This article is in the LA Times titled Doctors balk at request for data:
The state’s largest for-profit health insurer is asking California physicians to look for conditions it can use to cancel their new patients’ medical coverage. Blue Cross of California is sending physicians copies of health insurance applications filled out by new patients, along with a letter advising them that the company has a right to drop members who fail to disclose “material medical history,” including “pre-existing pregnancies”.
Firstly all aspects of medical care, including insurance, are regulated to bits in the United States (especially in California), and it is the government regulations and subsidy programs (such as Medicare and Medicaid – but in recent years SCHIP as well) that are at the root of the high price of medical cover. But to turn to the specific question:
If someone lies about their medical history when filling out a contract, in order to get less expensive medical cover, they are guilty of fraud. In an alternative world, which I am not saying I would support, they would not only be dropped by their insurance company when their fraud was exposed – they would also be prosecuted.
Of course, in our world, they will not be prosecuted and would not be convicted if they were prosecuted. It is much the same with all the political talk about “fraudulent lending” in the mortgage market. There has been vastly more fraudulent borrowing, but I doubt that the vast number of people who lied on their mortgage applications (for example claiming to have an income much greater than they really have) will be prosecuted.
However, in an alternative world (which, again, I am not saying I support) prosecution and conviction would solve the problems of customers guilty of fraud – medical cover and a roof over their heads.
Prison provides both.
California Blue Cross is a sub of WellPoint, a listed compnay which is coming under political fire for efforts (along with others) to purge its rolls of healthcare exposures before claims are filed.
“False” or misleading application data can be grounds for claim denial. But “Claims Expense” that is the admin of claims as distinct from claims payments is a major expense factor. Reduce that and premium increases can be restrained.
All said however, what this points out is the need to separate Insurance (the transfer of risk) from healthcare (provision for known needs [pregnancies and existing conditions])
Until that separation is made (and maintained) the U.S. will get nowhere with its “uninsured” issues.
Now, as to why doctors “balk,” it has nothing to do with confidentiality, that is waived by the app filed.
But this process asks practicioners to spend extra time, incur extra costs to serve the interests of facilities that challenge their charges, delay payments, and second guess procedures.
“Why should I spend my time and money to help those ….?”
Firstly, doctors do have a personal thing about doing stuff that might result in harm to a patient, even if the patient is breaking the law. (Like not necessarily telling law enforcement about treatment for drug overdoses or gunshot wounds.) If telling results in people not seeking treatment and dying as a result, they would prefer to keep quiet and save lives. Is a person’s life and health worth more or less than obeying the law?
They have their own personal oaths and ethics. I believe there is a part of the Hippocratic oath about respecting privacy – “What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.” The disclaimer might mean there’s no legal impediment to disclosure, but there may be others. Can insurance companies compel a doctor to disclose the information?
Also, I suspect the doctors’ ethics would dispute the idea that ticking a disclaimer is sufficient to override a person’s right to medical privacy. It’s the idea of “inalienable” or “natural” rights, like that you can’t legally sell yourself into slavery, or sign away your Geneva Convention rights. A contract including such a term would be void.
There’s also a question about liability regarding the information’s accuracy. If you’re effectively providing evidence regarding a crime, you might have to think about all sorts of standards of evidence, libel laws, and the potential for being sued should you mix up the records and tell them Mr Jones has a prior pregnancy when in fact he hasn’t.
Why is it the job of doctors to do the work of either insurance companies or police? A relationship of trust exists between doctors and patients. It should be preserved.
I think this blog has rightly expressed dismay at UK laws requiring accountants to inform the authorities of any irregularities in their clients’ declarations.
Should doctors be required to turn informer?
Since the matter of sub-prime was raised-well!
Afew years ago the Boston Rederal Reserve published a report purporting to show discrimination against Negroes by banks. Highly unlikely on the face of it but one has to wonder what role role various agencies (FTC , Fed.etc),ACORN et al played in getting these unsound lending processes started. With but one exception I have seen nothing of this in tne press, or anywhere else. Ignoring the elephant in the room-kind of like your MSM and Parliament pretending that they have any say in things and that Brussels doesn’t exist.
Paul,you are a true freak. If only our journalists here knew half as much and understood a tenth as much about the US we would be well served.
The Privacy or confidentiality between physician and patient belongs to the patient, not the physician. If, to obtain some other benefit – such as admission to a special treatment facility, or any other, the patient waives his claim, it is not the contracting away of some imagined “natural right” to privacy.
The implied “chilling” of full communication of patient to physician is a straw dog when one thinks it through.
Yes, if a waiver has been given, a physician can be compelled to give evidence of the communications with the patient. What do we suppose all those pieces of paper (consents, confirms, etc.)are for?
Once a person wraps another person or entity into their affairs, by contract or other relationship, that person’s segregated existence in those particular affairs ends, the person is conjoined.
That my friends is one of the elements of “compulsory health insurance” that gets little of much needed attention.
1) Word to the wise–the LATimes is especially liberal and especially selective in what it reports as news.
2) sometimes the definition of the term “pre existing condition” used by some insurance companies here in the US and the definition used by the layman don’t match very well. There have been cases in which, for example, someone is accepted for coverage, shortly thereafter is diagnosed with cancer or another illness, and finds that the insurance refuses to cover the condition–or even cancels coverage completely–because the cancer, although not yet discovered, was in existence before the coverage began, and therefore “pre existing” according to the insurance company.
Pre-existing pregnancy?
That’s an easy one to solve, really. Just have a 9-month delay before any expense related to pregnancy (other than abortion) is covered.
“Should doctors be forced to be informers for insurance companies”?
No – but insurance companies should not be forced to pay doctors who break contracts or will not sign them.
If you want to be noble, treat the people for free. Being noble at someone else’s expense is not being noble.
Before the 1950’s medical insurance was not the norm.
In the past mutual aid societies used to be far more important than they are now – “fraternity” (“friendly society” in Britain) did not normally mean group of drunken students.
Also medical care was much less expensive – so even individuals who were not in mutual aid socities could often pay their way.
It is NOT a natural process that has made it so expensive, relative to income, today – it is not really a matter of new technology and drugs making everything so expensive.
The real reason for the high cost of medical care is the vast web of government regulations and subsidy programs.
Unless they are rolled back there is no hope of affordable medical care.
Many years ago when I was on the fringes of the insurance business, those of our clients who wanted a very large policy had to take a strict medical examination at the hands of the potential insurer’s doctor….not his/her own. There was much at stake.
It is possible that this has changed but I would seriously doubt it.
It seems reasonable to me that those applying for Health Insurance should be ready to submit to examination by the provider. There is much (a lifetime’s health) at stake.
I do not see why family or other physicians should have to play any part in this whatsoever. Their job is to keep you alive.
……or have I missed something?
Paul, you also should consider that before the 1950s there were a lot more diseases classified as ‘uncurable’ and that getting old, weak and then dying was ‘normal’ rather than something that you were hospitalised for.
Got cancer? Die.
Liver failure? Die.
Kidney failure? Die.
Hips break when you get old? Bedridden.
All of these problems have now become ‘curable’ but at vast cost. It’s very well saying ‘just remove the regulation’ but there still has to be competency. If you were to remove competency regulations from surgeons, what would be the charges levied against them if they performed an operation and bungled it? How would a court be able to assess their competency? If you suggest a surgeon’s association that judges its members on competency and certifies them suitable to perform, what about the large numbers of ‘affordable’ surgeons that presumably wouldn’t meet that high standard and serve the ‘I’ll take a chance’ market?
Also, I think health has become overpublicised and people are paranoid. How many times are mothers meant to take their babies to the doctor in the first year? Apparently the average person visits their doctor in the UK 5x per year, which I find just insane.
I read the article to be saying doctors are baulking not at disclosing fraudulent claims, but at participating in an exercise calculated to result in policies being cancelled for non-material discrepancies in applications.
Would the premiums be refunded in such cases? If someone enters into a contract intending to take the money but afterwards to conduct a systematic search means to avoid giving the service they have offered, then I reckon that’s fraud too.
It is not “non material” Guy.
The medical condition someone is in, and what state they are likely to be in in the fututure, is what calculating a premium is about.
This is a prinicple that regulations in the United States (especially in States like California) often ignore.
And not just in health insurance.
“non discrimination” is applied to house insurance.
Lascaille:
Yes there is new technology and new drugs.
But the primary reason for the rise in health care costs is government regulations and subsidies.