Health Insurance Claims — Kickin’ It Old School

27 Mar

So, back in the day, billing insurance was fairly easy. Here’s how it worked. You (or your offspring, as below) went to your family doctor. Family doctor saw you. After seeing you, the doctor would write something incomprehensible in your chart, which he gave to the “girl” up front. The “girl” would then check off your diagnosis and what doc did on a piece of paper. Usually you got the carbon copy, and the doc’s office kept the original. This paper was called a “superbill”. I don’t know why.

The Doctor's Visit We All Remember, Right?

The original of this superbill was then sent to your insurance company. Large insurance companies would receive envelopes full of superbills, which would be sent on to claims examiners to work.

Back in the day, when I first started working in insurance, people still smoked at work. Even in the back offices of some doctors’ offices, believe it or not! We’d get superbills from doctor’s offices, and when you would open the envelope, a waft of stale smoke smell would come out. Sometimes the superbills had bits of lunch, or coffee cup rings on them. This could make processing difficult if someone’s tuna on rye was obscuring a piece of important information.

Superbill -- lots of little boxes, low-tech, easy to use.



Needless to say, this was time-consuming and the information on the claim wasn’t very detailed. And so changes came across the land, and there was much wailing and gnashing of teeth.


Hidden Costs of Healthcare — Who Pays the $363 Billion?

23 Mar

Today’s CNN Money included a story about hidden healthcare costs that aren’t covered by insurance, now or under the new legislation. The estimated costs are staggering — $363 billion dollars annually, according to the research group that performed the study. Examples of the kinds of healthcare services not included in the estimated costs include:

…ambulance services, alternative medicines, nutritional products and vitamins, weight-loss centers and supervisory care of elderly family members.

If we forgot about ambulances, someone wasn’t paying attention when adding up the numbers. I certainly don’t want to transport grandpa mid-heart-attack to the ER in the back of the station wagon. Ditto with supervisory care of elderly family members — we don’t need to warehouse grandma in an expensive facility just because she needs help cooking and remembering to take her medications. Supervisory care in the home (for as long as home is safe,) would be far less expensive and far better for grandma’s mental and physical health.

Some of these things aren’t paid for now under most health plans, which is ridiculous. Excess weight has been linked to numerous, serious, health problems, and it’s not always as simple as “eat less and exercise more”.  Not when researchers find out every day that something else causes weight gain (example — those antihistamines you’re taking for hay fever might be part of the reason for your weight problem.) But insurers will not pay for treating overweight or obesity as a medical problem, until it becomes a major, life-threatening problem, and a patient is a candidate for surgery. Which is rather like closing the barn door after the horse has run away, a fox has come in and sucked all the eggs and eaten the chickens, and that weird boy Seth from the next farm over set your place on fire and raped your wife.

I’m lukewarm on the use of vitamins outside of a) pre-natal vitamins, or b) obvious and medically-determined actual deficiencies (which are fairly rare in the US). Much has been written about the spotty quality and oversight of many companies, so I won’t add my pixels to that. But let’s say, I’m all for buying your own Flinstones’ vitamins. Or just eating a decent diet.

As for alternative medicine, I’m all for it, if it’s been proven via scientific studies and standardized testing to be demonstrated effective and safe.  As they say, “You know what they call alternative medicine that’s been proven to work? Medicine.” Medicine is good. But I do not want my tax dollar paying for, or my doctor prescribing, some woo-ful nonsense like Reiki or acupuncture or crystal healing or sprinkling fairy dust on the owie — these have more to do with faith healing than medicine. And keep your hands of my chakras.

But, yeah. Someone missed over $300 BILLION dollars in expenses. That’s a big whoopsie. We need to know how that was missed…and if so, what the hell else was missed. And we also need to demand that our tax dollars are used only to pay for real medicine. Ya gotta buy your own fairy dust, my friends.



Health Care Spending Accounts – No More Claritin or Tums

23 Mar

Note: This is a guest entry written by Dr. Z., a practicing physician, medical educator, and curmudgeon.

Via John Lott’s site, I see other people noticing a problem with health care spending accounts (HCSAs).  Lott links to this Wall Street Journal article regarding the problems people have with HCSAs.

I have a health care spending account. I love it. Every year, in November, I sit down and figure out how much money I will need to pay for prescriptions, co-pays, eyeglasses, and the like. I then put that amount of money into my health care spending account, and in return I get a nifty little debit card that I use to pay for the covered items. Stuff goes into the HCSA before taxes, so I get forced savings and a little tax break.

For some reason, people don’t like health care spending accounts. Mainly, I believe, because it saves the average person some money, and keeps money out of the hands of the government. One of the provisions in the health care bill is HCSA money can only be used for prescription items. Over-the-counter stuff, which used to be covered, is not.

So, people are going to the doctor to get prescriptions to use their health care spending account money. Of course, this leads to expenses with the pharmacies, and the extra paperwork. It leads to extra co-pays. Some doctors are worried about being sued for prescribing OTC meds, if something goes wrong. Personally, I think I should start a service where I write scripts for all these OTC things. I’d be happy to, it could be a real moneymaker–even at $10.00/script. The documentation would be a killer, though. That’s where all the money would go, into keeping the charts. You can’t just write a prescription, you have to write scripts only on people on whom you keep medical records. I need to think about it.

Child Dies From Abscessed Tooth

18 Mar

Note: This story is from 2007, and copied from my previous blog, but it’s worth repeating. We should never forget the consequences of a two-tier insurance system: some people get treatment for a hangnail while others watch their child die of untreated toothache.

How can anyone say that we have no need for universal health coverage when children die or become ill from abscessed teeth?

Twelve-year-old Deamonte Driver died of a toothache Sunday.

A routine, $80 tooth extraction might have saved him.

If his mother had been insured.

If his family had not lost its Medicaid.

If Medicaid dentists weren’t so hard to find.

If his mother hadn’t been focused on getting a dentist for his brother, who had six rotted teeth.

By the time Deamonte’s own aching tooth got any attention, the bacteria from the abscess had spread to his brain, doctors said. After two operations and more than six weeks of hospital care, the Prince George’s County boy died.

Deamonte’s death and the ultimate cost of his care…. could total more than $250,000….

from The Washington Post; full story at link.

As a country, we should be ashamed that even one person dies from a treatable bacterial infection. As a country, we should be on our knees begging forgiveness that a child died of a bacterial infection caused by an abscessed tooth.

That child could be yours or mine; that parent could be you or me. It takes so little to be kicked out of the privileged land of the insured and into the ranks of the serfs who have to wait for their handout from the feudal lord. One job loss. One extended illness. One financial hardship.

Deamonte Driver could be any of us, or any of ours.

Think really hard about this when you go to the polls.

Medical Costs Fall, But No Benefits to You or Me

18 Mar

CNN Money reported this week that for the first time a decade, medical costs actually fell, meaning that payouts from insurance companies should drop.

You’d think this would mean some relief from steadily rising health insurance premiums, wouldn’t you?


According to another CNN article, Blue Shield of California was planning to increase premium payments as much as 59% for nearly 200,000 policyholders. The company had already raised premiums twice since October.

Officials claim it’s because of increasing health care and medical costs. Do you believe it? I don’t, given the amazing lengths the Blues (locally and nationally) — and most other insurance companies — will go to to avoid paying claims – prepayment review, additional development requests, denial on a technicality (I’ve literally seen a claim denied because a diagnosis code was missing a fifth digit), and, when they get too expensive, dropping members entirely.

CNN’s article stated, “Blue Shield said higher medical costs, greater use of medical care and a growing trend of healthier people dropping coverage during a bad economy, were the reasons for seeking the increases.”   The article also stated, “… the decision to not raise members’ premiums this year will cost Blue Shield $35 million to $40 million in lost revenue.”

Of course, the CEO makes it sound like he’s doing the policyholders a favor: “By agreeing not to raise rates this year, we are helping to make coverage more affordable for our members during tough economic times,” said Blue Shield of California CEO Bruce Bodaken, in a statement. “It’s a financial risk for us, but a risk that’s worth taking.”

Mmmm-hmmmm. California Blue Shield makes $10 BILLION dollars profit overall per year. They spend millions of dollars on lobbyists and advertising to kill real healthcare reform, they can afford advertising to bring in more members; they can pay gigantic bonus and severance packages to executives. How much risk are they really taking with this “lost revenue”? What will they have to give up? The gold-plated faucets in the executive washroom? The elephant cutlets doused in leechee-and-diamond-dust-sorbet at the CEO’s annual board luncheon? A few private jets?

Looking into California Blue Shield a little further, I found that it was impossible to determine how much of the annual profit is eaten up by CEO Bruce Bodaken’s salary, because he won’t allow it to be released. What are you hiding, Brucie? Afraid your salary is not appropriate for a non-profit entity such as Blue Shield?

Ironically, Mr. Bodaken is a member of the New America Foundation’s Health CEOs for Health Reform. He proposed a “shared responsibility” policy. Of course he did; that will keep the customers just where he and others of his ilk want them: in his hand, where he can squeeze more money out of them.

Don’t believe the insurers; they do not have your interests at heart. They do not care about your health. They really only want your money. Wellpoint CEO Angela Braley (2009 compensation of $9,844,21, with a pay increase of 51% last year) bluntly said, at a business meeting, “We will not sacrifice profitability for membership.”

Of course they won’t.

Hello and Welcome

12 Mar

Welcome to my blog, HealthCare Mafia, which I’m writing under the nom de guerre OleanderTea.  I’ve spent nearly twenty years working in health insurance, mostly as an analyst of varying stripes.  I know the tricks, the doublespeak, where the money is really spent,  how it’s “saved”, and where the bodies are buried.

After the past several years of listening to the healthcare debate and all its attendant lies, prevarications, exaggerations, and hyperbole, I’ve decided to start throwing in my two cents’ worth as an insider, in case someone out there might be interested.

The blog’s name is based on a comment a colleague made one day. He said he sometimes feels like he works for the mafia — much like the mafia,  insurance companies offer someone a deal they’re ostensibly free to refuse. Except they aren’t, because the alternative is much worse than the “deal” you’re being given.  Actually, if you think about it, comparing the mafia to health insurance companies might be insulting to the mafia. My apologies. At least with the mafia, you know you’re paying extremely high rates and who’s getting the money.