by Robyne Rohde
Insurance companies cannot be trusted to make neutral and unbiased decisions in deciding to pay a claim. Not so long as they remain unregulated. The degree to which their profit motives drives behavior range from slightly sleazy to illegal to immoral are the same motives that drive Oklahoma’s GOP by denying Special Needs insurance mandates which eat into the profits of Oklahoma’s insurance monopoly and most certainly reduce the amount of PAC money lining the pockets of the GOP.
Insurance companies have a long history of non-payment to providers for services rendered. One common tactic is to go through the medical record, or the claims submission form and find some minor error or omission and deny payment for the whole claim on the basis of the minor error. The insurance companies know that a certain fraction of rejected claims will simply be written off by the doctor or paid by the patient, which is pure profit for them.
Additionally, insurers will automatically bundle multiple services into a lower single payment, or substitute one service for another, without any justifiable reason beyond the fact that they can. A class-action suit in Connecticut alleged an industry database designed to provide data on "Usual, Customary & Reasonable" charges was manipulated by United Healthcare to underpay physicians for out-of-network services.
The tactics of health insurers have not been limited to the provider side of the equation, patients bear the burden of the insurance industry's drive for profits. They will delay or deny authorization for treatments or impose difficult pre-authorization requirements for documentation and necessity, all in the hopes that a certain fraction of claimants will be deterred by the amount of administrative red tape and simply lose interest and go away. A procedure which is not performed is one they don't have to pay for, which represents increased profits for the health care company. It's important to recognize that this burden increases the cost of health care for everybody, as doctors and their staff have to waste their time dealing with insurers seeking approval (which is often denied anyway). But the insurance companies don't care about this -- why should they? They are private players pursuing their own self-interest by ensuring that their individual bottom line is protected.
There's also good money to be made by denying payment for care already provided! Some particularly egregious practices of retroactively reviewing the applications of patients who develop expensive health problems and rescinding coverage based on minor typographical errors or immaterial omissions is quite common.
These are not the isolated actions of occasional misinformed insurance claims representatives, but the result of deliberate policy decisions. They hire people who are trained to obstruct, delay, and deny payment for services. These same organizations are padding the pockets of the Oklahoma’s GOP so they do not have to cover the costs of diagnosing and treating children with autism. While it has been proven that the cost to the policy holder would be less than 1%, for autism insurance coverage, anytime an insurance company must pay a claim, eats into their precious bottom line and of course Oklahoma’s GOP PAC money.