'Fraud! It’s everywhere! Patients. Doctors. Lawyers'

A system that makes it hard on people who want to do the right thing

Fri, 03/29/2013 - 11:30am

This is the second in a series, and as I mentioned before all of this is recent, all of it is local, and none of this is likely to sound unfamiliar. Again, I hope this makes people good and mad. I don’t have any answers.

Previously: Erica on the working poor and Sidney on getting stonewalled:
A system that makes it hard on people who want to do the right thing

“Lee” is a college varsity athlete. One benefit of being a varsity athlete at her school is that she is guaranteed full health coverage as a team member. She also has not one but two insurance policies — one with her family, as a dependent student, and one purchased for a very reasonable rate through the college. Having two insurance companies brings about headaches of its own. Lee was injured several times last season playing rugby. She also has had a couple of common, nonsports-related health care needs. She lives a low-risk lifestyle in terms of general health, not smoking, using no recreational drugs, staying physically fit — but sometimes things happen that require a doctor no matter how much oatmeal one eats. (Here’s a myth: “I’m a young, low-risk person, so I don’t need health insurance.” Don’t believe it. Stuff happens.)

Anyway, the past few months have been quite a runaround for Lee, with many, many calls and faxes and emails. Medical bills from all sorts of different offices and providers keep arriving in the mail; she calls back faithfully, provides information for the umpteenth time, and is regularly told on the phone that it’s “being taken care of.” Yet the bills keep coming.

To her credit, as a 20-year old, Lee doesn’t whine that, “I don’t know how to handle this” and leave it for a parent to do—or leave it undone. She has tried and tried to answer every question and get every bill sent to the right place. She is well-insured, but it seems as though both companies are waiting for the other one to pay — and meanwhile, nobody pays — and the patient appears as a delinquent account through no fault of her own.

Despite her school’s policy of full coverage plus two paid-for policies, Lee reports that it takes a long time and a lot of work to get the medical bills to stop coming to her address. We’re not even talking about bills for strange, hard-to-explain things; these are all easily verifiable, well-documented sports injuries and ordinary, common health care requirements. Which company was the primary and which was the supplemental? Both point at the other. With a number of separate sports injuries, some occurring many months ago, it’s hard to keep track of which visit to which provider was for which incident, and the requests for more documentation keep coming. Who has time for this? As a full-time student and athlete with a job, spare time during business hours is pretty scarce. She has spent hours on the phone, faxed back heaps of forms, explained again and again. She is concerned that the physicians, physical therapists and other care providers she’s seen and may wish to see again will remember her as a deadbeat. She really doesn’t want that.



I figured it was only fair to check in with an insurance industry professional, since I do happen to know a couple. I asked “Margaret” whether she’s experienced a significant hurdle, has a constant complaint, or struggles with a major road block from the “other side” of the insurance company desk. Her response was immediate and, if I might add, particularly animated: “Fraud!”

“It’s everywhere! Patients. Doctors. Lawyers. People who truly don’t think they’re doing any harm to anybody. People who know full well that they are uninsurable but who come up with angles to game the system. Clerical confusion in hospitals not attributable to anybody in particular. Obstetrical packs billed to male patients. $4,000 doses of prednisone, which is a cheap drug. Three-figure aspirin. $30,000 foot surgery done on an outpatient. Back in the days before electronic billing it was people stealing letterhead and submitting bills. Practitioners unnecessarily seeing patients twice in the same day just to bill the insurance. You just would not believe how much fraud there is!”

Margaret is an LPN, a trained nurse who once worked in a large Maine hospital. She was initially hired as a health care professional to detect fraud for the first insurance company she worked for, to read through bills and find when some oh-so-expensive problem was really just the Latin word for hangnail.

“That happens all the time, and of course it drives everybody’s costs up.”

She describes how people often think that “getting money out of the insurance company” means getting money from some mysterious pot of gold somewhere, that it impacts nobody. People sometimes sue doctors not because the doctor knowingly did something provably wrong, but just because they assume the insurance company will pay. Margaret also explained about how insurers have legal caps on their profits, that most people’s retirement investments have at least some stake in the large, publicly-held insurance companies, and that “although there are bad insurance companies, they aren’t all out to deliberately cheat the customer.”

“I work for a company that wants to see claims paid when they should be paid.”

“Sometimes people will apply for insurance and never disclose the fact that they’ve just had an MRI, or just seen a neurologist, sought treatment for a known illness — they never tell us this. Then later, they file a claim (as though they just suddenly turned up ill.) Somehow it’s supposed to be okay that those things aren’t disclosed? They’re signing a legal contract stating that they’re telling us what they know about their health. Going to a neurologist isn’t like going to your primary care provider with some vague symptoms. It’s a whole different thing when they clearly know they have something serious going on and they don’t disclose it.”

I know; that’s a tough one. We cannot pay for expensive and necessary health care without insurance, so we might do what we feel we must in order to get it, including be a little sketchy with the whole truth. Still, insurance is a business, and there is no such thing as a free lunch.

In addition to the fraud issue, Margaret describes all the health care finance troubles as intertwined.

“We’ll never reform health care until we find a way to control the costs. We’ll never control the costs while providers work constantly to find ways to maximize their reimbursement. Physicians have billing specialists in their offices whose one job is to look for ways to maximize their insurance reimbursement. They feel they have to, because a lot of what they do is not reimbursed, and they also have the burden of the malpractice, which is like an albatross. The system is in a spiral that will not allow the costs to be reduced.”


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