Blue Cross pulls this shit all the time, usually when someone is about to undergo an expensive series of surgeries or therapies. The only difference is they usually have an internal investigator taking care of it, so this is pretty bold. I can't even believe this is still legal.

Hence, the police state...

These are the things that make me hate insurance companies. Not just health insurance, but all of them.

I'm a conservative at heart, but if Hillary or Barak will put Wellpoint out of business once and for all with socialized medicine then I'm all for it.

Disgusting. While fraud by patients is one thing, I think it pales in comparison to the fraud being perpetrated by health insurance companies. This is just going to get worse and worse until and unless government drops the hammer on them and nationalizes the healthcare industry. I'm now convinced that insurers are so corrupt that their industry is beyond redemption and should be outlawed and taken over by government. I don't condone lying on your insurance application, but what these guys are doing is fishing for some sort of technicality they can use to weasel out of paying claims they legitimately owe.

It's not the doctors' jobs to be acting as lawyers for the insurers. In fact, this tries to place them in direct opposition to the interests of their patients. Is it even legal for doctors to disclose private medical information to the insurers beyond what the insurers need to know to process claims? I would think it wouldn't be. Moreover, I can't see how it could possibly in the doctors' interest to cooperate. Cooperating would just increase the chances of insurers finding a reason to cancel coverage and stick doctors with unpaid medical bills. If I were a doc I wouldn't cooperate even if it was legal and even if I felt that application fraud was wrong.

@durkzilla: Unfortunately, neither of them want to do this. They instead want to create a sort of hybrid public/private system that works with the existing insurers. This may be the best chance to get at least some reform (I'm fully aware of the incredible lobbying power of the insurers). But I highly doubt it will solve the problems we're seeing with abusive insurers. The only thing that will work to do that is to get rid of the insurers' role in the healthcare system through nationalization of the industry. And I'm not holding my breath for that to happen.

The simple fact is that insurance does not do a good job of providing healthcare. Insurance works better for situations where you want to spread the risk of high-cost, low probability one-time events occurring. That's not what healthcare is.

@johnva:

Usually, if a patient wants an insurance company to pay a doctor, there's a waiver that the patient has to sign authorizing the doctor to share information with the insurance company, and I don't think it's very narrow. It's usually in that stack of papers that you sign when you first see a new Doctor.

uh, fuck you Blue Cross.

@BP2012: Police state? How so?

@JustAGuy2: OK. I can believe that. I still can't believe it's legal for them to just chat about your whole medical history with the insurance company. Fortunately I don't believe most doctors would ever want to disclose more information than necessary.

"WellPoint, which operates Blue Cross and Blue Shield plans, posted fourth-quarter net income of $859.1 million"

That's net income. Yah, they're reeeeaaallly hurting and need to hold down costs - gotta keep those shareholders happy (screw the patients!).

Not insinuating that gals can't be heartless but "Shannon" could be a dude, dude.

I hope the worst for these executives. Seriously, they just screw up people's live. They make so much cash and who cares if they have pre existing condition, where else are they going to go.

The insurnace company should think of themselves as god considering they can provide these people insurnace and that means they are able get care and live. They are saving lives.

When did it become so ethical that these companies see a live they can save but just say NO THANKS.

What if one day their wife or children are in an accident and you were walking by and could help them, would you say no? NO, you would probably help.

At this point I think more doctors would welcome national single payer coverage so they can quit wasting time and money playing games with insurance companies just to get paid.

Isn't this some sort of HIPPA violation?

A single-payor system would come with just as many hoops to jump through. Medicare, for example is pretty hard to keep up with.

I think the way to eliminate the abuse that insurance companies are currently engaged in is to re-vamp the laws that pertain to them. We need insurance, whetehr it's provided by the government or by private companies. But they have remained largely unregulated for too long.

@RandoX: For all insurance you ever get you sign a HIPPA disclosure authorization form which gives them full access to your medical records. This would clearly be allowed under your authorization. I have never seen a HIPPA disclosure with an expiration date which would mean it is available for use the entire time you have an active contract with the insurance company. When you leave or are canceled for insurance that would make the HIPPA disclosure void.

However since at that point everything they garnered from your medical records has already been added to the MIB (kid you not) insurance medical database it doesn't matter anyway as they have your records forever.

Actually, I think the HIPAA rules specify that communications with the insurance company (for billing purposes or something like that) are not covered by HIPAA. And with a net income of $895 million, they could successfully argue that this is for billing purposes.
cha-ching! Everything is coming up bluecross!

is his name seriously Dr. Frankestein?

There is no way that any doctor is going to do something that puts his getting paid in jeopardy. Did Well-point even consider this major snag in its plan?

"At this point I think more doctors would welcome national single payer coverage so they can quit wasting time and money playing games with insurance companies just to get paid."

That's exactly what single payer healthcare is meant to do, plus give coverage to those with 'pre-existing conditions', who, currently, have no options for insurance (we're not considering $2k/month premiums an 'option').

[www.ourfuture.org]

@RandoX: It's HIPAA and no it's not a violation.

You basically sign a document when you go in to a doctor's office to be seen that essentially says that they can discuss your condition(s) with your insurance company.

What's really sad is that otherwise honest people are forced to lie on insurance applications so they can get health care. That's an awful predicament.

Cooperating with this request is in direct conflict with the Hippocratic oath.

We've all come to hate insurance companies so much, that we're pissed off that they're trying to prevent insurance fraud? Are you the same people that bitch to State Farm that your brand new, original Rembrant was in the trunk of your car when it was stolen, too? What a bunch of bad, bad, bad consumers.

And thus WellPoint spokeswoman Shannon Troughton spoke the word "utilization" in a public statement, her shining hour, sinking back into the corporate soup and dooming herself to a career of mediocrity.

This is just the kind of thing that will usher in government managed care.

But not the HIPPAcratic oath.

"government managed care" ... talk about an oxymoron.

Dr. Frankenstien.

Can you imagine that coming over a hopital PA?

"Dr. Frankenstien to the morgue, please. Dr. Frankenstien to the morgue."

thank you Dr.Girlfriend, I wish more were of your wisdom.

Also: Dr. Frankenstein. That is awesome. Please tell me he does transplant surgery. Please.

Oh man, thankfully I saw SiCKO a little while ago! I bet that if one has a yeast infection, he/she will be denied insurance just because he/she had it!

Would you like to be the doctor that starts sending information out? Fastest way to end up on this site!

Are insurance companies expected to be responsible for KNOWN preexisting conditions? I am not talking about what is _right_ or _wrong_, just trying to find TRUE accountability.

"Enrolling an applicant who did not disclose their true condition (and the condition is chronic or acute), will quickly drive increased utilization of services, which drives up costs for all members,"

Actually that sounds very reasonable. You are required to disclose your medical history. This is akin the car insurance companies requiring you to disclose who else in your household has a driver license. This is how the insurance companies work. What's the big deal?

Well at least they haven't adopted the policy our former group health plan had. Everything for the first six months is considered pre-existing until you prove it otherwise. I made a part time job out of dealing with these clowns just to get medical bills paid.

The icing was when they called me demanding to know who hit me so they could go after their insurance to recover for my MRI. It took me a half hour on the phone to get them to go back and look that it was a diagnostic MRI for arthritis ordered by a rheumatologist. Morons.

"Fronk-uhn-STEEN!" Had to go for that one. I can just see someone trying to turn in a madical report or note from him, who the hell's gonna believe your doctor's name is Frankenstein? [Also, is he taking new patients? I don't really care if he's any good, I just really want to have a doctor named Frankenstein.

@balthisar:
It's only insurance fraud if the state says so. NY state does not allow refusal of health insurance OR change in rate due to pre-existing conditions. there is only a 6month waiting period before the pre-existing condition can be treated through the insurance.

My point is, it's fraud because some states LET it be fraud. everyone NEEDS health insurance.

The woman from Wellpoint is right. The more people use their insurance to pay for medical care, the more expensive it is for everyone else. The dollars you or your employer pay each month are what go out to pay the doctor.

Insurers are in a no-win situation. Patients say they charge too much. Doctors say they pay too little. Both sides try to game the system by buying coverage only when they're sick or favoring procedures based on profitability rather than effectiveness. In the end, it all boils down to medical inflation rising at nearly twice the rate of general inflation.

I don't envy those tasked with having to fix this mess. It's going to be extremely difficult to do. Until then, it would be best to avoid getting sick.

@Mr_Burmie: That's a really good point. Sure, let's rat on a patient, get them kicked off health insurance, and then kiss any reimbursement still due to the doctor goodbye! Oh, wait, even better, lose the patient because now they can't afford to come back and see a doctor!

@mexmexmex2000: That's the other thing about clamoring for universal health care. Not that I am against the idea of it at all - as I said above, we need health insurance. The problem is that no one is mentioning that there is so much more to this catastrophe than just insurance companies acting like greedy jerks. Medical costs in and of themselves are constantly going up. Drugs cost a fortune. Hospitals *charge* a fortune. It's one big vicious cycle and all elements affect each other.

@Stan LS: This would be reasonable if the system weren't so skewed in favor of the insurance companies. Consider a person who received coverage through his or her employment for 20 years and was laid off when his job was shipped to India. After about six months, that person would lose his employment based health insurance and be required to find individual coverage. If he developed health problems while on the job, that will be impossible due to the pre-existing condition clause on virtually all individual insurance. This is a person who would have paid into the system for 20 years and then, in a time of need, be refused the coverage that his former payments have underwritten (in the insurance industry sense of the term).

Then there are those who are denied coverage after the fact due to pre-existing conditions that are both minor and not-related to the claim at issue -- such as the woman whose policy was rescinded after a claim for cancer therapy due to non-disclosure of hay-fever as a preexisting condition. Blue Cross was fined over $1mm (peanuts) by the State of California for this little peccadillo.

If we are to have private insurance it needs heavy regulation. On the one hand, basic insurance must be mandatory so that even the healthy buy coverage. This will lower the current costs for all insured and lower the overall life-time costs for the currently healthy. On the other hand, insurance companies must be forced to offer a basic coverage package to all comers at a community (not experience) based rate. Beyond that, they could do what they want. That way everyone would have basic coverage at a lower cost than in our current system.

Even better - remove the middle man and offer single payer national health insurance. I daresay the extra taxes to finance that would be A LOT less than private health insurance premiums for identical coverage.

I know this is the wrong site for this, but does anyone else have a better plan for a company to minimize it's shot at moral hazard risk, which is an inherent (and ugly) part of the insurance game?

For those not familiar: I am shopping for insurance. I possess an information advantage over any company that would like to insure me. I know that I have conditions X, Y, & Z. In fact, my knowledge affects which plan options I'm interested in. The insurer only has my word that I'm healthy and free of XY&Z. They sign me up, and they wind up boned, as I get tons of drugs and treatment for XY&Z due to my information asymmetry.

Perhaps it would be draconian of them to require a physical, that they will pay for, before they quote you. That would solve it, but would probably have consumerists up in arms.

This is not ideal practice. It's anti-consumer. But since Insurance is a risk based business, don't they have to have some option to at least accurately judge that risk?

Last thought: A good socialized health model will create the equivalent of company group plans on a national scale, thereby eliminating insurance drops and the moral hazard problems inherent in insurance.

@DrGirlfriend: Is it possible that the skyrocketing cost of all things health, that outpaces general inflation by more than even college tuition has some root in the current, privatized system and might be fixed with a socialized model?

Fer instance: let's say as a doctor, you can charge whatever you like. You charge up to the max that the insurance company will reimburse, even if it has no relation to your actual cost. There's your incentive. Maximize profits. Given a single payer system, wouldn't the balance of power between suppliers and customers be shifted to the monosonist [en.wikipedia.org] ? Me thinks so, since that's what economic theory would tell us.

Two things from an MDs perspective:

(1) Not disclosing your medical information to the insurance company IS insurance fraud, and withholding this information the same information from your doctor severely compromises your care. There is really no way around this. The fact that the insurance companies have a hefty net profit doesn't change this.

(2) That being said, I find Blue Cross using the physician in this instance to be VERY troubling and highly unethical on their part even if it's not in violation of HIPAA. It severely compromises the doctor-patient relationship and strong-arms the physician into disrupting it. A doctor should be an advocate for their patient regardless of the status with an insurance company.

I fail to see how the govt can do any better at health coverage. I also find it ironic that people are willing to turn over such a private/important matter to the govt. Anyone that's dealt with govt healthcare (Medicare, Indian Health Services, VA) will tell you what a nightmare it is. In fact, it will make this little stunt by Blue Cross look quaint in comparison. I'd like to see health insurance revamped. Clearly it is not working for a lot of people as the OP proves. But turning it over to the people who brought us the DMV?? Hell no. I say change the health insurance market and allow consumers the ability to purchase privately much like car insurance. On a related note, I've always thought it odd that most of us at the mercy of our employer's HR person - they pick the policies offered unless you get one on your own. Lovely.

@bearymore: In my state, and I believe in most states, as long as you don't have a break in coverage, you would be able to sign on for individual insurance or new group insurance and not be subject to a waiting period or pre-existing condition exclusions. You're typically eligible for COBRA coverage to bridge until you can find a new policy (assuming you don't like the COBRA.)

The idea of a waiting period and a pre-existing condition exclusion is to prevent people from only buying in when they need care. The waiting period is usually nine months because of pregnancy.

Insurance companies seem heavy handed with these rules, but in many cases the way business is conducted is helpful to the majority of paying members in that it keeps costs down. Otherwise, people would only buy insurance after they got sick and that's not how insurance works.

Agree with you that states should require all to have insurance to keep costs down.

Don't agree that tax payer funded, government run single payer would be any cheaper. The drive for profit creates a demand for efficiency. This doesn't generally exist in the public sector.