Health Insurance Companies - Their Abuse And Tricks, Part One

There is little or no doubt that the HealthExample: I was asked to consult on a hospitalized
Insurance Industry has a strangle hold on doctorspatient because she was passing blood and in pain
and other healthcare providers and the delivery ofdue to a kidney stone. Imagine my surprise when
healthcare. There may be little hope as amy claim for payment was denied for pre-existing
significant number of these health insurancecondition. The insurance company claimed that the
companies get richer and richer; their buildings getstone was pre-existing!
taller and taller and they become more powerfulAbuse #2: Referral or Prior Authorization
political lobbyists. CEOs may command six orIt is my opinion that the practice of insurance
even seven figure salaries. In a significant numbercompanies mandating that healthcare providers
of cases, bonuses grow and flourish as life-savingget special permission (referrals or prior
or health preserving medicines and care areauthorizations) should be banned. These referrals
denied. This series of articles will focus on theor prior authorizations may be imposed on a
abuse inflicted on healthcare providers and thehealthcare provider before he or she can give a
healthcare system by a significant number ofpatient a health preserving medicine, diagnostic
health Insurance companies. "The nation's HMOstest, hospitalization or even an office visit.
reported a $3.6 billion profit for the first threeReferrals or prior authorizations in too many
months of 2005, representing a $646 million, orcases delay care and may place a patient's health
21.4 percent, increase over the $3.0 billion earnedin jeopardy. They are barriers to care and in
during the first quarter of 2004" according tomany cases are used as weapons to deny care in
Weiss Ratings, Inc.order to line the pockets of the insurance
Abuse #1: Pre-existing Condition.company. Isn't it silly to think that healthcare
Patient walks into a doctor's office to be seen andproviders who have spent many years in training
he or she presents his or her health insuranceand are indeed experts can't determine on their
card. The staff verifies insurance coverage and /own if a patient needs to be seen or is in need of
or obtains a valid referral (permission) from thea medicine or test.
insurance company to see the patient. The patientExample: A patient presented to my office just
is seen to take of the concerning health problem.after closing. I had seen her in consultation in the
The insurance company is billed. The doctor's claimpast for uncontrolled high blood pressure. She was
for payment is denied. Pre-existing condition is thenot feeling well and she complained that her blood
reason given by the insurance company. In otherpressure was elevated. The insurance company
words this condition started before (pre-existed)was closed so we could not get a referral
the insurance coverage. However, a doctornumber. I obviously saw the patient and
cannot know this unless he or she first sees theadministered medicine to reduce her blood
patient and takes a history. The doctor or otherpressure. She felt better. I also prevented a
healthcare provider may never get payment. Theneedless emergency room visit. The next day we
patient despite paying premiums may get stuckcalled the insurance company to explain our
with the bill. The insurance company pockets thissituation and they said they would deny our claim
money. The fight is on. Guess who usually wins,since we saw her without permission.
the company in that 20 or 40 story plushHealthcare providers and patients must speak up
corporate office building that has enough red tapeand demand that our elected officials make health
to tie up the healthcare provider for months toinsurance industry reform a priority.
come. Guess who usually gives up.