Incompetence By Design

One of the primary reasons I set about to write down my experiences while trying to survive cancer was to express the frustration that so many of us feel when dealing with so many of the matters with we are faced.  And rather than dwell upon the despondency and despair that is so much a part of having cancer, I have endeavored to turn my focus on these frustrating elements into humor.  And nothing about having cancer is more comical than dealing with insurance companies. 

For my friends who follow this blog from other countries (yes, this is truly a global platform) it may seem somewhat hard to rationalize the “system” of health care cost coverage that we Americans operate (no pun intended) within.  Although not meant as a political commentary, something I try to avoid in my writing as cancer is such a lonely proposition to begin with I figure I need not alienate a substantial part of the population by espousing any political views, I feel compelled nevertheless to come out and say one thing, political or not:  Insurance companies are almost certainly a scam. 

I am no economist or health policy expert.  I am, however, someone who unfortunately uses healthcare more than I would like, which means much more than my insurer would like.  Yet I didn’t ask for cancer as far as I recollect, so both my insurance company and I are stuck with having drawn the short straw.  Despite my lack of formal training in the mystic arts of insurance theory, I think I basically get the concept:  Take a whole bunch of people, pool them together (which means take money from them) and then hope that the money one takes in – which is really just used to bet on the stock market – is greater than the payouts to the sickest among the group.  And believe me:  If I had my druthers I would much rather pay in and never get my money’s worth than be sick like I am.  It may sound anti-capitalist or even downright un-American, but this is one area of life where I think most would agree we would rather “waste” our money than get a healthy return on our investment. 

Fortunately for me, unlike many Americans, I have relatively good insurance.  In theory.  I qualify it in this way because I am convinced that insurance companies are either the most dysfunctional of organizations known to humankind or intentionally act that way.  Or both.  As someone who deals with reams of EOBs and spends enormous amounts of my time, which I consider to be valuable, on the phone with these “organizations” let me set forth my reasons. 

Most basically, insurance companies are effectively at odds with their customers/members.  In fact, the less they can do for their customers, the better off they are.  A member pays them a fee, which is of course significant if not outright substantial, and then it is up to the insurance company to spend as little of that money as possible.  The way to accomplish this is to of course deny, deny and deny.  And they will go to extreme lengths for these denials, including hiring their own doctors, who are often not experts in the applicable area of medicine, to argue with the member’s doctor who actually is an expert.  And, by the way, happens to actually know the patient as well.  A minor fact. 

But oftentimes that is not good enough.  Because sometimes the insurers realize that they just have to pay out.  Yet, rather than do what they are obligated to do – minimally by contract if not by law as well – they will engage in what I am sure is willful ignorance.  They will repeatedly mis-record, mischaracterize, misclassify and just outright miss all relevant data, forcing the patient to spend countless hours in futile conversations with low-level “representatives” who are most charitably under-trained if not completely in over their heads. 

Why do this?  I think for two very obvious reasons.  The first is that insurers must know that they can likely outlast many patients (and providers) in the latter’s quest to get that to which they are entitled.  By throwing up countless “unintentional” errors many people, most of whom are sick (or else this wouldn’t even be relevant), don’t have the energy or, sadly, time to fight these inane battles incessantly.  The second reason is just greed.  It was not always like this, but health insurers are for-profit businesses.  As such, they have stockholders who are looking for a return on their investments.  While I have no problem with that in virtually any other area, I do have an issue with it when it comes to denying someone needed medical care so that the CEO can get a bigger bonus or the stockholders can net a higher return. 

Some would argue that the insurers serve a much-needed role in imposing efficiencies on the healthcare system.  I find such an argument to be at best highly specious.  I say this in no small part because the byzantine rules about what is and what is not reimbursable and at what rate and on and on is imposed largely by the insurance companies themselves.  In other words, how can we claim they are making the system more efficient when they are the ones largely making it so inefficient to begin with.  (I will acknowledge that Medicare engages in similar contortionism so this is not just a for-profit phenomenon.) 

All of this has once again come to mind as I spent an hour on the phone yet again with my former insurer.  Because my erstwhile insurance company mistakenly believes that it was my secondary insurer, when in fact I was lucky just to have any insurance much less two insurers, it is insisting on denying my claims until the phantom primary insurer ponies up.  Honest mistakes do happen, but given that I have repeatedly explained this to them using the smallest words possible – most recently ten days prior – I am, I think, understandably dubious about their intentions.  In fact, I had even offered to write a letter detailing all of the relevant dates of coverage and member ID numbers and all other pertinent information.  I was told, however, that such a letter would not be necessary.  Why not?  Because then that would make their incompetence that much harder to justify.  But I have faith in them – I am sure they would just claim to have never gotten the letter in the first place.   

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