Do health insurers use delaying tactics to save money?

Great Debates
#1

Let’s say you change from one health plan to another.

For years you’ve been on a certain med regimen. Nothing radical, nothing especially questionable: stuff that your doctor–more than one–has reviewed with you. You and hse agree that the stuff is working fine.

You change plans and the fun begins.

Half of the things you take are not in their “formulary.” And one that is, is only allowed at a much-reduced dosage.

OK, it makes some sense to have new eyes review one’s course of treatment now and then. If they wanna do that and THEN raise questions, fine.

But what kind of ethical or medical sense does it make to literally BLOCK the filling of one’s prescriptions from the get-go until you yourself, with many telephone calls and visits to your doctor (same doc, accepted by the new plan as well as the old) can get the approval to go through?–in my case a 2-week process during which I was stuck without my meds (unless I wanted to cough up a few hundred bucks to pay out-of-pocket).

I said “ethics”… Isn’t it ethically requisite to “grandfather-in” an ongoing course of treatment WHILE the company reviews the situation? In other words, shouldn’t the onus fall on the insurers?

Which brings me to this:

In the old days, before passage of a federal law on the subject, the banking industry typically required a span of several days–even a week to ten days in some cases–before deposits of verious sizes were allowed to be credited to one’s account. They swore it was because of certain bookkeeping processes and practices. The law was passed; gee, the problems weren’t much of a problem after all. And we customers were free to nod our heads and realize that the banks were making a little money off allowing deposits to “float” for a while, thereby collecting the interest.

Is this really what the unsurers (!) are doing here? Are they letting their insureds “float” for a week or two, in order to postpone having to shell out money for expensive meds? Not for any justifiable medical reason, but mainly to slip in what amounts to a hidden fee, which they need not highlight in their literature?

I’d love to hear from people who actually make policy in the industry on this one. (But all you Dopers are welcome, of course!)

#2

Insurance companies? Ethical?

#3

Let me give you an anecdote from personal experience.

Many Doctors offices run at a deficit from November through Jan1.

Why? Because HMO’s simply don’t pay during that fiscal quarter. No matter how many times the paper work is submitted or resubmitted they simply do not pay. Going to court to get moneys owed would take longer than the period of time, so that’s not an option.

Why do this? By not paying, they are able to show a larger profit on the balance sheet for investors at the end of the year.

This means, for many doctors, they must float their entire operation, payroll, taxes, physical overhead, everything for months without a large percentage of their income. Further, HMO’s reserve the right to approve a procedure and then come back later and disapprove it. After the fact and after the services have been rendered. And demand the Doctors repay them.

You get one guess as to who gets to eat the cost of this.

It’s no wonder that doctors have gone on strike and are trying to form their own HMO type organizations. It’s beyond being a mess.

Regards,
-Bouncer-

#4

It’s also no wonder that public opinion is swinging in favor of a government-admistered health insurance system:

Poll: Public Supports Health Care for All

The time has come.

#5

BOUNCER:

“…It’s no wonder that doctors …are trying to form their own HMO type organizations.”

How’s the effort going? And what will they do differently?

FEAR ITSELF:

Sounds good to me…but of course the objection is, this is just replacing a big self-interested bureaucracy with a bigger and even more self-interested bureaucracy. How will a single-payer government-run system put the public first?

I note in passing that we have Medicare; but in California docs are not required to accept Medicare-disabled patients, so it can be quite a task to find a doctor…and you definitely get treated as a second-class citizen. In other words, a seller’s market.

#6

To address the OP subject line, rather than the specific example: yes, I’m sure they do. It took them over two years to pay several of my claims. They kept rejecting them saying that the treatment was not authorized by my primary care physician. The treatment was by my primary care physician.

As a Brit in the US, my appreciation for the National Health Service has grown immeasurably since having to suffer under the alternative.

#7

In the case of the OP (delaying payments/agreements in order to keep the money a little longer), because it will be intended to provide healthcare to the public, not intended to turn a profit for the insurance company.

Beside, I don’t know how it works in other countries with a public healthcare system, the “government-run” system (which actually isn’t run directly by the government but by an organization representing the employers and the workers) doesn’t second-guess the doctor’s prescriptions (like in your reduced dosage example) nor give you complex formularies to fill out before being reimbursed for your expenses.

#8

In the case of the OP (delaying payments/agreements in order to keep the money a little longer), because it will be intended to provide healthcare to the public, not intended to turn a profit for the insurance company.

Beside, I don’t know how it works in other countries with a public healthcare system, the “government-run” system (which actually isn’t run directly by the government but by an organization representing the employers and the workers) doesn’t second-guess the doctor’s prescriptions (like in your reduced dosage example) nor give you complex formularies to fill out before being reimbursed for your expenses.

#9

In the case of the OP (delaying payments/agreements in order to keep the money a little longer), because it will be intended to provide healthcare to the public, not intended to turn a profit for the insurance company.

Beside, I don’t know how it works in other countries with a public healthcare system, the “government-run” system (which actually isn’t run directly by the government but by an organization representing the employers and the workers) doesn’t second-guess the doctor’s prescriptions (like in your reduced dosage example) nor give you complex formularies to fill out before being reimbursed for your expenses.

#10

Okay, get it now? Don’t make clairobscur have to come back and explain it again.

#11

Scott,

Some insurance companies do delay their payments to doctors, hospitals, etc. The company that employed me out of college had Sagamore as the insurance co. and they would take several months to finally pay my doctors. They then switched to CIGNA and I was amazed at how quickly they payed up, usually within the month.

But what happened with your prescriptions may not be a delaying tactic, but more of a nudge to get you to take cheaper meds.

I recently switched employers. My wife takes several prescription meds. The ins. co. won’t cover some of her meds that were approved by the last co., instead trying to steer her to the “recommended prescriptions”. They also limited the dosage on a few others. From what I can conclude, they have deals with some of the drug companies to discount the price of the drugs, thus the discounted drugs are what constitutes the recommended list. This is ok, if you can find what you need under the recommended list (ie, they wouldn’t cover Prevacid, but Nexium is approved), but if you need something not on their list, you gotta go through the whole shpeel of getting your doctor to send them a letter saying that you need it, blah, blah, blah, and even then they may not cover it.

They also offer cheaper copays for generics, and recently, they’ve been sending me brochures and coupons for Prilosec OTC.

So if your drug company is anything like mine, they are just trying to save money by trying to get you to take certain drugs. I doubt delaying payments for prescriptions your refill periodically will work for them in the long term since they will eventually have to start reimbursing you periodically.

#12

Scott,

Some insurance companies do delay their payments to doctors, hospitals, etc. The company that employed me out of college had Sagamore as the insurance co. and they would take several months to finally pay my doctors. They then switched to CIGNA and I was amazed at how quickly they payed up, usually within the month.

But what happened with your prescriptions may not be a delaying tactic, but more of a nudge to get you to take cheaper meds.

I recently switched employers. My wife takes several prescription meds. The ins. co. won’t cover some of her meds that were approved by the last co., instead trying to steer her to the “recommended prescriptions”. They also limited the dosage on a few others. From what I can conclude, they have deals with some of the drug companies to discount the price of the drugs, thus the discounted drugs are what constitutes the recommended list. This is ok, if you can find what you need under the recommended list (ie, they wouldn’t cover Prevacid, but Nexium is approved), but if you need something not on their list, you gotta go through the whole shpeel of getting your doctor to send them a letter saying that you need it, blah, blah, blah, and even then they may not cover it.

They also offer cheaper copays for generics, and recently, they’ve been sending me brochures and coupons for Prilosec OTC.

So if your ins. co. is anything like mine, they are just trying to save money by trying to get you to take certain drugs. I doubt delaying payments for prescriptions your refill periodically will work for them in the long term since they will eventually have to start reimbursing you periodically.

#13

(Is there an echo in here here here?)

I invite ultra-capitalist free-marketeer Dopers to respond to my example, and explain how delays and hidden fees are really the hidden hand at work making lemonade from lemons.

Even without all-out universal health insurance, couldn’t we make payment delays and ruptures in continuity of care unlawful?

#14

I don’t think that anyone, no matter how free-market, would try to make that claim. A more likely response would be that insurance companies that have to rely upon delays and hidden fees to be profitable will eventually be driven out of business by their competition.

#15

My anecdote:

My husband went to the doctor. He and I share this doctor. We got the bill 90 days later with nothing taken off for insurance. I call the doctor to ask if there was a problem with the insurance and they say they never heard back from the insurance company.

I call the insurance company. They ask my name. I tell them. They ask my policy number. I tell them. They ask what the problem is. I tell them that I want to check on the status of a claim, give the date and the doctor’s name. The woman tells me that she cannot tell me about the status of the claim because it was a visit by my husband and the new privacy laws don’t allow me to check on the claim.

I get a coworker to call in, posing as my husband. He gives all the info and then the woman tells him that they have no such claim on record and that we’d have to have the doctor resubmit.

Now, how did the first woman know that I was inquiring into a claim on my husband if they have no such claim on record and I didn’t say who the patient was?

Funny note: I told my coworker every bit of information I could think of, with one exception. I forgot to tell him my husband’s birthdate. Eric came bursting into my office crying, “When’s my birthdate? When’s my birthdate?”

When I went home, I told my husband, “Well, the insurance company lied to me. Oh, and they think you’re really stupid.”

Julie

#16

Okay, people who work for Kaiser, HealthNet, Blue Shield, Blue Cross, etc…

I’m challenging you to respond.

How do you live with yourself?