, most people either won't question a denial at all or will call once and then accept whatever lame excuse they get handed.

[Xipe Totec]

9. If only they were this dilligent in controlling the cost of executive compensations n/t

[Hugin]

11. K&R

[YvonneCa]

12. Brown for Governor !!! ...

...:7

[laughingliberal]

13. Governor, hell! Brown for President! n/t

[CountAllVotes]

25. Brown ran for president before

I hope he runs again. I went to see him when he was running in the late '70s. Everyone agreed that he was way ahead of his time.

He comes from a family of old San Franciscans that have served the State of California for generations. Anyone remember Edmund G. (Pat) Brown, Sr. (Jerry Brown's father)? He was another fine governor!

:kick: & recommend

[No Elephants]

29. "way ahead of his time" Liberals usually are. Just saying'.

[Auggie]

17. I wish. But if this goes through, the insurance companies will spend millions

against Brown.

[YvonneCa]

21. They'll spend it...

...either way.

[Auggie]

23. Right -- by denying more benefits.

[YvonneCa]

26. And specifically to defeat...

...Brown. IMHO.

[GreenTea]

14. I Love Jerry Brown, one of the last true liberal progressives.

[Vidar]

15. Knock 'em dead, Jerry!

[Amos Moses]

16. All the more reason to further entrench insurance in our

health care system, right? Make this fucking sleazy industry mandatory for everybody!

[David Zephyr]

18. K&R. This Californian can't wait to vote for Jerry for Governor. Can't wait.

[ayeshahaqqiqa]

19. I work at a clinic

and the "reasons" for denying claims are ludicrous. One company refused to pay because I left out the patient's middle initial--which was NOT on their insurance card. Another said the ink in my printer wasn't dark enough for them to read--even though I'd put in a fresh cartridge and you couldn't GET any darker.

Doc told of a friend who worked for an HMO for a while. That MD was told she could not spend over 6 minutes with a patient, even a new one. Doc spends 2 hours with a new patient.

[Ms. Toad]

20. Sad thing is

a lot of them are probably like the denial I just got for "invalid place of service."

Problems are:

1. It was ER service - which is covered everywhere so there are no invalid places of service, and everything is covered by the single copay I had already made.

2. Even if it wasn't ER services - we have a three tiered system, which provides SOME coverage wherever I go, even in non-emergency circumstances, and even without pre-approval.

Turns out the doctor's office (for farmed out services - as pathology, radiology, and lab work always are from an ER visit) coded it as an office visit. The insurance company couldn't find authorization for an office visit, and denied it - even though they should have noted the date of service, the place of service, and the type of service and figured it out. That explains #1. What it doesn't explain is #2, which should have been partly covered even without authorization.

Cost to me to fix the problems caused by their joint ineptitude: Five phone calls and about an hour of my time. If I hadn't known my rights and been persistent it wouldn't have gotten fixed. I think they count on people just paying the whatever bill they send.

[JeanGrey]

27. I worked as a claims examiner for a large company for

years and years. You'd be surprised at how little the average person knows about how their insurance works and even when they think they do, they don't.

Our company had a medicare supplement plan for the retirees at that time. In order for use to pay a claim, we had to have a Medicare EOB showing what Medicare paid, and an ITEMIZED bill to match it from the provider.

If I had a nickel for every time someone would send me a bill that was blank and said "balance due - 100" I could have retired early. I would always patiently explain that it had to be an ITEMIZED bill - not a "balance due" sheet. They would argue, get mad, hang up, and turn around and send me the same thing they just sent.

Drugs were the same way. Then, drugs were done on a "drug sheet" that the covered person filled in. Each and every entry that represented a drug purchased HAD to have a matching receipt. Want to know how many times the drug sheet and the drug receipts actually matched? Just about Never.

I get frustrated myself, because I now have Medicare and that bureaucracy is a pain in the ass as well. Everything there (and most other companies) are handled by CODES. Unfortunately, not all codes are created equal. Some doctors put a code down that they believe stands for a certain procedure but when medicare gets it, it is the wrong code (per Medicare) and the claim gets kicked out for a ton of reasons. I found out recently coding was what caused my Medicare bills to be denied. Then you have to go back to the doctor and his insurance people and pull teeth to get them to resubmit the claim (in a timely manner) with the RIGHT code.

This is one of the BIG reasons why SINGLE PAYER is the ONLY way this can be done. The middleman has to be done away with and the profit done away with.

I still feel fortunate however to have had Blue Cross even though it is secondary now. I am taking a cancer oral chemo now, called Tarceva, that costs 4,000 for a thirty day supply and I pay a 25 dollar copay.

Having said that, poor people will NEVER afford this public option if it is going to cost 8-12 percent of their pay. Because tax cuts aren't "money in your pocket" until April 15. On top of that amount of money, you will heap copays, for doctors, specialists, and drugs. EVERYONE's taxes will be raised, because there are too many Americans that aren't healthy and there aren't enough rich to pay for all this (unless we do away with the gazillions the insurance companies and big pharm makes).

For instance, Big pharm spends three times as much on advertising as they do on R&D. So the statement that the R&D takes all the money is horseshit.

Once that is mandatory and money starts disappearing from people, they aren't going to like it, trust me.

Ok I'm down from my soapbox.

"-)

[No Elephants]

30. Another favoritie of insurers: deny coverage for a covered test or procedure because

no one sought advance approval. Thing is, it is the doctor or hospital that is supposed to request advance approval. They never tell the patient when advance approval is necessary, they just set up the appointment for the test or procedure. But, if they don't seek advance approval, it's the patient who owes the money.

I was put into a coma medicinally once. Drugs that are supposed to make me drowsy put me to sleep for three days, so you can imagine what a drug designed to put me into a coma did to me.

The doctors stopped the coma-inducing drugs, but did not realize I was still comatose anyway. They decided I was deliberately choosing not to respond to their questions and directions. They called in a psychiatrist.

Psychiatric visits required prior approval. Being comatose, I could not possibly have sought prior approval and neither the hospital nor any of the doctors involved sought it. There were FIVE psychiatric visits before I finally woke up and was able to answer questions, such as, what year is it and who is President? (How is someone coming out of a coma supposed to know that anyway, but I knew to ask before replying, "How long was I unconscious?" LOL, who expects a pop quiz in intensive care?)

The insurance company denied the visits, saying they wanted to teach the PROVIDER a lesson. However, the provider just kept billing me for the visits, until someone at the insurance company who had been assigned to my case (because I had been in the hospital so long and the bills were so high) intervened on my behalf.

[JeanGrey]

34. That is untrue. I've had an HMO for YEARS, and I've always

known that ANY specialist that is seen other than certain ones require a referral. It is NOT the doctor's job to make sure that referral is done, it is YOURS.

Also I have NEVER heard of a bill being denied for someone in the hospital as long as getting there was on the up and up. Once they denied one for me, but I didn't have to pay it as the fault was with the doctor.

[panzerfaust]

31. Sure. You have health-care

? Right

[davsand]

32. Why are the bean counters being allowed to practice medicine?

EVERY freaking time my Doc orders a new med for me, we have to have a conversation about what my HMO will cover and what the co-pay will be. I bless my doc for being aware of the problem, but I have yet to be able to understand how the freaking INSURANCE guys can be allowed to set policy for what drugs docs prescribe.

It is frustrating enough when it is stuff like meds for High Blood Pressure or any other chronic condition, but it should scare the hell out of you if you stop to consider the drugs used to treat stuff like cancers and AIDS. If somebody wants to deem those drugs as "experimental" you are denied them, and essentially, you will probably die before your appeal ever gets processed.

Seems to me the insurance guys are practicing medicine without a license or even any med school. Where are the AG's at when it comes to investigating THAT particular issue? Here's a hint--take a quick look at campaign contributors for those state level AG races and someplace in there you are gonna find health insurance money. It is a given.

:puke:

I have come to believe that if any of us ever want any real reform for health care, the first step will need to be to strip ANY health care related industry of their ability to contribute to political campaigns.


Laura

[JeanGrey]

35. Think this won't happen under the government?

LOL. Sure it will. It already DOES. Medicare does it all the time. At least to me!

[DebbieCDC]

33. Go Jerry!

Always a good progressive -- and yes, as other posters pointed out, WAY ahead of his time back in the '70s.

[lovuian]

36. yep

its called fraud