Who Decides Healthcare in the US?

Posted on August 12, 2009 by Greenberg & Bederman

 

In the current health care debate, we hear many of the naysayers use the argument that they don’t want “some faceless bureaucrat in Washington making decisions about our healthcare.” We find that argument strange, mainly because as things stand right now, decisions about your healthcare are made by a faceless insurance adjuster. The decisions aren’t based whether or not the treatment is what’s best for the patient, but rather on whether or not the insurance company is willing to pay for them. We have noticed that many of the scare tactics used by opponents of health care are simply recitations of the status quo. They aren’t creating the imagery of some Orwellian nightmare as much as they are simply shining a spotlight on how things currently are.

As an example, consider the case of James D, who suffered a broken leg.  At the time of his injury, he was an editor at the Washington bureau of a well regarded science magazine.  His employee health insurance was covered by United Health Care, which is one of the largest private medical insurers in the United States.

What was thought to be a straightforward injury claim turned into an 18 month odyssey in which James was facing $30,000 worth of denied medical bills.  Anyone who believes that health care coverage in this country does not need reforming should probably hear his story.

GB: Tell us about the circumstances of your injury.

JD: I slipped and fell and broke my leg in three places. That was all there was to it. This was during the winter, and it was snowing outside, and I thought I had salted the walkway to my house the night before as well as I could, but it seems that I missed a spot. That was the spot that I stepped on the next morning, of course. I stepped on some ice, and I fell, and there went my leg.

GB: That could have happened to anybody.

 

JD: Exactly. There was nobody at fault here. It was just a straightforward accident.

GB: What happened next?

JD: Well, I managed to get my cell phone out and called 911, and the ambulance came right away. It certainly felt like a long time before they got there, considering that my leg was broken and I was lying in the snow. But actually they got there within minutes. They got me squared away and put me on the stretcher and put me in the ambulance and away we went.

GB: So far so good.

JD: I have to say, honestly, that the medical treatment I got was outstanding. Everyone, from the EMT’s to the doctors to the nurses, they all handled my care about as well as it could have been handled. I was put in a cast and was in the hospital for a few days because it was a very severe break. I had a plaster cast on for about eight weeks, and then I moved on to a soft cast.

GB: When did things start to go bad with the insurance?

JD: Almost immediately. Have you ever seen that Michael Moore movie, Sicko?  You know that scene where the woman who got hit by a car had her ambulance ride denied because it wasn’t preapproved? That was exactly what happened to me.

GB: They refused to pay for the ambulance ride because you didn’t call ahead for it? How were you supposed to do that?

JD: Those are some pretty rigid expectations, aren’t they? As a science reporter, I have a solid understanding of gravity, and I can tell you that it took me approximately one quarter of a second for me to hit the ground after I slipped on that ice. Even if I had the best cellular coverage in the world and the fastest fingers of any man alive, one quarter of a second is not nearly enough time to call your insurer to make arrangements for an ambulance ride.

GB: Did you appeal that denial?

JD: Well, fortunately my employer has someone on staff that handles things like that all the time. According to her, the ambulance ride is something that is almost always denied by the insurers. To them it’s just a way of negotiating lower costs. They go over the claims with a fine tooth comb, and they look for anything that they can possibly get away with denying. So she appealed it very quickly, and United Health Care realized that the standard denials weren’t going to work here, so they eventually ended up paying for it. But that initial denial gave me an idea as to how things were going to go.

GB: So how did this end up turning into $30,000?

JD: Well, when I went in for a follow up some weeks later the doctors looked me over and recommended me for surgery. The break was very bad, and they decided that to keep me from walking with a bad limp for the rest of my life, they were going to have to operate and insert two steel rods. The doctors went ahead and informed the insurance company, and booked me for the surgery. The night before the procedure, United Health Care informed us that they decided that they weren’t going to pay for it.

GB: On what grounds?

JD: They were convinced that the surgery was voluntary and not medically necessary.

GB: Not walking with a limp for the rest of your life falls under the category of “not medically necessary?”

JD: I don’t think they really believe that. I think it’s more along the lines of anything that has a five figure price tag can fall under the category of “not medically necessary,” whether it is or not.

GB: Was the surgery delayed?

JD: Actually, it wasn’t. The surgeons got on the phone and argued quite fervently, which I am grateful for. It is my understanding that there are some medical professionals who are so worn out with wrestling insurance companies that they don’t even bother anymore. But these surgeons got what they thought was approval and went ahead with it.

GB: What do you mean by “what they thought was approval?”

JD: Well, it turned out to be a tentative approval. Once the surgery was completed United Health Care went over the claim with a fine tooth comb and decided that having two surgeons handling the procedure was one too many. They argued that the procedure could have been done by just one surgeon, so they were refusing to pay for the services of the second one. That was the major cost, as well as some other denials that our company representative referred to as “standard denials.”

GB: “Standard Denials?”

JD: Denials like the ambulance ride, which are apparently denied as a matter of routine. So what with the standard denials and the surgeon that they weren’t paying for, I started getting bills in the mail for $30,000.

GB: So what happened after that?

JD: That was when it started to get really ridiculous. For one thing, my employers acquired the services of an attorney, not to handle everything, but just to help advise them through the process. The first thing the attorney told me was to not pay them a dime, mainly because if I did that would be considered a willingness to accept their decision. So basically every week I would receive five or six bills for staggering amounts of money.

GB: What was the reaction of the insurance company?

JD: Well, one thing that they kept doing was switching adjusters on us. So every time that we tried to call or e-mail, we would get a new person who knew nothing about the case, so we would essentially have to start from scratch, because they would use the first reason for denial that was initially offered, and then they would have to “deliberate” again, and then they would use excuse number two, and then they would have to “deliberate,” and then excuse number three, and so on and so on, and then they would switch adjusters on us again, and then it was back to square one.

GB: How did you get past all of this?

JD: We actually didn’t. There was this one glorious moment where we were informed that United had finally given in and had decided to pay for everything, but three weeks later I was still getting bills for $30,000 in the mail. So we got back in touch with United and were informed that the adjuster who had made that decision to pay was mistaken, and that his decision was overruled. So we were back on the treadmill again. Then my employer decided to switch insurers.

GB: Did that affect your claim?

JD: I understand why they switched providers, considering how I was being treated. But this just served to make United Health Care even more unresponsive, because now they really had no incentive whatsoever to pay. They weren’t getting those monthly premiums from my employers anymore. There were a few instances where they basically said “You will have to sue us.”

GB: So how long were you fighting this?

JD: About eighteen months.

GB: How did it get resolved?

JD: Well, what happened was that we found out that some adjusters who worked our new provider had been indicted for fraud. Some of them were filing fake workers compensation claims and had been doing so for months, and from what we understood of it there was practically no oversight on the part of the health care provider, which made it very easy for the adjusters to keep this scam going. My employers decided that spoke volumes about the sort of care that they could expect, so they decided to go back to United Health Care.

GB: Why did they go back to United Health Care after the way that they treated you?

JD: Well, there really weren’t all that many other options. There isn’t a huge list of health insurance companies out there. But actually, returning to United Health Care was how my case got resolved. When my employers sat down to negotiate the new terms with United Health Care, they said that the only way they would give United their premium dollars was if they made my case go away. My employers have hundreds of workers, so United decided that the monthly premiums would be a fair trade towards paying the $30,000.

GB: Couldn’t they have come to that conclusion while you were being covered by United the first time around?

JD: I really have no idea what they were thinking.

GB: So in order to simply get your bills paid, your company had to essentially fire United Healthcare and then hire them back?

JD: That’s it in a nutshell.

GB: Have there been any negative after effects from all of this?

JD: Well, my leg is fine, but you have to remember that I was sitting on $30,000 worth of what was basically considered unpaid debt for eighteen months.  They tell you that medical debt is different from credit card debt or mortgage debt, but the banks certainly don’t see it that way.  The people who do credit ratings don’t see it that way. Loan officers don’t see it that way.  Debt is debt is debt. So things are slowly getting back to normal, but when your credit rating takes a hit life does not get easier for you. Another thing to consider is that I had people willing to work for me.  I had the weight of a company with tens of thousands of premium dollars a month behind me, I had someone at the company who made handling the appeals a full time job, and I had a company that was willing to hire an attorney to advise us on how to handle all of this.  The vast majority of people who deal with private health insurance don’t have any of those things going for them, and the insurance companies know this. So as a result you have things like “standard denials,” and the basic attitude of “So? Sue us,” rather than providing the health care coverage that is supposed to be provided.

Greenberg & Bederman is a personal injury lawfirm, located one half block from the Washington DC Metro Station in downtown Silver Spring, Maryland.  We offer free consultations.
Tags: , , , ,