GODZILLA HAS RISEN:
THE INSURANCE INDUSTRY UNDER THE AFFORDABLE CARE ACT
When inquired if Godzilla was "good or bad", producer Shogo Tomiyama likened it to a Shinto "God of Destruction" which lacks moral agency and cannot be held to human standards of good and evil. "He totally destroys everything and then there is a rebirth. Something new and fresh can begin.” (Godzilla, Wikipedia)
Despite all the hopes many of us had for the Affordable Care Act, the current system of medical insurance is a twisted and dysfunctional nightmare. I should know, because I am in the unique position of experiencing it from three perspectives simultaneously: that of a patient who uses an insurance plan, that of a small business owner who purchases insurance for a group of employees, and that of a physician who contracts with and gets paid by insurance.
As a patient, I am tricked by the insurance plan I bought. Even though the card says “HSA 2000”, the deductible for my family is actually $4000. After that the insurance only pays for 70% of covered charges until I spend $8,800 on covered charges. ( I am on my own for things the plan does deem worthy of covering) My business pays over $2000 monthly for the premium, and $545 a month that goes into the Health Care Savings Account does not accumulate fast enough to keep up with the bills. When I call my insurance company I must make sure that I have several hours of free time, so that I can stay on hold long enough to get through to the low level representative who has no power to really do anything. As I hold, the oft repeated disclaimer “Description of covered benefits is not a guarantee of payment” makes me fearful and insecure. I am at the mercy of large, for -profit corporation that is beholden to shareholders and run by greedy CEO’s who do not care about me.
Before purchasing the policy I made sure the medication I need was listed on the formulary I found on the company’s website. After receiving the denial of payment for my medication I am told that the formulary I viewed was not the formulary associated with my plan. When I ask to see the formulary for my plan I am told it is not available.
My daughter incurs bills at the local emergency room. The EOB arrives and the insurance denies the claim because they believe she has another insurance policy. Puzzled, I wonder how they could have gotten this idea. I am not aware of other plans. I call her and she confirms, no other plans. I call the insurance company again (long phone tree, half an hour on hold, messages informing me that they are experiencing “an unusual number of calls”. [It is amazing how frequently they have “an unusual number of calls”]). Finally I get a representative on the line, who does not know anything. She puts me hold to investigate. 20 minutes later she returns and says they believe there is another policy. I tell her no, no other policy. We cancelled the other policy last year because your insurance company kept fighting with the other insurance about who should pay, and then both companies would deny payment. Besides, in order to have an HSA plan, you required that we cancel all other policies--don’t you remember we did that upon signing up? But of course she would not remember, because she is just a receptionist located in Texas or Arkansas or Calcutta or somewhere.
“Are you trying to drive your customers insane?” I ask. You require us to cancel all our other policies in order to get this particular type of plan, and then you deny payment because you accuse us of having another plan. She sighs, wearily, and asks if there is anything else she can help me with today?
“Yes!” I feel like yelling---”Pay the medical bills! If I refuse to pay my premiums you would cancel my coverage, but when you refuse to pay my medical bills I have no recourse!” ...but I don’t. She is a person who needed a job badly enough that she ended up with this one. She has no decision making power.. A day later, while I am still seething in frustration an automated call will reach me at home and ask me to participate in a survey about the service I received when I called the company. What a rotten job she has.
Once, out of spite, I called the Company while I was at work. I held until a representative answered, but by then I had patients waiting. I asked her if she would hold while I saw my patients, and surprisingly, she was very accommodating. After 20 minutes I was able to get back to her and address the latest problem. I imagine it was probably the highlight of her day--sitting on hold, peacefully waiting, no angry customer at the other end of the line.
Having insurance means little anymore. Deductibles are high, share of costs are high, and many benefits are simply not covered. Deny, deny , deny! The Company has so many devious ways of denying payment that even a sophisticated health care “consumer” (what an odious phrase!) can be taken by surprise. The reason for denial could be the type of treatment (no counseling for you!), it could be lack of a contract with a specific provider, or that your medication is non generic or not on formulary. Deductibles can vary depending on the type of service--medical, pharmacy, durable medical, or mental health (don’t even mention dental or vision!). With my current “good” plan, if I am lucky, after spending close to $24,000 on premiums and $6480 for HSA contributions (a wash, as that money comes out of my office, into my HSA account and out again for medical expenses), I will have the privilege of then paying my own medical expenses to the tune of $4,000 (family deductible) and another $4,800 dollars towards “share of cost”, and paying for any non-covered expenses. Just as soon as I have paid all of that (or gone through a medical bankruptcy) January first arrives and I get start all over again.
I am tempted to call the company and keep the receptionist on the line to discuss my personal problems. After my therapy bills were denied, I no longer have anyone else to talk to.
After the third bogus denial, I realize what is going on. In the past insurances could kick you off for getting sick or refuse to accept you for having a pre-existing condition, but now they are legally obliged to accept all comers--but they have found a new way to shed their undesirable patients. Their new tactic is to balk, deny, hassle and ignore you until you willingly transfer your diseases to another company. The tactic is working. I am ready to go elsewhere.
Ah, insurance is wonderful---JUST DON’T GET SICK!
As a small business owner, I have over 25 employees, most of whom rely on me to provide insurance. Over the past decade, we dread the arrival of each new year, because the insurance plans we offered previously are cancelled and replaced by more expensive plans with fewer benefits. Typically we see the price of premiums increase by 25-40% every year. The plans are so complicated we can’t even understand them, and we have 3 full time medical billing specialists on staff. The alphabet soup of HMO’s, EPO’s, PPO’s, HSA’s are overwhelming, the rules that regulate the deductibles, copays, share of cost, prior authorizations and formularies can be mind boggling, and and even if you understand them, remember: DESCRIPTIONS OF BENEFITS ARE NOT A GUARANTEE OF PAYMENT.
My newest employee in our billing office quit today. She felt she could not continue in a job that was so hurtful to young families. After sending out patient after patient in tears, she decided the bad karma invoked by performing the duties required by the position could not be justified, and she decided to move on to a happier job. When things reach a point where your employees feel like they will face eternal damnation just for doing their job then THE SYSTEM IS BROKEN. One of the Covered California plan that starts with the letter “A” and also has the letters “B” and “C” in it’s name offered us a 30% pay cut to see their Covered California patients. We refused. The alphabet company threatened to cancel all of our many mutual patients. We held firm. For four months we held our head high and did not accept the pay cut. However, those patients came in with insurance cards that were identical to those of our contracted patients. Our office and our patients did not find out that our services were not covered until the bills were denied. It fell upon my staff to inform parents that they owed us the full amount of the charges. Dumbfounded and dismayed, families wept and raged at our medical billers.
About half our patients have private insurance. We accept 9 different types of insurance which requires adherence to 9 different contracts and 9 different fee schedules. Our office has 3 full time employees whose job it is to make sure the claims we send in get paid correctly. Each day I pay my staff their hourly wage as they sit on hold trying to get through to the companies to address problems. It seems that any reason is good enough for the insurance to underpay us or deny payment. If we don’t catch the mistakes, we lose out. My employees beg, bicker and bargain to try and get the paid for the work I have done. Sometimes we call the California Medical Association to get help, and sometimes we yell at our insurance broker. We can call the Department of Insurance or the Department of managed Health Care, but they are understaffed and overburdened so usually we don’t bother. I also have to pay my staff for work to overcome the other hurdles and barriers the insurance industry has created. The amount of time wasted on obtaining the “prior authorizations” so patients can get their medications, consults or procedures is incalculable.
Every time the Company refuses to pay for a procedure or a consult or a medication, the Company gets to keep the money! Every time the Company forgets to pay the claims my office generates, the Company gets to keep the money! Each time the company raises premiums, the Company gets to keep the money! Are we crazy to tolerate such a system?
Continue doing what doesn’t work--is that not one definition of insanity?
Continue doing what doesn’t work--is that not one definition of insanity?
The Affordable Care Act, despite the best of intentions, has fortified a monster. By mandating that we purchase insurance, the industry is stronger and feels emboldened to augment its egregious practices. Being exponentially larger and more powerful than the agencies assigned to oversee them, the industry finds ways to circumvent and resist restrictions imposed upon it. This enormous parasitic leech has gotten firmly latched on to the lifeblood of American medicine. It is sucking money and energy out of medical care from all angles, and like a cancer, creating harmful malfunctioning growths. How long are we going to stand for this?
I wish “ObamaCare” was what the conservatives imagine it to be and hate--a comprehensive, MediCare-like, government-run system--and I wish I could sign up for it.
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