You dutifully pay your premiums, then the day comes when you actually need the insurance company to pay for something.
This is how it's supposed to work. But it doesn't.
What follows is a real lesson in Murder by Spreadsheet.
In California, Blue Cross will "pre-authorize" a particular procedure, then when the time comes to pay, Blue Cross feels entitled to say,
"Blue Cross' pre-authorization for healthcare services is an advance determination of the medical necessity of a proposed procedure only; it is not a guarantee of payment," she said, adding that the caveat is "stated expressly" when the pre-authorization request is made.
"Our authorizations for care, based on medical necessity, include express statements that they are not guarantees of payment," she [Blue Cross spokesperson] said.
I'd go much further and state, that this is the Murder by Spreadsheet business model for the entire for-profit insurance industry.
This situation is not unique to California, not by a long shot. The for-profit health insurance business model is to delay, deny and deceive. Delay payment. Deny care. And deceive, doctors, policyholders, hospitals and even government regulators.
No one is safe any longer unless you work for a Fortune 500 company. And if you are employeed by a huge corporation, your insurance options are eroding, your benefits are shrinking,your costs skyrocketing, and most likely you're being conned into signing up for Junk Insurance.
But truthfully all insurance in the United States has become Junk Insurance with the notable exception being the insurance member of Congress give themselves.
This ain't nyceve making such an outlandish claim, even Senator Clinton agrees.
Kathy Byars: Why do members of Congress get the Mercedes of insurance plans and pension plans while many of their constituents are just trying to pay for the basic necessities?
Clinton: I believe that one of the ways we can get health care for everyone is to open up the federal plan that's available to members of Congress ... to everybody. That would be one way that we could say to you that you have the same right as anybody in Congress
I think it is past time for the Congress to do for everybody else what we do for ourselves.
I believe we can no longer continue with Cadillac policies for people in Congress unless we give other people in America the same policies.
One of the worst for-profit insurance companies (actually they are all criminal, and again, I'm asking everyone of you to call your representative and demand Congressional hearings-now!) UnitedHealth found itself facing some unexpected costs which impacted its 1st quarter 07 profits.
But the truth is that beleaguered UnitedHealth customers will now find themselves in extremis at the end of next year, as Unitedhealth scams its policy holders in one unholy way or another.
Seems um, Unitedhealth never anticipated actually paying a few claims. Mark my words, something bad is coming next year to everyone conned into buying one of their High Deductible Junk Insurance products.
First-quarter profits rose 4 percent compared to the prior year, an anemic result for a company once seen as a fast grower.
UnitedHealth Group Inc. shares dropped $2.16, or 4 percent, to close Thursday at $52.05 on the New York Stock Exchange.
The quarter started Jan. 1 with a hangover from the end of the year. People who had satisfied high deductibles in traditional insurance and health savings accounts rushed to get in that last physical or prescription at the end of the year, before their deductible reset in the new year. UnitedHealth was hit with $100 million in charges left over from the prior quarter that it wasn't expecting, including $70 million for high-deductible health plans.
"The intensity in the second half of December was striking," Chief Executive Stephen Hemsley said on a conference call with analysts.
High-deductible plans have been expanding as employers look to shift more of the costs of health care onto employees. High-deductible and health savings account plans now have 2.2 million members, and added 290,000 in the first quarter alone, Hemsley said. Such plans now account for 40 percent of the insured customers in the company's UnitedHealthcare division (as opposed to policies where the employer carries the insurance risk and UnitedHealth runs the program.)
Some analysts suggested that UnitedHealth ought to have seen the end-of-the-year surge coming. Piper Jaffray analyst Melissa Mullikin said it's possible that consumers are just getting smarter about maximizing their health insurance once the deductible has been satisfied.
"While you would hope that they would expect that kind of consumer behavior, I am mindful of the fact that these are relatively new products," she said.
http://www.chron.com/...
Returning to the the dire and awful situation in California for a moment, the largest state in the richest nation on the planet.
Once again, heroic Lisa Girion of the Los Angeles Times is doing among the best health reporting in the country.
This is the latest installment of the case most aptly called, Blue Cross against the people of California.
The largest organizations representing California physicians and hospitals joined a lawsuit against Blue Cross of California on Thursday, accusing the state's largest health plan of illegally and routinely refusing to pay them millions of dollars for medical care provided to enrollees whose policies were later canceled.
The move puts the doctors and hospitals on the side of patients, regulators and consumer advocates who have criticized Blue Cross and its competitors for canceling individuals' policies after they incur costly treatment. Such cancellations have left some patients with significant financial or medical hardships.
Blue Cross, owned by Indianapolis-based WellPoint Inc., defends the practice, saying it cancels policies only after determining that individuals submitted incomplete or inaccurate applications for coverage. In such cases, the insurer contends, the patients are responsible for paying the doctors and hospitals.
http://www.latimes.com/...
Keep in mind, what these criminal murderous companies do, is they "pre approve" care then after the fact--after the care has been rendered, they refuse to pay the claim citing fraud. What a fucking load of crap. But truth is no longer your friend in George Bush's America.
Disgruntled former policyholders have filed hundreds of lawsuits against Blue Cross and other carriers in California, accusing them of digging up application flaws after the fact so they can shirk their promise to cover medical bills. They allege insurers are violating state law by failing to determine whether policyholders intended to lie on applications, or merely made mistakes.
Now, the California Hospital Assn., representing about 430 institutions, and the California Medical Assn., representing more than 35,000 physicians, are joining a lawsuit against Blue Cross filed in Los Angeles in October by Coast Plaza Doctors Hospital and Methodist Hospital of Southern California.
. . ."The hospitals are saying, 'Just pay us for what you authorized us to do,' " said Jan Emerson, a spokeswoman for the California Hospital Assn. "Hospitals have done the right thing. The doctor referred them to the hospital for a procedure. The hospital called and got authorization for the procedure. We provided the care. And, after the fact, Blue Cross decides to rescind coverage. And the hospitals and the doctors are left holding the bag."
Now you can probably understand why huge medical debt is the leading cause of bankruptcy among insured Americans.
Although Blue Cross also contends that rescinded patients are responsible for the bills, the consumers often are unable to pay because the medical debt dwarfs their income and they are caught up in a struggle to obtain new coverage — or come up with the cash for their continuing care.
But it gets even worse.
The thieves (calling them thieves is far too generous, how about the Murder by Spreadsheet boys), at Blue Cross are going to fight a take no prisoners battle to maintain the status quo in California. They will fight all the pitiful Schwarzenegger reform as long as it requires them to actually devote $$$$ to patient care. Any one want to bet that at the end of the day, Schwarzy will cave to the special interests. Well actually, stupid me, his proposal is one big giveaway to begin with.
And here's why Blue Cross is gearing up for holy war. They are in business to take your money then deny your claims.
SACRAMENTO -- When Blue Cross sells health insurance to someone who isn't covered at work, the company typically makes a 27 percent profit. By the time salaries and other administrative costs are accounted for, only half the money the company collects in premiums from that person goes for medical care.
Those figures may help explain why Blue Cross -- the insurance provider for roughly one in four people in the state who have health coverage, and with political heft in the Capitol to match -- so far is the only major insurer opposing Gov. Arnold Schwarzenegger's universal health care plan.
State records show that among the state's top insurers Blue Cross profits most from the current system -- to the detriment, critics charge, of consumers. And so the company may have the most to lose if the governor succeeds in reforming the system.
Given those stakes, and the insurer's formidable presence in Sacramento, Blue Cross could emerge as a potent force in the debate over the governor's ambitious health care plan.
. . .Blue Cross devotes significantly less than that -- from 51 percent to 79 percent, depending on the type of insurance plan -- according to financial data filed with state regulators.
. . ."The idea that you have to sell health insurance to any comer is antithetical to their business model," said Peter Harbage, a health care expert at the nonpartisan New America Foundation who has advised the governor. "It's not how they make money."
Blue Cross recently was fined $1 million by the state for dropping members who became sick or pregnant, the second such penalty in less than a year. The company says the cancellations were justified, but some say the fine is just one example of a company driven excessively by money.
Blue Cross "is known as the most aggressive in trying to avoid covering people who actually need care, and the most aggressive in offering scaled-back, bare-bones plans," said Anthony Wright, executive director of Health Access, a consumer advocacy group. "In the policy arena they've been the most resistant to reform."
http://contracostatimes.com/...
Sorry for the overly long diary. In the United States we are knee deep into a disaster of epic proportions with this cruel, inhumane and ultimately evil for-profit health care system.