Cigna Provider Dispute: Fill & Download for Free

It bears mentioning up front that I am a capitalist, that I don't have any particular beef with the insurance industry or the medical industry, and that I am a Republican in the Jeffersonian sense (but with enough Teddy Roosevelt that I don't have a lot of patience for corporate abuse). With regards to the GOP, I don't think they're being particularly Republican anymore, but I'll come back to that later.The fundamental problem with health insurance—and one we would be wise to understand up front—is that it involves an *inherent* conflict of interest, in ways that no other insurance scheme has.Making a profit as a car-insurance company is straightforward. You calculate the risks, charge enough to cover the payouts you are likely to incur, and try to keep your prices competitive while providing drivers incentive not to drive in ways that are likely to result in payouts. People that pay into the system but never get into accidents wind up providing the funds to pay out to people that *do* get into accidents.Ethical insurance companies work this as a relatively straightforward system. Unethical insurers found early on that they could increase their profits by just not paying claims. This led to quite a load of insurance regulation over the years—additional law that applies to a specific industry—and justifiably so, because it cut down on this abuse.But the fundamental model is about balancing risks between those who don't get into accidents and those who do.This doesn't translate well to the health insurance industry, because you can't really balance out those risks. Pretty dang near everyone needs medical care from time to time. A very fortunate few of us can go decades without exhibiting any illness and then suddenly drop dead, but that doesn't describe the experience of most of us. From childhood diseases to accidents to infections to cancer, the vast majority of us are going to incur something that will necessitate medical care.So there's rarely (if ever) a case where the people that never get sick cover those who do—*everyone* is likely to need medical care.So how do you make it as an health insurance company?You're still balancing risks, but your main tactic is (a) to reduce payouts by pushing medical facilities and personnel to take much lower payments, (b) pushing medical facilities to provide the least expensive care, and (c) try to engineer your cash flow so that people wind up essentially paying for their own medical care over time (with the benefit of your fee negotiation), recognizing that some kick off earlier than others.That said, the *very* best way to improve your profits is that good old standby: not paying out even when you should. There are some real advantages to doing this in the health industry, though: if you don't pay out in a timely manner, thus denying treatment to a particularly costly customer, the customer is less likely to sue you because being dead tends to rein in litigation.The case of CIGNA's handling of Nataline Sarkisyan is a case in point. Nataline was a 17-year-old who needed a liver transplant—the only way she could survive. In spite of liver transplants having been done for twenty years with a very good success rate, and that Nataline had a good chance of recovery, CIGNA denied the claim on the grounds that it was an "experimental procedure." They did reverse their stance, after a massive public backlash, but only did so a few hours before she succumbed to liver failure.In the meantime, CIGNA was informing its shareholders that its profits were increasing (22% that quarter).That's what the free-market healthcare system was coming to.The PPACA, for all its flaws, continues to keep insurance embedded in private industry, but imposes further regulations to try to rein in further abuses while at the same time trying to bring down costs so that health insurance is more affordable. This is a reasonable compromise, to my mind, and I'm watching to see how it shakes out, but the positives significantly outweigh the negatives so far. No, it's not a perfect solution (what is?), but it was significantly better than the status quo, which was all that the GOP was offering.Which brings us to the nut of the question: why are single-payer plans so attractive to some people?The main reasons are these:Fee negotiation can be much more effective. When there's a single-payer plan, facilities and equipment manufacturers and suppliers can't really play off one company against another, and the plan can negotiate aggressively.Simplicity for both the consumer and supplier. This isn't to say that it isn't complex, but with only one set of processes, it's easier for everyone to deal with. Streamlining processes helps everyone, not just people with a particular insurer.No conflict of interest—single-payer plans are not profit-driven.That said? I'm not that crazy about a single-payer plan, for one reason: there's no good escalation process.For example, my parents are on Medicare, which is a government-run single-payer plan. It's actually worked out pretty well for them, even though they're both devoted to the Rush Limbaugh School Of Everyone Else Is Evil. They've gotten various parts replaced in a timely manner, and haven't gone broke in the process.BUT, should there be a dispute, there's not really an escalation path. With a normal health insurance company, you could involve your state representation, the state insurance commissioner, and maybe even get your federal representation involved if it came to that. When it's the government, . . . that's pretty much the end of the line as far as dispute resolution.I think the best answer is going to be something along the lines of the PPACA in its final form. Yes, I think it will have to be adjusted over time, but the GOP fantasy of eradicating it (and thus affordable health insurance) is misguided and frankly vile. Come up with sensible regulation and amendment to make it better? By all means. Shut down the government over it? Reprehensible.

Well it depends. It depends on who you think the healthcare industry should serve: Corporations or citizens.Republicans are convinced that corporate profits are of uppermost importance and that having a lot of hands in the pot somehow makes everything less costly (one could point to the actual statistics to dispute this).Democrats believe that the general welfare clause of the Constitution is pretty clear: the government isn’t here to serve up as much profit as possible to the healthcare industry, but is rather here to make universal affordable healthcare available.So seeing that new $10 million dollar mansion built for one of the VPs of Cigna or United Healthcare may cause a Republican’s heart to beat a bit faster, stronger, and with great pride. There! He says—the American dream, built by the sweat of brow and the determination that only an Ivy League education can give you.A Democrat can look at that same house and see the steady drip of pennies stolen from poor families who cannot pay the sums of money necessary for cancer and stroke treatments. There! He says—America, built on the backs of all those who were unlucky enough to have diabetes, heart attacks, cancer, kidney disease, or who were in accidents and brought to an ER on a helicopter, a helicopter ride that just bankrupted them for life.So…it depends.

Let’s put this answer in a hard brass tacks ‘In the waiting room’ perspective…This is a RULE. Not a LAW.There’s a whole ocean’s worth of difference between those two little words.In short— A RULE can be argued, disputed and delayed. A LAW Must be OBEYED.“…The federal rule, which would not take effect until 2021, is part of a broader push by Trump officials to make health care markets more transparent to patients…” [I got this from the New York Times— but the NYTimes is paywalled. Google this topic and you will get pretty much the same info]First—The fact that it won’t take effect until 2021— a WHOLE YEAR LATER— gives all the Interested Parties involved time to mount their research & lobbying efforts to the involved agencies and to their Local Representative Senators & Congresspersons.Interested Parties… as in Hospitals and Hospital Industry Groups. Doctors and Medical Professional Interest Groups. Insurance Companies and Medical/Health Insurance Interest Groups.Oh…By the way: They ALL do so with Lobbying Groups stationed on K Street. Lobbying Interests with DEEP pockets and the ability to write VERY LARGE campaign contribution checks. The VERY SAME Interest groups who were present at the table when the Affordable Care Act was drafted.Rest assured…by the time 2021 rolls around, this RULE will be very much sliced and diced into worthless diminutive pieces once all these political worthies start popping out their smart phones and ringing their respective Congresspersons Cellphones for an ‘Urgent meeting’And PS— A LOT of those Congresspersons…will be REPUBLICANS as well as Democrats. They WILL answer those phone calls.Second—Hospitals don’t have just ONE set of Prices. They have MANY.Each Price Set is determined and negotiated for EACH Separate Insurance Plan.Note— I said Separate Insurance PLAN. NOT Each Separate Insurance COMPANY.Each single Insurance Company, be they United Healthcare, Cigna, Blue Choice, etc have MULTIPLE TIERED PLANS under their corporate umbrellas.The Rates and negotiated Plan Prices per Procedure (The Things the Medical Professionals do when they TOUCH you, Poke you, IRRADIATE You, or just TALK [The Blah-blah-blah ‘Consultation’] to you) are DIFFERENT.Each DOCTOR in the Hospital ALSO accepts Different PLANS that may be Different from THOSE PLANS Directly Negotiated by the Hospital.Remember— There is a Difference between the Doctor who is an EMPLOYEE of the Hospital and the Doctor who is a Medical CONSULTANT looking at your case.The First one works for the Hospital— The Check gets made out to the Hospital.The Second one is only AFFILIATED with the Hospital— A SEPARATE Check gets made out to him or her DIRECTLY.THIRD—The Average person thinks of a Doctor Visit like the following:You get to the Office.You sit down.The Reception calls you inYou get into the Exam room.A Nurse or Physician Assistant come and goes.The Doctor walks in, Talks to you. You tell him things. He writes prescription.You Leave.Most of the General lay public get back outside and thumbs their car key pad thinking: ‘That was my Doctor Visit.’ With the most annoying part being sitting in the waiting room for more than 15 minutes.No— That was NOT a Visit.The ACTUAL ‘Visit’ is ONE CPT Procedure Code: 99213BTW— There’s more than ONE Visit Code depending on Complexity and amount of Time involved.99213 is Just you walking in for your appt and sitting your behind on the crinkly paper on the exam Bench.The Nurse or Medical Asst walking in...They drew Blood for a CBC— Phlebotomy CPT Code - That’s another 5 digit code NOT for the CBC test— it’s the CODE for DRAWING the Blood.The actual CBC Test— A Blood CBC Test Code - CBC with Differential? CBC with Platelets? Different Additional CPT Codes.Blood Sugar Screen? Additional CPT codePee in the cup? Urinalysis CPT CodeDid the Medical Asst scrape your mouth? Did they take a saliva Sample? Additional Quick Strept CPT Test CodeDid the Clinic send you to another floor for an Xray? Radiology CPT Code.Now that’s just a Basic Well Visit.EACH Separate CPT Code has a Price Tag. They ALL ADD UP.Each individual Price Tag is DIFFERENT depending upon whether your Health Insurance is United Healthcare, or Local Union 509, or if you have NO HEALTH INSURANCE AT ALL.In our Office… we PAY YEARLY for Updated CPT CODE BOOKS. They are INCHES THICK.But there are NO PRICES in these books…because the Prices we will be paid for these procedures are Determined By the INDIVIDUAL CONTRACTS with the INDIVIDUAL Health Insurance Companies according to their VARIOUS Insurance PLANS that our Office PARTICIPATES IN.Now imagine if the Doctor Office were to somehow ‘POST’ a List of his CPT CODE VISIT Prices to his ‘Customers’ in the waiting room.They would have to cover ALL the CPT Codes and what they actually MEAN. Then they would have to group them by Insurance and then By Insurance Plan.We would just as well have to print a 20 page BOOKLET in 6pt font and hand it to the patient.A Hospital would have to print an ACTUAL BOOK since they do EVERYTHING.And when you visit a Hospital, in pain, possibly needing Surgery… who has the time or frame of mind to deal with all that information.MOST PEOPLE really don’t even have a CLEAR IDEA as to WHICH LEVEL INSURANCE PLAN they are currently, actually enrolled in! They just know they have Health Insurance and “Here’s my Card…”Back to the Question—It’s a Rule. NOT a Law.And even as a Rule…it’s frankly UN-enforceable. I would dare say it’s more of an election campaign public relations blurb than an actual policy…especially since it’s actually staved off until AFTER the Nov 2020 Election.As a concept, it’s Laudable…but not Practicable. Our Health Care ‘System’ IS NOT A MARKET.We are NOT ‘Customers’ who can intelligently or cogently choose between Service Providers according to ‘Advertised’ Prices. I say this as a factual statement in that we DO NOT HAVE ACCESS to the CONFIDENTIAL CONTRACTUAL PRICING negotiated between the Medical Professionals and the Insurance Companies.There is a REASON for this — and that Reason is NOT for the Benefit of the Public.Hospitals and Doctor Offices are NOT Retail Stores.It’s an Interconnected System of Privately Brokered Confidential Contracts between Medical Professionals, Hospitals and Health Insurance Companies that services People as Healthcare CLIENTS.Healthcare in the USA is far more complicated than we’d like to think.It’s going to take far more than a campaign blurb to fix…