Is health insurance only for those lucky enough to be healthy and wealthy?
Today MSNBC.com published an article by Jonathan Cohn, a writer for Self Magazine, When you are denied health insurance: Sometimes even healthy people can't get a company to sell them a policy
(http://www.msnbc.msn.com/id/26664727/). Cohn writes:
The health insurance crisis affects millions of Americans. At any given moment, the United States Census shows, 47 million people are uninsured. Some 25 million more are underinsured, meaning their benefits aren't sufficient to meet their needs, according to a recent study by the Commonwealth Fund, a health care policy foundation in New York City. Combine those two groups and the total suggests that almost one fourth of Americans don't have adequate health benefits.(http://www.msnbc.msn.com/id/26664727/)
The reasons for not having insurance can include:
- inadequate income
- no insurance through employer
- rejection of application for health insurance
- rescinded policy
Cohn's article included testimony from various individuals who lacked health insurance for a number of reasons. Either Cohn or some of the interviewed people have some facts wrong. One woman, Delozier, relayed that her insurance was rescinded because she had taken Metformin and Actos to "help her ovulate" so she could get pregnant. Those two medications are for diabetes mellitus, not for menstrual irregularity. Although this part of Cohn's article does not hold up to scrutiny, the fact remains that at least 45,000,000 people in the United States have no health insurance. Delozier had insurance, but it was rescinded for nebulous cause.
The problem of obtaining and maintaining health insurance coverage has led to the organization of the National Association of Health Underwriters (NAHU) and on their website (www.nahu.org) you can find details for insurance laws in most states. This is an excellent source of information, although the first two sentences of their opening paragraph does not address the fact that the uninsured had virtually no choice.
There were as many as 45 million Americans that went without health insurance coverage at some point during the last year. Many of these people may not have obtained needed medical care as a result, and all took a significant financial gamble. The National Association of Health Underwriters, a professional association of more than 20,000 health insurance agents, brokers and benefit specialists, is extremely concerned about the problem of the uninsured. One of our primary goals is to help ensure that Americans have access to appropriate health coverage. To help address this problem, we have developed the Healthy Access Database, an online tool to help make American health care consumers aware of all of the coverage options available to them. The Database contains information about private health insurance coverage, as well as the many public and private programs available to Americans to help them obtain the medical care they need. Policymakers, the media and other interested parties can also use the Database as a means of comparing health care coverage options for Americans on a state-by-state basis.(http://www.nahu.org/consumer/healthcare/)
If you are looking for health insurance you can go online and search any carrier's website. You can also go to eHealthInsurance and comparison shop (http://www.ehealthinsurance.com/). Inserting this writer's information the policy premiums ranged from $62 to $306 per month and deductibles ranged from $2,500 to $10,000 per year. Generally, the less premium you pay, the higher the deductible. The problem with affordability is that if your income is such that all you can scrape up is $62 per month for premium, your medical bills could put you in debt for $10,000 before your insurance starts paying. An overnight stay in the hospital could wipe you out financially for years to come.
No Insurance Through Employer
The Washington Post picked up a story written by Steven Reinberg for HealthDay Reporter on Friday, May 2, 2008. Reinberg wrote:
Working people and their families who don't have employer-based health insurance cost the American public $45 billion a year, a new study reveals. This includes $33 billion in the costs of Medicaid and the State Children's Health Insurance Program, and $12 billion in uncompensated care expenses, which are paid by federal, state and local governments and shifted to other payers. In addition, one-third of low-paid workers do not have health insurance, an increase of 9 percent since 1996, another study finds. Both reports were released Friday by The Commonwealth Fund.(http://www.washingtonpost.com/wp-dyn/content/article/2008/05/02/AR2008050201945.html)
Many industries and services have uninsured workers. Small business owners often cannot afford to pay their own health insurance premiums nor offer health insurance benefits to their staff. The food service industry employs workers often at minimum wage, often seasonally, with a fast turn-over of staff, and health insurance is not offered. Farm workers, cab drivers, construction workers, and many others often work without the option for health insurance.
Another trend is the "on-call" worker. One employer of this writer hires most of its staff on "on-call" basis and lures the applicant with "eligibility for insurance in three months." Three months roll around and no insurance is offered. The rules change to "three months after probation." Another three months roll by and still no insurance is offered. This time "records are being reviewed and the committe to determine eligibility meets only once every three months" which takes another three months. For this writer, pay was cut 20% in May, 2008, so that health insurance premium could be paid and as of October 6, 2008, this writer still has no proof of insurance after 13 months working for this employer. If a worker complains to the labor union, the representative blames the lack of insurance on the employer. If a worker complains to the employer about the problem, the employer blames the labor union. Both union and employer say the insurance costs the employer $688 per month per employee. Meanwhile the worker has no insurance despite a cut in wages and already paying premium for several months. If hours are cut (which is possible because of the on-call status), insurance can be canceled the next month and the whole year-or-more process has to start over with no interim insurance. This is all clearly illegal if the worker is a full-time employee. It is not illegal if the worker is "on-call." This writer's employer is not the only company that denies benefits this way. Many companies do this. The employees may work for 7 or 8 years for 32 to 40 hours per week "on-call" without benefits without ever being offered "full time" status. In these times of high unemployment and dismal economy, more and more people will feel compelled to accept "on-call" work and thus become part of the growing mass of uninsured workers.
Rejection of Application for Health Insurance
States usually forbid insurance carriers from going back more than 6 months to research for pre-existing conditions, and more than a year and a half for specific ailments; however, a patient's claim history follows them from policy to policy and with the advent of electronic medical records, everything is on the record. Before electronic records, a patient would have to sign a release of information paper stating exaclty who may have a copy of any part of their medical record. Once the paper was received at the medical facility, a physical chart would need to be found, information found, and someone had to photocopy the requested information, stamp it "copy," and send it off to the third party via fax, mail, or physical delivery. Release of information by the patient (or guardian) is still required; however, electronic records can easily be printed out "by accident" or cut and pasted to other documents and sent to others. Hospitals employ information technology personnel to monitor access and keystrokes of employees who must view or work on patient records.
In 1996 the Health Insurance Portability and Accountability Act (HIPAA) was passed by the United States Congress. HIPAA is managed by Health and Human Services division of the U. S. Department Office of Civil Rights (www.hhs.gov/ocr/hipaa). You can search and read about HIPAA on many sites including www.hipaa.org. The act protects workers from loss of insurance and protects people from unlawful release of their Protected Health Information. Wikipedia's article about HIPAA gives the facts, both good and not so good (http://en.wikipedia.org/wiki/HIPAA). Because of HIPAA regulations, there are strict rules about giving medical information within hearing distance or sight of other people. When you see those signs at a pharmacy, "Please wait here for the next available clerk," those are meant to minimize your obtaining information about the person already at the counter and the person behind you from gathering your personal information. This is also why you cannot call a hospital and ask if a particular person is a patient. The volunteers or staff may not tell you.
Before HIPAA, snoop agents employed by insurance carriers could call hospitals at odd hours and pretend to be someone needing the medical record or information on almost anyone. If you worked in a hospital then, you really had to be aware of all the tricks. Sometimes it was a judgment call. Sometimes it was in a patient's best interest to give some information without a formal signed release, but that is usually in a trauma situation. The key was "in the patient's best interest." It is best interest to save a life. It is not best interest to just hand out information to someone who sounds nice on the telephone. HIPAA clarified the issue and most of the calls from snoops stopped.
Insurance carriers who want to deny claims, rescind coverage, or reject applications for policy now have to find other ways to obtain information for that purpose. They ask for personal information on forms you complete. When you complete a form at your doctor's office listing all your previous illnesses, surgeries, family medical history, and the medications you take, if you want your insurance to chip in to pay the bill, you must also sign a form saying you give your permission to release this information to the insurance carrier. That is just one way they gather information. If the insurance carriers used that information in the patient's best interest, there would be no problem.
Regarding denying policies, Cohn writes:
To exclude people they deem poor risks, insurers today use sophisticated techniques. They can tap into databases that reveal your past prescriptions and use "predictive modeling"--a complex, computerized algorithm--to estimate how likely it is that your medical bills will exceed the amount you pay in premiums. Every insurer has its own list of medical conditions for which it may charge higher premiums (have you ever been treated for anxiety, an eating disorder, an ulcer, fibroids or even irritable bowel syndrome?) or, in some cases, nix coverage.(http://www.msnbc.msn.com/id/26664727/)
Medical coding is an important industry in that it simplifies the processing of insurance claims and also supplies statistical data. A medical coder should be well educated to understand the written chart. Thorough knowledge of medical conditions, anatomy and physiology, medicines and their usage, procedures and all the codes that can be applied to them is necessary. Most coders have taken at least one certification exam to prove they know the material. Medical coding translates the information documented in the patient record into alpha-numeric sequences. The letter-number combinations are sent to the insurance companies whose staff then process or reject claims for payment or reimbursement. Ideally, this system should make the process neat and clean, easy. In some ways, it works, because the patient can be assured that the person who codes their chart has some knowledge.
Medical coders are expected to follow a code of honor of honesty and fairness. If someone asks a coder to put in a specific code, there has to be documentation to back up that code. Evidence has to be present. All of this is fine and good. However, as with any industry, sometimes people find themselves in a position of doing something illegal or immoral because their only source of income demands it. Some coders have been offered bonuses at insurance companies if they can find minute reasons to deny claims or rescind policies. This is clearly not in the best interest of the patient.
During the past couple of years, a backlash against the exclusionary practices of insurance companies has been brewing, following revelations in the Los Angeles Times that California companies were systematically reviewing high claims among individual consumers--and one was even awarding bonuses to staff who came up with grounds for cancellations.
One carrier, HealthNet, agreed to pay $9 million to a breast cancer patient whose chemotherapy was interrupted because the company annulled her policy. Such lawsuits prompted the state to investigate, and it separately brokered agreements with five major insurers to reinstate coverage for 3,370 people who lost policies. But a more sweeping change is necessary, and in this election year, there is serious talk of universal health care. (http://www.msnbc.msn.com/id/26664727/)
Free Advice, a website dedicated to providing free legal information and advice wrote:
A number of lawsuits have been filed recently against Blue Cross, alleging that Blue Cross has breached its contracts, along with its duty to policyholders to act reasonably. These claims rest on the assertion that Blue Cross wrongfully rescinded policies based on the insured's alleged failure to provide important medical history on their original insurance application. Post-claims underwriting is used by insurers to eliminate the financial exposure of paying large claims of seriously ill members. Instead of investigating the medical history disclosed by the insured at the time of the application, the "post-claim underwriting" practice (declared illegal by California law) is used by the health insurer to investigate an insured's medical history only after a claim for benefits has been submitted. As the insured seeks his or her benefits, the insurer looks for an excuse to cancel the policy and deny the claim. The insured is then left with medical costs he or she will probably not be able to pay.
The website Insurance Claims & Issues has abundant information about laws and insurance fraud. You can read more about the Blue Cross case mentioned above on that site. (http://insuranceclaimsissues.typepad.com/insurance_claims_and_issu/2008/07/post-claims-underwriting-or-rescission-feds-battle-states-over-insurance.html)
You can read about the change in California law that was prompted by the Blue Cross case at website "An Act Concerning Postclaims Underwriting" (http://www.cga.ct.gov/2007/BA/2007SB-01214-R000112-BA.htm.)
Fraud the Other Way
Insurance companies are not always the bad guys.
The Coalition Against Insurance Fraud (CAIF) describes themselves as
one of America's most trusted and credible anti-fraud forces, thanks to our remarkable diversity. Together, our members are working to control everyone's insurance costs, protect the public safety, and bring this crime wave to its knees. Their website www.insurancefraud.org includes a Hall of Shame, statistics, news, and resources. They cover all kinds of insurance fraud including arson, life insurance, disability, and medical. Regarding medical fraud, they reported three sets of statistics from the American Medical Association:
Nearly one of three physicians say it's necessary to game the health care system to provide high quality medical care. Journal of the American Medical Association (2000). More than one of three physicians says patients have asked physicians to deceive third-party payers to help the patients obtain coverage for medical services in the last year. Journal of the American Medical Association (2000). One of 10 physicians has reported medical signs or symptoms a patient didn't have in order to help the patient secure coverage for needed treatment or services in the last year. Journal of the American Medical Association (2000) (http://www.insurancefraud.org/stats.htm)
You can read these statistics differently in that two out of three physicians would not game the health care system; less than one in three physicians would deceive third-party payers, and nine out of ten physicians did not falsely report signs or symptoms. It is good to know that most physicians remain honest.
Nevertheless, there are patients who claim they need durable equipment which insurance pays for and then the patient sells for money. There are physicians who lie about the need for particular procedures. There are nursing homes and hospitals that file false claims. There are clinical laboratories that charge an insurance company three times the usual fee for a test.
Three Missouri nursing homes run by Robert D. Wachter were hellholes. Residents were denied water, food and sanitation while he billed Medicare and Medicaid for many of the same services. Some residents died from neglect. Wachter received 18 months in federal prison and fines of $750,000. (http://www.insurancefraud.org/hallofshame.htm)
Some suppliers of goods overcharge hospitals and doctors just because they are a captive market. The medical facility has the responsibility to find a less costly provider rather than passing that excessive cost onto patients. For example, when Aqua Net hair spray was still on the market, it was used in laboratories to fix microscope slides. At that time the hair spray was about one dollar a can. The same substance could be purchased from a medical supply house for about three times as much. The products worked the same; only the labeling and cost were different.
The number of uninsured United States citizens will increase dramatically in the next several years for many reasons: insufficient income to pay for premium, employers unable or unwilling to provide group health insurance, aging population with long medical histories of excluded illnesses, and greed by many insurance companies, some medical practitioners and facilities, and a few unscrupulous individuals.
If you are healthy, wealthy, and do not need health insurance you can get it. Otherwise, many health insurers will find reason to deny you and insurance policy or rescind the policy if you find yourself needing coverage.