[Update-I read a couple of comments and thought of a more appropriate title.]
jancw is confused.
Please read her excellent diary. I don't want her, or anyone, to be rattled by obligatory insurance company denials.
CA125 cancer tests and routine denial of coverage
http://www.dailykos.com/...
Obligatory? Has nyceve lost her mind?
Read on, my children.
P.R.O.F.I.T.S.
WALL STREET
The for-profit insurance industry serves investors--not you and not me. That's why it's called for-profit. Investors pay money to buy their stock. Investors invest to make money. Last time I checked, the way a company makes investors happy is to increase earnings and control costs.
Think of our monthly premiums as earnings or revenue. Our bodies are costs. When our bodies get sick they become big costs.
Costs are bad. Costs must be crushed and defeated.
Here's the ugly story. The financial success of the for-profit insurance industry is due to their business model that must limit their medical losses. We, that means you and I, are medical losses.
My children, this is called the medical loss ratio. You and I (and our health needs) are known in insurance lingo as "losses".
Every dollar they spend our our healthcare needs goes against the bottom line.
That said, these are good day$ for the in$urance indu$try. The market is performing, profits are up. Champagne is flowing. The Street is pleased.
Let's go a little further and see why they deny. And as you read this Guide to Insurance Company Denials, remember costs are bad and we our bodies are costs.
Heeeeeeeeeeeeeeeeere's Humana.
Humana profit beats outlook; shares jump
Health insurer Humana Inc. on Wednesday reported higher-than-expected second-quarter profit, mainly because of improving cost trends, and its shares rose as much as 10.4% to a record high.
The company, one of the largest providers of Medicare health plans for the elderly, also raised its full-year earnings forecast, which easily topped Wall Street's forecasts.
Investors have been concerned about the prospects for Humana, the fifth-largest U.S. health insurer by market value, because the U.S. government may seek to cut reimbursements for Medicare plans administered by companies.
http://www.businessinsurance.com/...
How 'bout a round of applause for Aetna.
Aetna quarterly profit rises
Aetna Inc. (AET.N: Quote, Profile, Research), the No. 3 U.S. health insurer, posted a 16 percent rise in second-quarter earnings on Thursday, helped by an increase in enrollment, and the company raised its full-year forecast
http://www.reuters.com/...
Oh it gets better--much better. Aetna is "wowing" Wall Street.
Aetna Earnings Wow Wall Street
The giant health insurer on Thursday posted second-quarter results that beat Wall Street estimates and raised its guidance for the current year to boot. Moreover, the company enjoyed improvement in two key areas -- customer enrollment and medical costs -- that have caused problems recently for rivals UnitedHealth.
. . .During the latest quarter, Aetna managed to grow its health insurance base -- which now totals 15.8 million customers -- even as some competitors lost ground in a tough industry environment. Perhaps more importantly, Aetna kept its medical costs under control as well.
Aetna's commercial medical cost ratio -- a closely watched metric in the industry -- dropped to 80.5% from 81.1% a year ago, falling in the low end of the company's guidance range.
http://www.thestreet.com/...
Do y'all understand how the game is played?
Healthy Customer enrollment: taking our money-- all those dutifully paid premiums.
Controlling costs: denying us care--not paying for things like jancw's CA 125 test.
Damn, am I crazy, or does this sound like a racket crime?
Take a look at Wellpoint.
UPDATE: WellPoint 2Q Net Up 11%, Raises Fiscal Year EPS Guidance
WellPoint Inc.'s (WLP) second-quarter profit rose 11%, but the company continued to report an increase in the ever-important benefit expense ratio.
The benefit expense ratio, a measure of medical costs as a percentage of premium revenue, rose to 81.8% this quarter from 81.2% a year ago. In the first quarter, the ratio was 83.1%. The company's ratio has been higher in recent quarters, in part because of a shift to more government business. During the most recent quarter, the increase from the year-ago period was due to the company's specialty, senior and state sponsored business segment.
http://money.cnn.com/...
Now, God help you if you happen to have insurance through Wellpoint because you'll note that their loss ratio inched up.
In order for Wellpoint to be fully graced by its Wall Street masters, it will have to demonstrate that it is cracking the whip against its policy holders.
So, you can expect Wellpoint to go into battle mode. In the days ahead, denials like the one described by jancw, will flow fast and furious.
Let's end with one of my favorites UnitedHealth.
UnitedHealth posts 22% profit increase
Higher commercial medical-care ratio weighs on shares
UnitedHealth Group Inc. said Thursday second-quarter profit rose 22%, but shares of the health insurer sagged as medical costs in its commercial division came in higher than expected.
The Minnetonka, Minn.-based company subsequently increased its forecast for commercial medical costs as a percentage of premium revenue, also know as the medical-care ratio, for the full-year period.
This doesn't bode well for managed-care insurers overall, according to one analyst.
http://www.marketwatch.com/...
So what does all this mean for us?
Imagine for a moment that you're a senior executive with UnitedHealth and you're seeing these medical cost ratios creep up. This means you're not doing your job. Your job is to crack down on costs you and me.
You're scared, you're just waiting for the banker on Wall Street to call. So what does a thieving insurance executive to do?
Number one, you have a fiduciary responsibility to Wall Street. You must produce $$$$$$ for your investors.
So you will issue an edict. Word will come forth from the executive suite that costs our healthcare needs, must be curbed--by any means necessary. UnitedHealth has a long and vile history of using devious and illegal methods to avoid paying for health care and meeting its obligations to its policyholders.
Sadly I'll end by saying God help you if you are insured by UnitedHealth. There are some dark storm clouds on the horizon. They're going into battle mode, so should you.