Long before he ran for president, Senator Bernie Sanders told national treasure Bill Moyers “the business model for Wall Street is fraud.” It is hard to dispute this description, even as the law winks at and lawmakers and other canny investors profit from the business model of Wall Street. The business model for American health insurance companies is fraud. Their profit is based, in part, on their ability to deny services that customers pay for. I offer the following maddening illustration.
Leave aside the debate over if it was fair to make insurance companies offer reasonably priced coverage (or any coverage) to people with ‘pre-existing conditions.’ I’d argue it is fair, but fuck my opinion. You can argue whether it’s fair to make insurance companies, collecting decent premiums from consumers, cover an annual preventative visit to the doctor. You can argue the fairness of it, it’s your absolute right as an American to argue. You can even elect a living turd to bully his party into dismantling the timid, conservative think tank-created baby step in the arguably right direction for ‘failing American health care.’ I’m here only to point out a concrete instance of the basic business model of American health insurance: fraud.
You are faced with a single choice for treatment of, let us say, chronic kidney disease. You are being strong-armed toward the one treatment available to medical science: immunosuppressive therapy, a kind of chemotherapy described as an “atom bomb that knocks out your entire immune system and hopefully straightens out your auto-immune disease when the immune system comes back on-line.” The treatment involves IV steroids and other agents with possibly severe side effects. On the other hand, one third of all sufferers of this mysterious disease are cured from it without medical intervention. Nephrology does not have a clue about this “spontaneous remission”. You seek a second opinion. You’d like a medical opinion about how to increase your chances of being in this one third who recover from the disease without undergoing a form of chemotherapy.
The only opinion you will get from an American nephrologist is that immunosuppressive treatment is the only medical treatment currently available, and that you’d probably be wise to start before you suffer permanent kidney damage. You hope for a thoughtful nephrologist, who will not prey on your fear but allow you to make a fully informed decision about treatment, but the rest is a matter of the chance and the doctor’s personal style, whether they listen well and answer questions, return calls, are supportive or dismissive, sensitive or prick-like. The one I happened to see was a jerk. Luck of the draw.
Anyway, better still, let’s leave aside the specifics of the case. To see an out-of-network provider, paid in part by the insurance company, you need to obtain pre-authorization for the visit. This pre-authorization is granted , based on medical necessity. The insurance company gives you a number for the doctor to call to get pre-authorization. They must convince the Medical Management department that the services they provide are not offered by anyone in-network.
Once the case is made, Medical Management renders a determination. A week later you learn whether or not the visit will be partially covered by insurance. Without pre-authorization insurance will never pay anything towards the visit.
Provider calls Medical Management. They are told that the patient they are calling about does not have coverage in his policy for out-of-network visits. No request for pre-authorization can be made on behalf of that patient. Thank you for calling, the end.
When the patient is informed of this, and calls the member’s services number at the insurance company, he is told that he does have coverage for out-of-network visits. The problem, he is told is that the provider did not have pre-authorization.
You point out that the provider called the number you were given to get pre-authorization. Perhaps they are referring to some pre-authorization for pre-authorization you have not been informed of. Or perhaps, since they have told the prospective doctor a plain untruth, which forecloses the request for pre-authorization, their business model is closer to fraud. If you have the ninety minutes to devote to this discussion, and sufficient patience and skill, you can get it worked out and the provider can submit a request for pre-authorization. For virtually everybody else– bingo! we just made some more money for our CEO.
You get an Initial Adverse Determination from the insurance company. There is no need for this esoteric specialist, it informs you, when we can provide you a dozen in-network doctors with the same expertise as the doctor who did not answer your questions, the one you don’t want to see anymore.
You call the insurance company to ask them what the hell this determination means, as it makes no mention of medical necessity or the argument presented, it merely denies the pre-authorization based on the fact that they have many specialists in the same field, as well qualified as the jerk you no longer trust to give you medical advice.
Here’s the kicker, though. Membership, the only number you can call, as a member, has no record of any request for pre-authorization or any determination affecting you, adverse or otherwise. You read to them from the determination you are holding. They seem to believe you, they just have no record. You are, of course, free to appeal the Adverse Determination, in fact, you have, under state law, a generous 180 days to do this. They are Member Services, after all, only the Provider side has any of this information.
It happens again with the next doctor. “This consumer has no coverage for out- of-network visits, thanks for calling.” Now it is a pattern, a pattern and practice. It is part of a fraudulent scheme. Only my opinion, of course, but can you think of a word that describes this better than fraud?
“Did you try calling the Provider number?” suggests Sekhnet, thinking outside the box.
I do. I am patient, I am persuasive, I do not pretend to be a doctor, I state my case. The representative is understanding, tries to be helpful. Her hands are pretty much tied. She speaks to a supervisor. Tells me only Member Services can help me. I describe the fraud again succinctly. She does not disagree with my description of the ingenious scheme that separates these two parts of the corporate brain. She asks me to please hold while she speaks to another supervisor. I listen to the hold music for a few minutes. She returns with helpful news.
“You can ask for an EXPEDITED APPEAL,” she tells me happily. The regular appeal takes at least a month. I ask how long the expedited appeal takes. She has no idea, but I can find out at Member Services, she believes. She can transfer me there now, she tells me for the sixth time.
I rest my case, over and over again, on my own head. I’ve got to finish that fucking letter to the New York State Attorney General, the one who got the current president to cough up a token $25,000,000 to settle the case against him for his fraudulent university. New York State needs to regulate these lucrative, legally created pseudo-person psychopaths.