
I have a Masters in Business Administration. I was a Business undergraduate specializing in Finance. I worked in the private sector for my entire career - with over 15 years of Corporate America / For Profit under my belt.
So I'm no softy. I understand that cold, hard business decisions that need to be made sometimes. Sometimes the sales just aren't there. There's no demand, so there's no need for the labor and the material to produce and you cut back, and you need to lay off workers. It sucks.
I've never worked in the insurance industry, but as a Finance professional I understand the shared risk concept. People all pay in and the pool of funds collected is theoretically used to cover the needs / losses of the participants in the plan. Actuaries figure out the right amount to charge to cover the estimated risks. The pool should always be able to pay if the funds are managed properly and the underlying assumptions made by the actuaries were based on reasonable assumptions and good data.
Then, in theory, if an insurance company is for profit, they need to manage the whole thing so that they can take the profit they want out of the mix.
AHHHH... there is the rub.
Profit is not a bad thing. Profit is the reward for superior work. In the insurance industry superior work means that the people that paid you premiums got covered when they had a loss. Manage your data, your assumptions, and your business processes properly and your reward is a profit. Profit is good. If you earn it, profit is good.
Earn it? That means that if you do what your business model says you do, you have earned it. However, if you collect money from people after picking and choosing your customers, then turn away customers, and eliminate coverage for people that paid you when they were not experiencing losses...because they started having losses, then you are NOT doing your job. The business model is all about understanding risks and applying statistics to determine fair premiums. The job isn't about avoiding losses, it's about determining the right premiums.
If you are selling insurance and not protecting your customers when they experience loss; and you are not doing your job, and you enjoy a nice profit, then you are stealing. You are a crook. Sadly, the United States health insurance companies are crooked.
Not long ago, while I was seeking medical coverage in the private market, I had the humiliating and depressing experience of being a middle aged woman seeking medical insurance. As if the insane price for coverage was not humiliating enough, the process of obtaining coverage was worse.
The insurance company asked me to have my doctor respond to them with answers to a couple of questions from my application. I expected the customary one year waiver on a couple of things, but in general I didn't think it would be a problem.
Wrong.
The idiot office manager in the doctor's office didn't read my letter to the doctor. She saw the insurance form, pressed a couple of buttons, and my ENTIRE MEDICAL RECORD was electronically sent to the insurance company. If she had read the letter, the doctor was supposed to answer three simple questions with the truth - nothing more. My letter to the doctor told the doctor what to say, which was the truthful answer to the questions. I was a new patient and I wanted to remind her what I had told her, so I wrote the letter to leave no room for error. Sadly, the idiot in the office chose to ignore the cover letter, which wasn't addressed to her in the first place.
This is when I learned about HIPAA. The sad truth I learned about HIPAA is that it has no teeth whatsoever and that it's intentions when implemented were perfect, the policy never delivered on the enforcement side. ugh.
The insurance company rejected me, citing about TEN conditions that I didn't have.
It took months for me to resolve the situation. My medical records had tons of details that were misused by the insurance company. My doctor had documented everything we talked about, including suppositions, possibilities, maybes, and stuff to watch. There were no diagnoses and no treatments for of the items, except the items that they asked about. I had not withheld information and had disclosed the complete truth about anything that was diagnosed and required treatment.
It didn't matter. The insurance company said, "They are in your medical records, and we only allow three waivers."
I said, "But those were not diagnoses. They were discussion notes. You weren't even supposed to get that."
Well we did get it, and we can use it. You can not have coverage.", was the reply.
The doctor called and talked to them personally. It didn't matter. She was going to blow me off, but I scheduled a meeting. While I had become painfully aware that there were no teeth in HIPAA, and I had failed to find even ONE lawyer that was interested in helping me in civil court, I implied to the doctor that I had a case for civil court. We developed an action plan.
She took me into an examination room and we talked about each of the items in the file. For each item she asked me specific questions and had me perform specific maneuvers. For example, we had talked about the possibility of carpel tunnel syndrome that flares up for me from time to time. However, since I had no symptoms either time she saw me, and I could perform the physical movement that would indicate that I do not have carpel tunnel syndrome, she documented the test and the conclusion: no carpel tunnel syndrome - which is true, I've never been treated for it, nor been to the doctor for it. I had simply mentioned that from time to time ...
Another example: I had asked her if I should get a DEXA (bone density study) to use as a baseline. I had no symptoms of osteoporosis, but the baseline would need to be done within the next couple of years anyway, and the coverage I had from Mr. Ex was really good, so I asked to get it done a couple of years early. When the insurance company saw that the test had been performed they decided that I was likely a high risk. Never mind that the results of the scan indicated that I have the bones of a 25 year old!! The insurance company let that one go after I argued it, but it was on the original rejection letter.
Long story, almost finished, the insurance company received a new version of the medical records and rescinded their rejections. By the time they made this decision I had secured coverage elsewhere and told them to go to hell.
Ironically, the company that I secured coverage from back then has since left the Arizona market and the original company that rejected me picked up their customers... and raised their rates over 10%. . Blue Cross Blue Shield is the company. Asshats.
So I'm no victim. I won my battle, I guess. I pay insane premiums for catastrophe coverage, but I do it to protect my assets for my children. My children are covered by a plan provided by their father's employer. I have the knowledge and skills necessary to fight with the crooks and bullies that run the health insurance racket, and while I won't call myself a winner, I'll say that I am not a victim.
But what about the people that don't have the skills or knowledge? What about people that just need to be able to take care of themselves and their dependents?
>Check out this short and oh, so nauseating article.
>How can anyone know that, when left to operate without legislation, the insurance crooks consider being a battered woman a "preexisting condition", and still think that there isn't a need to correct the health insurance business model and its abuses? Without a public option that provides real market competition and coverage that doesn't victimize people, the insurance crooks will continue to abuse their 'for profit' business model - simply because they can. They have proven this to us.
So I'm no softy. I understand that cold, hard business decisions that need to be made sometimes. Sometimes the sales just aren't there. There's no demand, so there's no need for the labor and the material to produce and you cut back, and you need to lay off workers. It sucks.
I've never worked in the insurance industry, but as a Finance professional I understand the shared risk concept. People all pay in and the pool of funds collected is theoretically used to cover the needs / losses of the participants in the plan. Actuaries figure out the right amount to charge to cover the estimated risks. The pool should always be able to pay if the funds are managed properly and the underlying assumptions made by the actuaries were based on reasonable assumptions and good data.
Then, in theory, if an insurance company is for profit, they need to manage the whole thing so that they can take the profit they want out of the mix.
AHHHH... there is the rub.
Profit is not a bad thing. Profit is the reward for superior work. In the insurance industry superior work means that the people that paid you premiums got covered when they had a loss. Manage your data, your assumptions, and your business processes properly and your reward is a profit. Profit is good. If you earn it, profit is good.
Earn it? That means that if you do what your business model says you do, you have earned it. However, if you collect money from people after picking and choosing your customers, then turn away customers, and eliminate coverage for people that paid you when they were not experiencing losses...because they started having losses, then you are NOT doing your job. The business model is all about understanding risks and applying statistics to determine fair premiums. The job isn't about avoiding losses, it's about determining the right premiums.
If you are selling insurance and not protecting your customers when they experience loss; and you are not doing your job, and you enjoy a nice profit, then you are stealing. You are a crook. Sadly, the United States health insurance companies are crooked.
Not long ago, while I was seeking medical coverage in the private market, I had the humiliating and depressing experience of being a middle aged woman seeking medical insurance. As if the insane price for coverage was not humiliating enough, the process of obtaining coverage was worse.
The insurance company asked me to have my doctor respond to them with answers to a couple of questions from my application. I expected the customary one year waiver on a couple of things, but in general I didn't think it would be a problem.
Wrong.
The idiot office manager in the doctor's office didn't read my letter to the doctor. She saw the insurance form, pressed a couple of buttons, and my ENTIRE MEDICAL RECORD was electronically sent to the insurance company. If she had read the letter, the doctor was supposed to answer three simple questions with the truth - nothing more. My letter to the doctor told the doctor what to say, which was the truthful answer to the questions. I was a new patient and I wanted to remind her what I had told her, so I wrote the letter to leave no room for error. Sadly, the idiot in the office chose to ignore the cover letter, which wasn't addressed to her in the first place.
This is when I learned about HIPAA. The sad truth I learned about HIPAA is that it has no teeth whatsoever and that it's intentions when implemented were perfect, the policy never delivered on the enforcement side. ugh.
The insurance company rejected me, citing about TEN conditions that I didn't have.
It took months for me to resolve the situation. My medical records had tons of details that were misused by the insurance company. My doctor had documented everything we talked about, including suppositions, possibilities, maybes, and stuff to watch. There were no diagnoses and no treatments for of the items, except the items that they asked about. I had not withheld information and had disclosed the complete truth about anything that was diagnosed and required treatment.
It didn't matter. The insurance company said, "They are in your medical records, and we only allow three waivers."
I said, "But those were not diagnoses. They were discussion notes. You weren't even supposed to get that."
Well we did get it, and we can use it. You can not have coverage.", was the reply.
The doctor called and talked to them personally. It didn't matter. She was going to blow me off, but I scheduled a meeting. While I had become painfully aware that there were no teeth in HIPAA, and I had failed to find even ONE lawyer that was interested in helping me in civil court, I implied to the doctor that I had a case for civil court. We developed an action plan.
She took me into an examination room and we talked about each of the items in the file. For each item she asked me specific questions and had me perform specific maneuvers. For example, we had talked about the possibility of carpel tunnel syndrome that flares up for me from time to time. However, since I had no symptoms either time she saw me, and I could perform the physical movement that would indicate that I do not have carpel tunnel syndrome, she documented the test and the conclusion: no carpel tunnel syndrome - which is true, I've never been treated for it, nor been to the doctor for it. I had simply mentioned that from time to time ...
Another example: I had asked her if I should get a DEXA (bone density study) to use as a baseline. I had no symptoms of osteoporosis, but the baseline would need to be done within the next couple of years anyway, and the coverage I had from Mr. Ex was really good, so I asked to get it done a couple of years early. When the insurance company saw that the test had been performed they decided that I was likely a high risk. Never mind that the results of the scan indicated that I have the bones of a 25 year old!! The insurance company let that one go after I argued it, but it was on the original rejection letter.
Long story, almost finished, the insurance company received a new version of the medical records and rescinded their rejections. By the time they made this decision I had secured coverage elsewhere and told them to go to hell.
Ironically, the company that I secured coverage from back then has since left the Arizona market and the original company that rejected me picked up their customers... and raised their rates over 10%. . Blue Cross Blue Shield is the company. Asshats.
So I'm no victim. I won my battle, I guess. I pay insane premiums for catastrophe coverage, but I do it to protect my assets for my children. My children are covered by a plan provided by their father's employer. I have the knowledge and skills necessary to fight with the crooks and bullies that run the health insurance racket, and while I won't call myself a winner, I'll say that I am not a victim.
But what about the people that don't have the skills or knowledge? What about people that just need to be able to take care of themselves and their dependents?
>Check out this short and oh, so nauseating article.
>How can anyone know that, when left to operate without legislation, the insurance crooks consider being a battered woman a "preexisting condition", and still think that there isn't a need to correct the health insurance business model and its abuses? Without a public option that provides real market competition and coverage that doesn't victimize people, the insurance crooks will continue to abuse their 'for profit' business model - simply because they can. They have proven this to us.






