I believe that the majority of health insurance clients have little knowledge of how the industry works and the problems inherent in the current system until they have a serious medical situation and have to become an expert on the process. Most of my new clients are in the dark about their benefits and the situations behind the scenes that have an impact on their own financial lives. After being quite involved with the health insurance industry for 20 years, I finally had to give it up for the sake of my sanity. One of the main difficulties is the inherent conflict of interest in making payments from a pool of money designed to reward shareholders and executives. The companies make it quite difficult to get paid accurately and fairly in the hope that I ( or now my clients) will simply give up and take a smaller amount. And since most insureds have no idea of their benefits, they are often not in any position to challenge the jargon and system of payment. Over the years, here are some of the many abuses I have seen:
1. A client who uses mental health benefits decides to open his or her own business and must buy private insurance. If they answer the insurance questionnaire honestly,they will be denied private insurance for health, life and disability because they have seen a provider for depression..or they will be charged an exorbitant premium.
2. The legislature of Georgia decides to allow Blue Cross to be run as a for-profit business licensed to Wellpoint and the non-profit coop is dissolved. Over the years, the mental health side of the plan is targeted to lowered reimbursements for providers. Because mental health treatments can lead to stigma, the patients are afraid to fight this within their companies. The reimbursement for me as a doctoral level expert psychologist with 20 years of experience is dropped from July’s rate (112 per hour) to August’s rate (78 per hour) in 2007 and I have to leave the plan as I cannot pay overhead and earn a living at that rate. Meanwhile, the CEO of Wellpoint is the highest paid CEO in Indiana, earning 14 million in one year. The clients are the ones who are hit hardest as their costs rise for the treatment they need.
3. At the same time I get the notice of my change in payment, I also receive a threatening letter stating that I tend to see Blue Cross patients for 16 visits while the average number of visits should be 4. Because of my tendency to see patients for a longer time, I will be subject to in-office audits where the charts of my patients will be reviewed and assessed for the appropriateness of my treatment.
4. Approximately 50% of all claims paid directly to me are full of errors and the error always results in a lower payment than I am due. The errors are predictable: a visit in a series of visits is left off; the code is entered incorrectly; I am deemed to be in the network when I am not; the usual and customary fee for that service is not at all realistic, etc. I am rarely able to get the errors corrected without spending an hour on the phone or paying an assistant to do this.
I am clear that the health insurance industry is rife with abuses that harm clients and the providers but currently there is not another alternative. I would like to see a 3 tiered program for our needs: A private corporate option for those who are well-employed and can afford it; a set of non-profit cooperatives for the self-employed and those who cannot afford the private corporate tier; and a government safety net plan for those with life-changing medical problems, unemployed and unable to afford the others. There are numerous debates about health care and reform but the industry has created its own difficulties as they attempt to maximize profits and minimize care and reimbursements. Even with these caveats, it is better to use your benefit if this is the only way to afford treatment as the decision to forego mental health treatment has many negative effects.