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Those awful insurance companies

Those awful insurance companies are at it again, screwing up payments to doctors, causing lawsuits, strife, accusations and counter-accusations. While it looks like the same old case of an insurer short-changing physicians, it isn’t.
Horizon Blue Cross of NJ paid 600 cardiologists too much. Over a two year period, Horizon paid these lucky docs $15 million more than they should have. The case is now settled, the docs paid some of the dollars back, and things look to be calming down.
As one who spent years working for managed care firms, insurance companies, workers comp managed care firms and workers comp insurers, I am not terribly surprised that Horizon overpaid docs. Im sure this happens every day, and that most payers are guilty of the same type of mistakes.
Point being, whenever an insurance company is accused of short-paying docs or policyholders, they are accused of fraud, denial of care, interfering in the physician – patient relationship, and just being awful people in general. While this level of opprobrium may occasionally be justified, my educated suspicion is in the majority of these cases the insurer either screwed up or there is an honest disagreement.
Most of the folks at insurance companies are people who are trying to do the right thing, working pretty hard, and concerned about how their customers perceive them. Sure, a few have horns and a tail, but that is true in all businesses.
Even in cardiology practices.

4 thoughts on “Those awful insurance companies”

  1. I agreed with you when I was working for a managed care firm. But when I went over to work for a billing company, part of me thought they were intentionally designing the claims payment process to be as confusing as possible to lower payouts as much as they could. I never could tell if it was incomptence or malice, or a generous mix of the two.

  2. Joe- are you comaring this with the massive settlements of Aetna, Cigna, United, Prudential, HealthNet, WellPoint, Humana or PacifiCare with a single event where the settlement is likely signifiantly less than $10 million. Plus, there appears in the story to have been no malfeasance on the part of the docs.
    plus- you must be aware of the >$350,000 fine in Arizona levied against United (the largest fine in AZ history by 50%).
    The issue is that, in healthcare, the services are long-since provided before payment in these cases of ‘honest mistake’ (if they are and the big settlements bring that into question) and the loser is the physician (the insurer keeps the money, interest, etc.)

  3. Eric – good questions and excellent points. I would also point to the massive upcoding and unbundling that occurs, the hyper-inflation of charges for such items as surgical implants, the practice of inflating charges in some jurisdictions by some facilities for some payers (known as cost-shifting), the abuse of loopholes in payment laws leveraged by ambulatory surgical centers, the over-utilization of PT seen in many occupational medicine centers…
    another point is the confusing nature of Medicare and Medicaid reimbursement regulations that ensnare providers, patients, facilities, med gas companies, and others – some of whom are bilking the system, and others who are just not billing correctly.
    point being there are plenty of problems in the industry on all sides, and plenty of folks trying to do the right thing.

  4. Joe makes valid points. When MDs play games (i,e, try to commit fraud) and insurance companies pick it up, this is not news and patients, for the most part, don’t know or care.
    When it appears to work the other way, the insurance companies are presumed guilty.
    Interesting media we have in the US.

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Joe Paduda is the principal of Health Strategy Associates



A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



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