Apparently, insurance companies don't want to let customers cancel policies.
"Kaiser, the state’s third largest provider, doesn’t allow users to post directly to its Facebook page. It’s also where some callers complained they were receiving a pre-recorded message that ended with a dial tone when they called customer service."
Sadly, long before the new health care law went into effect, Kaiser was preventing patients from making complaints.
DMOC isn't likely to do much. There's a long history between DMHC and Kaiser.
Health Insurance Complaints Skyrocket in CA
Having trouble reaching your health insurance company? You're not alone. State regulators say in January alone, they've seen a 53% jump in complaints, in part because calls about Covered California. A little known state hotline can help
By Vicky Nguyen, Felipe Escamilla, Liza Meak, and Scott Pham
NBC News
Apr 22, 2014
The Investigative Unit has learned complaints to state regulators have skyrocketed as people find themselves unable to reach anyone at several major health insurance companies. Vicky Nguyen reports in a video that aired on April 21, 2014.
Even if you aren’t one of the 1.2 million people signing up for Covered California, chances are you’re feeling the pinch when calling your insurance company. The Investigative Unit has learned complaints to state regulators have skyrocketed as people find themselves unable to reach anyone at several major health insurance companies.
For some health insurance companies, the influx of calls is so bad, they’re hanging up on customers after a pre-recorded message, while others put callers on hold indefinitely.
“I’ve been put on hold anywhere from 15-40 minutes,” said Don Tran, a full-time grad student at San Jose State.
Tran said he wanted to cancel his individual health plan with Blue Shield of California because he was eligible for less expensive coverage through his employer. But getting in touch with Blue Shield turned out to be much more difficult than he anticipated. “It’s been over a month and a half and I still haven’t been able to reach anybody,” Tran said.
Tran's story is a familiar one to Marta Green, spokeswoman for the California Department of Managed Health Care. The agency regulates [or at least, it collects a lot of money from the taxpayers in exchange for promising to regulate] health care plans and protects consumers.
“We have seen our call volume go up quite a bit,” Green said. She attributes much of the increase to the sudden spike in health insurance enrollment due to Covered California.
The rise in complaint volume was so extreme, the department began tracking the number of complaints from people who said they couldn't even reach their insurance providers.
“It was never an issue before this year,” Green said. But the department is only tracking “can’t reach plan” complaints for customers enrolled in Covered California. Of the roughly 1,000 complaints received between January and March of 2014, 1 in 10 people said they were trying to cancel or couldn’t reach their plan.
Green said there’s little consequence at this point for health plans that aren’t responsive to consumers. “If a health care plan is found to have violated the law, they can face enforcement action…[but] there is no specific law in relation to wait times.” Green said consumers can call, email or even send postal mail to the department regarding any issues with their health insurance. She said the department is committed to helping consumers resolve their problems, a process that can take anywhere from a day to a month.
“Every complaint we receive is investigated,” Green said. She encouraged consumers to call the department’s hotline, 1-888-466-2219, where they are guaranteed to reach a human being during business hours.
Don Tran took his complaint online, joining dozens of others NBC Bay Area found on social media, who are posting pictures of their wait times and airing their complaints on Facebook and Twitter. A check of the Facebook pages for the two largest providers in California—Anthem and Blue Shield – revealed new complaints daily.
Kaiser, the state’s third largest provider, doesn’t allow users to post directly to its Facebook page. It’s also where some callers complained they were receiving a pre-recorded message that ended with a dial tone when they called customer service.
“It’s a real hassle,” Tran said, adding that Blue Shield only responded after he posted several comments on social media. Now, more than 2 months later, he finally has his cancellation notice, but didn't get a reimbursement check until a few days ago.
Blue Shield of California spokesman Sean Barry said via email the company has expanded its customer service staff, adding, “We’re committed to delivering a high-quality customer experience. We have put several measures in place to reduce the delays in resolving issues by phone, receiving new ID cards and making payments.”
He directed customers to this customer service home page with a list of contacts to help resolve issues.
Darrel Ng echoed a similar sentiment. In an emailed statement, the Anthem Blue Cross spokesman said, “At the beginning of the year, hundreds of thousands of Californians were added to the insurance rolls on Jan. 1 as our nation’s health care delivery system went through a complete transformation. Because of that, in the first two business days of January, our company received a million calls nationally. Since then, we hired and trained hundreds of additional customer service agents and reassigned hundreds of other internal assets to assist on our phone lines. Through those efforts, the average hold time for customer service was under 3 minutes in March and is down to less than 90 seconds thus far in April.”
Kaiser Permanente spokesperson Karl Sonkin emailed this statement. "Prior to the deadline for Affordable Care Act Kaiser Permanente experienced a higher volume of calls to our Member Services Call Center during peak hours than we typically receive in the first part of the year, and that had resulted in longer than normal hold times. However, now that the enrollment deadline has passed our call volumes have returned to more typical levels and we are no longer experiencing delays."
[Maura Larkins' comment: This seem to be Kaiser's way of saying that patients will be experiencing the same treatment that they received for years before the Affordable Care Act.]
Showing posts with label Blue Shield. Show all posts
Showing posts with label Blue Shield. Show all posts
Tuesday, April 22, 2014
Friday, April 15, 2011
Insurer denied needed medical tests, Senate finds
Insurer denied needed medical tests, Senate finds
In 10 to 15 percent of cases, crucial heart test was rejected by firm hired to screen requests
By Lisa Myers, Rich Gardella and Azriel Relph
NBC News
2011-04-16
“I gotta tell you Kathy, I can’t keep living like this,” said Michael Fields, 46, who was experiencing tightness in his chest, numbness in an arm and light-headedness as he begged the voice at the other end of the line for help. “It’s been going on for weeks. I don’t know what else to do. I mean you know, I’m trapped here.”
“Alright, let me put you back on hold,” came the reply.
Fields, who lives with his wife and son in Elkton, Md., was not speaking with a 911 operator. He was calling a representative from his insurance provider, Blue Cross/ Blue Shield of Delaware, and he was about to find out that for the third time he was being denied a crucial test to determine if he had coronary artery disease — a nuclear cardiac stress test.
A Senate investigation released Friday found a pattern of inappropriate denials for tests like the one Fields’ doctors say he should have received from the start.
The investigation looked at 1,600 cases over a six-month period from 2009 to 2010 involving requests for nuclear cardiac stress tests in the state of Delaware. All of the cases studied were handled by MedSolutions, a company that screens test requests in the state for Blue Cross/Blue Shield of Delaware and other insurers.
According to the report, “10 to 15 (percent) of requested tests appear to have been denied inappropriately. MedSolutions and the Delaware insurers denied a significant number of medically necessary nuclear stress tests.”
“It is a huge number,” Sen. John D. Rockefeller, chairman of the Senate Commerce Committee told NBC News. “I don't care if it is 5 to 2 percent, it is a huge percent. It follows a pattern that never stops with health insurance companies. It is always the bottom line. The more they say no, the more money they make.”
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Michael Fields was one of those found to have been wrongly denied.
Request for test denied repeatedly
When Fields first complained about his symptoms over a year ago, his physician sent him to get a stress test. The request was denied by Blue Cross Blue Shield, and denied again after two appeals by the physician. Finally, his doctor sent him to the hospital, where cardiologists found that a key blood vessel to his heart was almost completely blocked.
Phone calls edited to remove personal info, holds
The next day Fields had an emergency quadruple heart bypass.
“This is as serious as you can get,” said Dr. Andrew Doorey, the cardiologist who saw Fields at the hospital. “There’s no second chance with this.”
When Doorey learned that Fields had been repeatedly denied a stress test by Blue Cross/Blue Shield and MedSolutions, he fired off a complaint to the Delaware Insurance Commission.
Coronary artery disease occurs when arteries supplying oxygen-rich blood to the heart become blocked. It causes one out of every six adult deaths in the United States, according to the American Heart Association. Nuclear stress tests are a way of taking a three-dimensional picture of the heart and diagnosing the disease. Radioactive “tracers” are injected into the bloodstream and an X-ray camera takes multiple pictures of the heart from different angles.
Experts say the nuclear stress tests have a diagnostic accuracy in the 90 percent range. A basic stress test, in which a patient exercises on a treadmill while connected to electrocardiogram (or ECG) equipment, is accurate 70 percent of the time. According to data from the American Medical Association, nuclear stress tests can cost up to five times as much as an ECG test.
Concerns over increasing costs
Over the past decade, there have been concerns about the rapidly increasing cost of imaging tests, as well as accusations that physicians — some of whom own and operate the expensive equipment used — were overutilizing the tests.
In response, in 2005 the American College of Cardiology published guidelines for the appropriate use of nuclear stress tests. In 2009 after one in five heart scans performed were found to be unnecessary, those guidelines were updated. Meanwhile, insurers began using third-party “radiation benefit management” companies, like MedSolutions, to conduct prior authorization reviews of test requests.
MedSolutions claims on its website that it can deliver insurers savings of 25 to 30 percent, stating that it “rewards the clinically accurate providers while protecting patients from unnecessary utilization and associated risks.” But, according to a report from the Delaware Insurance Commission, the company had a financial incentive to deny tests. The report says a provision of MedSolutions’ contract with Blue Cross Blue Shield of Delaware required it to return 10 percent of its administrative fee if the annual costs associated with the services it managed did not fall by 20 percent.
According to Delaware law, it is illegal for an administrator’s fees to be “contingent upon savings effected in the adjustment, settlement and payment of losses covered by the insurer’s obligations.” MedSolutions and Blue Cross Blue Shield say they dropped the provision last year — after the investigation had begun and before any annual cost savings had been calculated.
Karen Weldin Stewart, Delaware’s Insurance Commissioner, was mildly critical of Blue Cross Blue Shield’s overall handling of nuclear stress tests. She complained that, in some cases, tests were denied by medical personnel not fully qualified to make the decision. She said that the company used guidelines less likely to result in approval of the tests than those adopted by the American College of Cardiologists.
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Insurer asked to change guidelines
“Overall, we did not find a lot of problems,” said Stewart. “What troubled us most was that the criteria they were using was more stringent than the American College of Cardiologists uses.” The state is asking Blue Cross to change to the less restrictive guidelines.
In the ACC guidelines, patients with intermediate and high risk to coronary artery disease should be considered for a nuclear stress test. But according to MedSolutions’ guidelines, even a high-risk patient — like Michael Fields, who was a diabetic and a smoker with a family history of heart disease — must first take the cheaper and less accurate ECG treadmill test.
“A stress test, had it been carried out when it was first ordered almost a month earlier, would have definitely picked this up,” said Doorey. “This is someone who was a perfect candidate by broad consensus and the only reason to deny him would be to cut your expenses.”
Neither MedSolutions or Blue Cross Blue Shield would comment on Fields’ case, citing privacy laws.
In a statement to NBC News, MedSolutions' chief medical officer, Dr. Gregg Allen, disputed the Senate's findings and argued that cardiologists overuse these tests, often because they have a financial interest.
MedSolutions has developed guidelines to "ensure that patients receive the right tests at the right time," it said. "At no point, ever, is any criteria considered that doesn’t put quality and safety patient care first."
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Blue Cross/Blue Shield of Delaware said in a statement that it has since changed its procedures, provided staff with additional education, and no longer requires pre-approval of nuclear stress tests. (Manufacturers of machines for these tests include Phillips, Siemens and General Electric — a part owner of NBC Universal, a partner with Microsoft in msnbc.com.)
Michael Fields still has not gotten over the desperation he felt last year. He considers himself lucky to be alive and treasures time with his son even more.
“They're playing God,” Fields said of his insurance company and its subcontractor. “I'm probably cheaper dead than alive to them.”
He pointed to a picture of his 10-year-old son: “I almost left him without a father. It’s crazy.”
In 10 to 15 percent of cases, crucial heart test was rejected by firm hired to screen requests
By Lisa Myers, Rich Gardella and Azriel Relph
NBC News
2011-04-16
“I gotta tell you Kathy, I can’t keep living like this,” said Michael Fields, 46, who was experiencing tightness in his chest, numbness in an arm and light-headedness as he begged the voice at the other end of the line for help. “It’s been going on for weeks. I don’t know what else to do. I mean you know, I’m trapped here.”
“Alright, let me put you back on hold,” came the reply.
Fields, who lives with his wife and son in Elkton, Md., was not speaking with a 911 operator. He was calling a representative from his insurance provider, Blue Cross/ Blue Shield of Delaware, and he was about to find out that for the third time he was being denied a crucial test to determine if he had coronary artery disease — a nuclear cardiac stress test.
A Senate investigation released Friday found a pattern of inappropriate denials for tests like the one Fields’ doctors say he should have received from the start.
The investigation looked at 1,600 cases over a six-month period from 2009 to 2010 involving requests for nuclear cardiac stress tests in the state of Delaware. All of the cases studied were handled by MedSolutions, a company that screens test requests in the state for Blue Cross/Blue Shield of Delaware and other insurers.
According to the report, “10 to 15 (percent) of requested tests appear to have been denied inappropriately. MedSolutions and the Delaware insurers denied a significant number of medically necessary nuclear stress tests.”
“It is a huge number,” Sen. John D. Rockefeller, chairman of the Senate Commerce Committee told NBC News. “I don't care if it is 5 to 2 percent, it is a huge percent. It follows a pattern that never stops with health insurance companies. It is always the bottom line. The more they say no, the more money they make.”
Advertise | AdChoices
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Michael Fields was one of those found to have been wrongly denied.
Request for test denied repeatedly
When Fields first complained about his symptoms over a year ago, his physician sent him to get a stress test. The request was denied by Blue Cross Blue Shield, and denied again after two appeals by the physician. Finally, his doctor sent him to the hospital, where cardiologists found that a key blood vessel to his heart was almost completely blocked.
Phone calls edited to remove personal info, holds
The next day Fields had an emergency quadruple heart bypass.
“This is as serious as you can get,” said Dr. Andrew Doorey, the cardiologist who saw Fields at the hospital. “There’s no second chance with this.”
When Doorey learned that Fields had been repeatedly denied a stress test by Blue Cross/Blue Shield and MedSolutions, he fired off a complaint to the Delaware Insurance Commission.
Coronary artery disease occurs when arteries supplying oxygen-rich blood to the heart become blocked. It causes one out of every six adult deaths in the United States, according to the American Heart Association. Nuclear stress tests are a way of taking a three-dimensional picture of the heart and diagnosing the disease. Radioactive “tracers” are injected into the bloodstream and an X-ray camera takes multiple pictures of the heart from different angles.
Experts say the nuclear stress tests have a diagnostic accuracy in the 90 percent range. A basic stress test, in which a patient exercises on a treadmill while connected to electrocardiogram (or ECG) equipment, is accurate 70 percent of the time. According to data from the American Medical Association, nuclear stress tests can cost up to five times as much as an ECG test.
Concerns over increasing costs
Over the past decade, there have been concerns about the rapidly increasing cost of imaging tests, as well as accusations that physicians — some of whom own and operate the expensive equipment used — were overutilizing the tests.
In response, in 2005 the American College of Cardiology published guidelines for the appropriate use of nuclear stress tests. In 2009 after one in five heart scans performed were found to be unnecessary, those guidelines were updated. Meanwhile, insurers began using third-party “radiation benefit management” companies, like MedSolutions, to conduct prior authorization reviews of test requests.
MedSolutions claims on its website that it can deliver insurers savings of 25 to 30 percent, stating that it “rewards the clinically accurate providers while protecting patients from unnecessary utilization and associated risks.” But, according to a report from the Delaware Insurance Commission, the company had a financial incentive to deny tests. The report says a provision of MedSolutions’ contract with Blue Cross Blue Shield of Delaware required it to return 10 percent of its administrative fee if the annual costs associated with the services it managed did not fall by 20 percent.
According to Delaware law, it is illegal for an administrator’s fees to be “contingent upon savings effected in the adjustment, settlement and payment of losses covered by the insurer’s obligations.” MedSolutions and Blue Cross Blue Shield say they dropped the provision last year — after the investigation had begun and before any annual cost savings had been calculated.
Karen Weldin Stewart, Delaware’s Insurance Commissioner, was mildly critical of Blue Cross Blue Shield’s overall handling of nuclear stress tests. She complained that, in some cases, tests were denied by medical personnel not fully qualified to make the decision. She said that the company used guidelines less likely to result in approval of the tests than those adopted by the American College of Cardiologists.
Advertise | AdChoices
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Advertise | AdChoices
Insurer asked to change guidelines
“Overall, we did not find a lot of problems,” said Stewart. “What troubled us most was that the criteria they were using was more stringent than the American College of Cardiologists uses.” The state is asking Blue Cross to change to the less restrictive guidelines.
In the ACC guidelines, patients with intermediate and high risk to coronary artery disease should be considered for a nuclear stress test. But according to MedSolutions’ guidelines, even a high-risk patient — like Michael Fields, who was a diabetic and a smoker with a family history of heart disease — must first take the cheaper and less accurate ECG treadmill test.
“A stress test, had it been carried out when it was first ordered almost a month earlier, would have definitely picked this up,” said Doorey. “This is someone who was a perfect candidate by broad consensus and the only reason to deny him would be to cut your expenses.”
Neither MedSolutions or Blue Cross Blue Shield would comment on Fields’ case, citing privacy laws.
In a statement to NBC News, MedSolutions' chief medical officer, Dr. Gregg Allen, disputed the Senate's findings and argued that cardiologists overuse these tests, often because they have a financial interest.
MedSolutions has developed guidelines to "ensure that patients receive the right tests at the right time," it said. "At no point, ever, is any criteria considered that doesn’t put quality and safety patient care first."
1.
Only on msnbc.com
1. Ryan budget plan passes House; only 4 GOP no votes
2. 'Creepy' new software is a stalker's dream
3. Cosmic Log: Is this the age of megaquakes?
4. Why watching 'The Office' makes us cringe
5. 10 deadly do-it-yourself gadgets
6. Americans moving near nuclear reactors
7. Wacky minds behind Taiwan's viral videos
Blue Cross/Blue Shield of Delaware said in a statement that it has since changed its procedures, provided staff with additional education, and no longer requires pre-approval of nuclear stress tests. (Manufacturers of machines for these tests include Phillips, Siemens and General Electric — a part owner of NBC Universal, a partner with Microsoft in msnbc.com.)
Michael Fields still has not gotten over the desperation he felt last year. He considers himself lucky to be alive and treasures time with his son even more.
“They're playing God,” Fields said of his insurance company and its subcontractor. “I'm probably cheaper dead than alive to them.”
He pointed to a picture of his 10-year-old son: “I almost left him without a father. It’s crazy.”
Friday, December 21, 2007
Blue Shield Illegally Canceling Policies
Blue Shield Illegally Canceling Policies
Working Californians
The WC Blog
posted by Julia Rosen | 12.13.07
Illegally canceling health care policies is stock and trade for the industry. Their competitor Blue Cross was already fined $1 million by the state in March and Health Net faced a massive court case for doing the same thing. There are lots of reasons why our health care system is a mess and this is one of them. LAT:
California's top insurance regulator has accused Blue Shield, one of the state's largest health plans, of 1,262 violations of claims-handling laws and regulations that resulted in more than 200 people losing their medical coverage.
Calling the allegations "serious violations that completely undermine the public's trust in our healthcare delivery system and are potentially devastating to patients," Insurance Commissioner Steve Poizner said he would announce today that he would seek a $12.6-million fine.
http://workingcalifornians.com/blog/julia_rosen
Each one of those cases is a person who had insurance and got sick. They filed for payments authorized by their coverage and Blue Shield said no and attempted to cancel their policies. These sick people then had to fight tooth and nail to get the payment to their doctors so they would not be liable for the bill. In over 200 of those cases they lost and the companies dropped them completely from coverage. Of course that means that they then have a pre-existing condition and thus would have a next to impossible time getting coverage from another company.
It is a disgusting practice that is all about trying to squeeze out a few more dollars in profits. It is illegal and I am glad to see the state launching the investigation and moving to fine them. It sure would be nice if that dissuaded the companies from trying this in the first place, but I don't hold out that much hope that it will.
Working Californians
The WC Blog
posted by Julia Rosen | 12.13.07
Illegally canceling health care policies is stock and trade for the industry. Their competitor Blue Cross was already fined $1 million by the state in March and Health Net faced a massive court case for doing the same thing. There are lots of reasons why our health care system is a mess and this is one of them. LAT:
California's top insurance regulator has accused Blue Shield, one of the state's largest health plans, of 1,262 violations of claims-handling laws and regulations that resulted in more than 200 people losing their medical coverage.
Calling the allegations "serious violations that completely undermine the public's trust in our healthcare delivery system and are potentially devastating to patients," Insurance Commissioner Steve Poizner said he would announce today that he would seek a $12.6-million fine.
http://workingcalifornians.com/blog/julia_rosen
Each one of those cases is a person who had insurance and got sick. They filed for payments authorized by their coverage and Blue Shield said no and attempted to cancel their policies. These sick people then had to fight tooth and nail to get the payment to their doctors so they would not be liable for the bill. In over 200 of those cases they lost and the companies dropped them completely from coverage. Of course that means that they then have a pre-existing condition and thus would have a next to impossible time getting coverage from another company.
It is a disgusting practice that is all about trying to squeeze out a few more dollars in profits. It is illegal and I am glad to see the state launching the investigation and moving to fine them. It sure would be nice if that dissuaded the companies from trying this in the first place, but I don't hold out that much hope that it will.
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