Was This Personal or Professional: (UHC CEO murder)

BTW, for those who are experiencing what appears to be inappropriate denial of claims, every insurer has a multi-step appeal process, which should be used as a precursor to following next steps. The ultimate step is contacting the Department of Insurance in your state or other entity, such as the Department of Health who owns this process. The state can put downward pressure on the insurer and the medical appeals process. Whenever I had a call from the state, I always on edge as were others(review nurses, Medical Directors, etc.) as to whether or not we had crossed our t's and dotted our i's in terms of justifying service denials. The other criterion was, were we being arbitrary and capricious in our service review criteria(judging like cases in the same manner?)?
Another possibility is contacting your benefit manager, if your company is self-insured. If the circumstances are particularly egregious and/or multiple individuals are being unfairly denied, then the client can elect to have the insurance(in this case administrator) company pay those claims across the board.
 
Private Citizen said:
What a sad descent into tribalism. Things like this make me wonder if the US is already in a civil war.
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We may not have had bullets, blood, guns - however the civil war has never stopped.

rfisher said:
Medicare fraud by clinicians is an entirely different matter. DRGs have made a huge difference in orders for Medicare. Any procedure has to be justified.
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Too many clinicians have scammed Medicare and Medicaid forever. Florida seems to lead the number

I've had experience with two attempts. I got a huge packet of EOBs in claims for medical equipment that I would never use. The physician name on the ordering was a doctor in Florida I called Medicare Fraud line immediately to report. the claims person said they were nearing the end of the investigation, ready to file charges. She asked how I knew it was fraud. I said I always, always read my EOBs. Not everyone does

For the last 6 months, I've got phone calls from Orthopedic Associates, telling me my physician is ordering outpatient medical supplies - at no cost to me, Medicare will cover it. After the first time when I asked where they got my medical history then hung up. With every phone call after that (I recognize the voice), I've asked for different things and said I needed it to report fraud. They usually hang up.

Every one is responsible to be alert to scams and read EOB.
 
Like several people on this thread, I have the knowledge to work through a denial as well as the tenacity to do so. And I use the correct buzzwords, so the first level of appeal is more likely to listen to me. But in my state, the two top insurers are not for profit, so it’s less of a battle. Gawd forbid I ever have to deal with a for profit insurer again.
 
once_upon said:
We may not have had bullets, blood, guns - however the civil war has never stopped.



Too many clinicians have scammed Medicare and Medicaid forever. Florida seems to lead the usually wes.

I've had experience with two attempts. I got a huge packet of EOBs in claims for medical equipment that I would never use. The physician name on the ordering was a doctor in Florida I called Medicare Fraud line immediately to report. the claims person said they were nearing the end of the investigation, ready to file charges. She asked how I knew it was fraud. I said I always, always read my EOBs. Not everyone does

For the last 6 months, I've got phone calls from Orthopedic Associates, telling me my physician is ordering outpatient medical supplies - at no cost to me, Medicare will cover it. After the first time when I asked where they got my medical history then hung up. With every phone call after that (I recognize the voice), I've asked for different things and said I needed it to report fraud. They usually hang up.

Every one is responsible to be alert to scams and read EOB.
Click to expand...
I, briefly, took a job with a mobile radiography company. It was supposed to be on call only for emergencies at the various nursing homes they serviced. The 2nd weekend I worked, I got a call from the company owner wanting me to go to all the nursing homes and ask if they needed any images done. I said, that's unethical. He said, no, it was just that if I showed up, they might decide they needed a film done on somebody. I quit on the spot. Two months later, the owner was charged with massive medicare fraud and went to jail. All his employees were charged as well. I always use this as a cautionary tale to students. Ethics and the law matter.
 
Aceon6 said:
Like several people on this thread, I have the knowledge to work through a denial as well as the tenacity to do so. And I use the correct buzzwords, so the first level of appeal is more likely to listen to me. But in my state, the two top insurers are not for profit, so it’s less of a battle. Gawd forbid I ever have to deal with a for profit insurer again.
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Correct buzz words is the key. I worked with a couple of lovely RNs doing certifications who would give me the newest buzz words
 
once_upon said:
And the pre auth nurses or billing department are not notified of denials until someone who gets a denial and fights it.

I would get immediate denial of care and file maybe 5 or 6 times before I could get it approved. But you had to know the word of the quarter. And PT/OT needed the therapist's progress records.

AI or adult doctors had no idea what speech therapy does, especially in children. Swallowing and feeding issues to them doesn't mean speech. PT and OT had to be certified providers - not just the therapy provider

Same with anesthesiologist. The practice might be a preferred provider, but not individual physicians or CRNA.

Or your doctor might refer you to a specialist during a hospitalization. Even though the hospital might be approved provider, the consulting Dr is not.


Same holds true for radiologist. The hospital radiology department may be a preferred provider, but the radiologist isn't.

Insurers make the rules so complicated and easier to deny
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These providers were what we used to call RAPER's (radiologists, anesthesiologists, pathologists) and are most likely to be a non-perferred provider. There are two reasons why; either they have not been credentialed yet or met credential criteria or will not participate because they won't accept the negotiated rates. Hospitals or hospital systems are able to negotiate blanket contracts on behalf of these providers because they are considered to be staff employees.
 
sk9tingfan said:
These providers were what we used to call RAPER's (radiologists, anesthesiologists, pathologists) and are most likely to be a non-perferred provider. There are two reasons why; either they have not been credentialed yet or met credential criteria or will not participate because they won't accept the negotiated rates. Hospitals or hospital systems are able to negotiate blanket contracts on behalf of these providers because they are considered to be staff employees.
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IME, it is most likely they aren't willing to take pennies on the $ for reimbursement.

One of my doctors - that I had for 20+ years - her practice partners were not willing to be screwed over by UHC. I begged her to keep me as a private pay, but the practice wasn't doing that. She gave me a list of specialists who were accepting new patients but none were taking UHC. Fortunately for me DH employer changed insurances.
 
once_upon said:
We may not have had bullets, blood, guns - however the civil war has never stopped.



Too many clinicians have scammed Medicare and Medicaid forever. Florida seems to lead the number

I've had experience with two attempts. I got a huge packet of EOBs in claims for medical equipment that I would never use. The physician name on the ordering was a doctor in Florida I called Medicare Fraud line immediately to report. the claims person said they were nearing the end of the investigation, ready to file charges. She asked how I knew it was fraud. I said I always, always read my EOBs. Not everyone does

For the last 6 months, I've got phone calls from Orthopedic Associates, telling me my physician is ordering outpatient medical supplies - at no cost to me, Medicare will cover it. After the first time when I asked where they got my medical history then hung up. With every phone call after that (I recognize the voice), I've asked for different things and said I needed it to report fraud. They usually hang up.

Every one is responsible to be alert to scams and read EOB.
Click to expand...

As for fraud in Florida, just think of Senator Rick Scott of Columbia/HCA under whose leadership defrauded Medicare and required a 1.7 billion dollar settlement to the Feds for both Medicare and Medicaid and included 14 felony convictions. Scott obviously suffered no consequences. As for individual cases, during my tenure in care management, I was always coming across negligence and malpractice cases in the state of Florida.
 
MacMadame said:
It's because we preach empathy for the downtrodden and otherwise oppressed. A CEO of a major healthcare company doesn't fit either of those categories.
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As the actual preacher, I’d say that when Jesus preaches, he’s on the side of the poor. His encounters with the rich are usually about them giving up their wealth.

Private Citizen said:
What a sad descent into tribalism. Things like this make me wonder if the US is already in a civil war.
Click to expand...

Is heading a company that systemically causes illnesses and deaths of thousands to maximize profit just as morally problematic as someone who shoots that person?
 
Prancer said:
Why not? One can earn a profit and be a decent human being. It does, however, usually mean not making as much profit.
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Obligation to shareholders?

Prancer said:
I agree that no one should be shot. But I don't agree that CEOs should not be blamed. Like the rest of us, they have made choices.
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Blamed for what? Deaths that occurred from denying treatment that the policy doesn't cover? I don't see how they're responsible at all.

skatfan said:
Is heading a company that systemically causes illnesses and deaths of thousands to maximize profit just as morally problematic as someone who shoots that person?
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My answer is an unequivocal no, and I don't accept the "systematically causes illnesses and deaths of thousands" as fact.

Where does it stop? What about cigarette company CEOs? Alcohol company CEOs? Fast food company CEOs? Pharma (given the opioid epidemic)? Companies that harm the environment (virtually all)? Can we gun down their CEOs, too? They're all causing deaths of thousands.

Your insurance company is not your friend. They're a business. There are terms and conditions. They are not responsible for your health; you are.

No one likes insurance companies. That's fine, they probably don't like you, either, unless you're perfectly healthy and pay in way more than you'll ever take out. That's the nature of the business.
 
Denials are one thing. It's the jump through hoops to receive care. The time consuming step therapies that are required that not only waste time, they waste the patient's money. Unneeded copays and coinsurance for care that doesn't solve the problem. It can take weeks to months to get an effective treatment plan in place. It's absurd because usually those types of things are not laid definitively out in the plan for the average person to understand. It's always buried in language about the standard of care. And what's covered under "standard of care" can vary from company to company or procedure to procedure. So tell me how does reading the plan document help in those cases?
 
Private Citizen said:
Blamed for what? Deaths that occurred from denying treatment that the policy doesn't cover? I don't see how they're responsible at all.
Click to expand...
The issue is that policies aren't clear about many things that are or aren't covered. There is black and white, like annual physical (covered - thank you, ACA) and cosmetic procedures (not covered and explicitly listed), but then there is the very large world of "medically necessary" grey, and that's where much of the conflicts arise. Your doctor orders a test, procedure, or drug that in their professional opinion is necessary, and your insurance rejects it claiming it isn't. Is your insurance company your doctor? No, they're not. They're focus isn't trying to get the best health outcome for you, it's trying to reduce their costs. And when that financial decision leads to a poor health outcome, yes, they are responsible.

Here's a doctor's take on things:

www.nytimes.com

Opinion | What Doctors Like Me Know About Americans’ Health Care Anger

As a doctor, I’ve been on both sides of frustrating health care debacles.
www.nytimes.com www.nytimes.com

ETA: There's also the well-documented practice of frivolously denying coverage as a business strategy under the assumption that some percentage of insureds won't pursue the claim further. In this case, they're not denying something because it's not covered, they're denying it to (unethically) increase their profits. Really, if you're reading any of the news about this case you've seen a very ugly underbelly of the U.S. healthcare system exposed for what it is - a for-profit, often unethical business that is focused on profits rather than health. Your position seems to be, "Yup, that's the system," and it is alas the system. What most other people in this thread are saying is that the system is badly, badly broken and needs to be re-aligned to center patients not profits.
 
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If they only denied what isnt covered, that would be explicable. But denying care that IS covered is the business strategy. I was put on medication that flatly didn't work until I could "qualify" for what did, which two doctors knew and attested to. And people wonder why there is so much waste in the system.
 
There are also huge issues with insurers' in-network provider lists (whether online or printed) being flat-out wrong, which leads people to see providers that turn out to be out-of-network. Most insurers fail to have enough mental health professionals in their networks (and California has nailed some of them for that)--meanwhile, mental health therapists complain that their requests to join the networks are denied. Local pharmacies are paid less to fill a prescription than the prescription costs, and get paid less than the insurers pay their captive pharmacies. Drugs are a mess. Mr. BarbK had a cough that required an asthma inhaler for years...and the insurance company kept changing which inhalers were covered at a reasonable price. Every change required a visit to the doctor to figure out which of the currently-covered inhalers might be worth trying, and multiple attempts to find one that fit. Until recently, it was impossible to find out in advance how much a given procedure would cost at a given in-network facilitiy--and those costs vary significantly, even when all the providers are in-network. What other product do you "buy" where you can't find out how much something will cost before you hit the buy button?

I don't expect insurers to pay for excluded services. I do expect that they will honor their responsibilities. Unfortunately, they don't.
 
Asthma medications are an example of denying care. You find something that actually helps prevent ED visits or frequent office visits, used for years. Suddenly it gets denied. Why? Because it's changed it's pricing schedule or something else. Long tern control requires doing what works, not some algorithm.

But the deny because it costs too much and eats into profits is the business model.
 
Private Citizen said:
I stand corrected. I did say "they got what they deserved" two years after the attack, and I should have done a more thorough search than just pulling up the original thread on the Pelosi attack. I should not have used this phrase, and I do not condone violence against Paul Pelosi or anyone (which I also said in the post two down from the one you linked).
Click to expand...
It's hard to know when to believe you. You say one thing off the top of your head, and you say another thing when you are called out.
 
once_upon said:
Asthma medications are an example of denying care. You find something that actually helps prevent ED visits or frequent office visits, used for years. Suddenly it gets denied. Why? Because it's changed it's pricing schedule or something else. Long tern control requires doing what works, not some algorithm.

But the deny because it costs too much and eats into profits is the business model.
Click to expand...
PBM is its own racket. One of the new policies is removing established name brand drugs from a formulary in favor of a new “bio similar” that is made by an affiliate of the PBM. In the middle of a coverage period.

Network issues are not always the fault of the insurer. A friend went to an in network hospital emergency room (passed out/lung cancer) and was treated by a newly hired physician who apparently was so new the hospital had not done the paperwork to add him to the in network roster so they billed him as out of network. After the insur. co paid its share and we paid his in network copay, the hospital balance billed him and hounded his mother for payment even after he died. He was an adult so his mother had nothing to do with this and signed nothing. I made a phone call and the hospital wrote off the balance. One would hope this would have been resolved favorably for someone who lived.
 
I'm not saying vigilante justice is good. But things seem to trend this way, and if it's going to exist ... (Though I'm more a fan of orcas taking down yachts - more of that, less of this)

I'm sorry, but I can't find it in myself to see this as tragic. Not when you look around. But the capitalists panicking can keep panicking. Maybe we'll get a real look at gun control at this rate. A man like this CEO is not a good person, and justice hasn't existed in with much fairness in the US for some time.


Vagabond said:
It's hard to know when to believe you. You say one thing off the top of your head, and you say another thing when you are called out.
Click to expand...
Because they're a troll and shouldn't be taken seriously.
 
The only change that will come out of this is that CEO security budgets will skyrocket (and get passed along to the consumer). Sad to say.

You’re not going to get insurance companies to regulate themselves, no matter how many people you shoot. (And fwiw that’s not a right wing thing to say.)
 
BittyBug said:
The issue is that policies aren't clear about many things that are or aren't covered. There is black and white, like annual physical (covered - thank you, ACA) and cosmetic procedures (not covered and explicitly listed), but then there is the very large world of "medically necessary" grey, and that's where much of the conflicts arise. Your doctor orders a test, procedure, or drug that in their professional opinion is necessary, and your insurance rejects it claiming it isn't. Is your insurance company your doctor? No, they're not. They're focus isn't trying to get the best health outcome for you, it's trying to reduce their costs. And when that financial decision leads to a poor health outcome, yes, they are responsible.

Here's a doctor's take on things:

www.nytimes.com

Opinion | What Doctors Like Me Know About Americans’ Health Care Anger

As a doctor, I’ve been on both sides of frustrating health care debacles.
www.nytimes.com www.nytimes.com

ETA: There's also the well-documented practice of frivolously denying coverage as a business strategy under the assumption that some percentage of insureds won't pursue the claim further. In this case, they're not denying something because it's not covered, they're denying it to (unethically) increase their profits. Really, if you're reading any of the news about this case you've seen a very ugly underbelly of the U.S. healthcare system exposed for what it is - a for-profit, often unethical business that is focused on profits rather than health. Your position seems to be, "Yup, that's the system," and it is alas the system. What most other people in this thread are saying is that the system is badly, badly broken and needs to be re-aligned to center patients not profits.
Click to expand...
Good article although depressing that the best policy belonged to the dog (happy for the pooch.) My life was saved while on Obamacare in 2018. I’m not sure what might have happened without it. I went to see my Doc a few yrs back and took her a list of covered (and not covered) medications on my current plan. She looked at it and threw it across the room. Brian Thompson is a victim. So are some policy holders. And everyone is frustrated.
 
I'm not sure CEOs are innocent victims, but they do not deserve murder.

ACA certainly was a lifesaver for me. And my adult son. I refuse to call it Obamacare when speaking to large group who have GOP in the audience or discussion. It's not tied to Obama, but works for GOP to instill hate.

I've had the generic drug cost more than name brand. I'm assuming it is in part do to kickbacks.

I don't need everything paid, if not included in plan. But the amount of leg work I need to do qualifies me for a marathon.

Before I fill a new drug (to me) I check the prescription coverage plan. Symbicort is not covered in current plan but Breo is. One migraine med is, another not. So on and so on
 
Rob said:
newly hired physician who apparently was so new the hospital had not done the paperwork
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If anyone says they’re new and it’s not a matter of life and death, I always check the hospital’s website to make sure they’re added and cross check the doctor’s Unique Physician Identifier Number (UPIN) in the state registry to make sure they’re added and have admitting privileges there. I shouldn't have to do this.

I had a long back and forth with UHG about a PT claim they kept denying because the provider was supposedly out of network. My not for profit insurer had a contract with a multidisciplinary practice that said that everyone employed by the practice was in network. When UHG signed an affiliation agreement with my insurer, with specific language saying that all networks would be preserved, they screwed up importing the network and excluded PT, OT, most mental health providers, and a bunch of other things. It took me nearly 3 months to get the claim paid and required me escalating to the not for profit’s head of credentialing. Lay people just get flummoxed by insurance and fooled into over paying every single time.
 
I take Synthroid (name brand). It's cheaper for me to buy it without using my insurance than going through insurance. :rolleyes:

But I agree with whoever said (@Rob ?) that PBMs and pharma coverage are their own separate issue that is as problematic as broader health insurance coverage, especially since so many of the insurance companies own PBMs (UHC owns Optum, CVS owns Aetna and Caremark, CIGNA owns Express Scripts).
 
@Andora, is name-calling ever appropriate? This is not PI. Plus you said: "I'm sorry, but I can't find it in myself to see this as tragic." Why not? A human person lost his life & his family & friends are deeply affected. If a family member of yours was gunned down because of his/her business practices would that be okay with you?

When I first went to work for the employer that I retired from the ins company (I think Aetna) who handled our insurance claims denied a good many of my legitimate claims. It was so annoying. I had to appeal & then they finally always paid. Depending on the amount some employees wouldn't bother calling, sitting on hold, etc to appeal so Aetna made illegal profit. My company changed to UHC after many complaints & it was so much better that maybe I think they are good just in comparison.
 
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