Further Evidence of CIGNA's Denial of Claims Based on Profits and not Medical Evidence

From the Center for American Progress is this posting by Scot J. Paltrow, "Insurers’ Black Box, Now-Secret Claims Denial Rates Could Tell Consumers a Lot About Their Insurance Company."

Because of the nature of the pending legislation, especially the Baucus Bill, which is an outright gift to the insurance companies, we consumers would have the ability to go "shopping" for health insurance.  But it's hard to buy a good product when there is a fundamental lack of information about the product you are buying and the behavior of the company you are buying into.

(It's also hard to buy a decent product when your choices are limited thanks to a legal monopoly, which will, hopefully, being going away.  And I would ask Mr. Mackey of Whole Foods to read Mr. Paltrow's well-researched posting regarding insurance and consumer choices after his Murdoch-owned WSJ opinion piece full of hot air.)

Explained is how insurance companies hold on tightly to information that would be beneficial to the consumer, such as the rate at which they deny claims, which is pretty much a key piece of information needed when assessing an insurance product.  Emphasis is mine.

But health insurance companies don’t disclose the percentage of claims they reject and decline to pay. And inquiries by the Center for American Progress show that the nation’s insurance regulators have not asked them to do so.

Remember, insurance is regulated by each individual state. And this, along with McCarran Ferguson (which may be going away sooner than later) is why insurance companies can operate under a veil of secrecy.  The states need help in regulating the "business of insurance."  Even the NAIC has said so. "The NAIC recognizes that the nation’s health care crisis is beyond the capacity of the states to solve independent of federal reforms."

As for the insurance companies releasing claims data themselves?

CAP also asked each of the nation’s seven largest for-profit health insurers—Aetna, Anthem Blue Cross Blue Shield, Cigna, Coventry, Health Net, Humana, and UnitedHealth care—if for the purposes of this report they would disclose their overall rates of claims denials and breakdowns by reason for the denials. All of the companies declined or did not give any direct response to the request. Spokesmen for the companies in general said that the insurers pay the vast majority of claims, and that denials are fair, with most occurring for routine reasons such as a patient erroneously submitting the same claim twice or a physician sending a claim to the wrong company.

Declinced or no response and said "that denials are fair."  I have an aresenal of proof against that statement.

Only one state, California, has required the insurance companies doing business here, to release their claims data. The data released in California shows that 30% of all claims filed within the first 6 months of 2009 were denied and that Gasp! insurers may be going beyond "reasonable standards" and "may be improperly using claims to boost profits."

Anyway, what is most bothersome is who is making the decisions to deny claims.  Doctors?  You know, the men and women who actually went to Medical School?

The most sensitive and potentially controversial claims are those based on medical criteria—such as whether a treatment is medically necessary or should not be covered because it is deemed experimental. CAP learned in interviews with former senior medical personnel at several of the largest insurers that big insurers—including Aetna, Cigna, and UnitedHealth care—made internal changes in recent years that gave business executives more direct authority over the companies’ doctors who evaluate claims based on these medical criteria.

Insurance companies had previously maintained a separation between the medical evaluation staff and the executives responsible for financial performance. The doctors and nurses reported to the companies’ chief doctor—known as the chief medical officer—who had final say on whether coverage for a particular individual’s treatment should be granted or denied based on medical criteria. But beginning about a decade ago, in a shakeup that evidently received no public attention, companies changed their policies so that the medical staff reported to regional business executives. These executives were given the authority to determine the doctors’ pay, bonuses, and promotion, and consequently they gained the power to influence the doctors’ decisions. The new systems generally kept “dotted line” reporting to the chief medical office, who would still weigh in on the most difficult claims decisions.

Former Cigna Executive Wendell Potter said that having medical directors report to business managers “means they are part of a team that is very much involved in making sure that the company is profitable at all levels.”

I would say to all the doctors who bought into the Faustain deal (stock options, big offices, 2 martini lunches and no patients to see, what?) of working for an insurance company, "Get out now, while you still have an inkling of what your Hippocratic Oath was for."

When we reach this point in our health care, we no longer have any control over our health.  None. Your own doctors don't have control either.  The only ones calling the shots are the corporate grunts trying to keep their jobs by denying you medical care.

For example, from the posting:

Insurers say that they base decisions to turn down claims only on objective, clear-cut standards, but individual stories highlight that companies at times can take wide latitude in applying them. For example, records from a federal lawsuit in North Carolina show that Cigna of North Carolina refused to pay for specialized treatment for a baby born with a severely deformed skull. The baby’s doctors wanted to use an orthotic device to help mold her head into a more normal shape as she grew. The doctors said that without the treatment more medical problems could ensue, such as a worsening malformation of her jaw. Cigna declined to pay on the ground that such treatment was a “cosmetic procedure.” A 2002 federal appeals court decision noted that Cigna never provided any definition of “cosmetic procedure” in its policy and ordered the company to pay.

What further proof do we need that we are at a tipping point in our society?  We need a National Plan like every other civil and industrialized nation in the world.