With the murder of the UnitedHealthcare CEO, many have expressed vitriol towards the insurance industry.
Having worked in non-profit health care all my life, I decided in 2018 to switch to the “dark side,” or the insurance industry, out of curiosity. What is it that they do, and how are they doing it? I thought knowing would make me a better health care worker when I returned.
As a registered nurse case manager, I was in the room where it happened: approvals, denials, and decisions. These were rational and straightforward. Clinical guidelines were followed, and medical reviews were completed by MDs. I worked for a Blue Cross Blue Shield plan. Nothing was ever done out of malice or profit. It was an honorable process.
I learned that employers and other entities choose benefit options like an à la carte buffet. This means that what the employer selects must be carefully weighed against what the patient wants. A member was irate that we wouldn’t pay for a service dog. It’s a wonderful idea, but I couldn’t approve it because the employer had not chosen that as a covered benefit.
Nevertheless, I came to realize that the system is full of hidden traps and unexpected costs, and it’s hard for people to differentiate between the insurer and the system’s broken rules. We need to rescue people from the quicksand of surprise bills and many other things, but that’s going to take a lot of work from regulators, legislators, and insurers.
Not only am I an insider, but I am a heavy user of health insurance. An out-of-network provider of mine raised his rates 83 percent to $550 per visit. I submitted the bill, insurance balked, demanded medical records, and took up to six months to reimburse me. I decided to switch to an in-network provider rather than be hassled further. That said, I will miss my doctor of 10 years. No one is looking out for the consumer.
The huge bill from an out-of-network provider is a great example of the traps that lie in wait for patients. There are many others, ranging from shocking ambulance bills to the $1,600 that traditional Medicare patients must pay for a hospital stay. It feels like an organized crime shakedown when you’re on the receiving end.
Medical problems are cited by two-thirds of bankruptcy petitioners as a major factor in their financial collapse. Although filing for bankruptcy has long been prompted by the high cost of care, research indicates that the Affordable Care Act has not fixed the problem. Most consumers are unaware that their health insurance can be insufficient to protect them.
Helen Hunt, in the 1997 movie As Good As It Gets, rages against her HMO when it won’t cover her asthmatic son’s treatment. Her magnificent meltdown made audiences cheer in the theater. But while the scene had elements of truth to it, it was way overdone. Many insurers run excellent preventive programs for patients with asthma. They have a big incentive to keep members well and out of the hospital.
The reality is our system can’t afford all the care that people want. The insurer is the gatekeeper whose task is to say no. It’s the reality check that’s sure to get a lot of flak.
I suspect that AI systems have contributed to the backlash against insurers. Call any business, and there is an automated menu to wade through. Insurers and large pharmacies make it particularly hard to reach a human being. I started refilling my daughter’s prescription at 8:30 a.m. and didn’t complete it until two hours later. When the pharmacy started refilling the prescription, the copay card had a problem. Eventually, it was fixed, and the prescription refilled. But this took eight phone calls. Even I felt my tone rising.
What consumers need is a sherpa to guide them through the Himalayas of health care. Some employers buy these advisory services for their staff, so ask about it. Lacking that, you must be your own best advocate. Rather than blaming the insurance industry, we need to be proactive in working with them. Keep your receipts. Take notes of every interaction. Always be polite as well as professional and concise in your communications. Tell them what you would like them to do.
And escalate the problem to the next level if needed. If all efforts fail, call your local senator or reach out to the state insurance commissioner because they regulate insurers. State Health Insurance Assistance Programs (SHIP) can also be helpful for complaints.
Remember, the people who answer the phone are insured like you are and may even have the same benefits. They’re the bouncers we’ve created to keep the billing process honest.
Lynne Moronski is a post-doctoral research fellow.
