Cigna: Crapification or Insurance Fraud?

We’ve been slowly working toward a theory of crapification and if we manage to sort it out, we might even develop a school of craopnomics. But in reality, Corporate America presumably already has that well codified but has yet to release the playbook to the great unwashed masses.

As much as I am of two minds about sharing personal anecdotes with readers, my recent experiences with the health insurer Cigna amount to several case studies in crapification in one nasty package. Moreover, since the American health care policy is to force even more Americans into the health insurance regime and call it “health care,” I thought my tale might elicit similar accounts from readers, as well as input from people who’ve worked in the insurance industry as to how much of what I am experiencing is incompetence versus design.

We’ll start with some examples (trust me, I have even more) of what’s been going wrong with Cigna. Then we’ll step back and consider why this might be happening.

Continuing Deterioration in Cigna Claims Processing

I am in the unusual position of having had the same policy since 1991. That enables me to speak with knowledge about how Cigna’s service has decayed over time.

The policy terms have not changed, save for price increases and some changes mandated by Obamacare, the most important being the lifting of a lifetime cap. The policy was not very good by 1991 standards, but due to the general degradation of health insurance, it is now an extremely good policy. Its most attractive features are that it has a low deductible (and no separate pharmacy deductible), is pretty cheap, and is an indemnity plan. That means I am not restricted to a network, nor am I subject to gatekeeping (I can go directly to specialists). It also covers doctors all over the world. For instance, when I was in Australia for two years, it reimbursed my doctor visits there, and has also covered medical care in the UK and Thailand.

Another big positive feature is that my Cigna policy is regulated by New York State, which means I can go to the state insurance bureau for external appeal. The few times I have, the state has come down on Cigna like a ton of bricks.

For most of my first 15 years, when I submitted claims, the would be processed quickly and without dispute. Occasionally, there would be some drama (and this would come in 6-18 month episodes) where it appeared Cigna was on some profit-increasing exercise and my policy would get included among the targets. For instance, certain charges would suddenly be haircut as being in excess of “ordinary and customary” or services that were clearly covered would be denied. One example is that New York State mandates that insurance plans cover 15 chiropractic treatments a year. Cigna started trying to deny chiropractic claims after having paid them for years. That led to a letter to the state bureau and the state told Cigna that it was out of line.

Things started taking a turn for the worse in 2007 when my policy was moved from one database to another, and the records showed it being a new policy as of that date. Claims were regularly processed incorrectly, and I’d have to tell agents to look in the legacy database to see that claims that were being denied had clearly been covered in the past (fortunately, I keep all my records and so could point to specific past claims). But in fairness, that problem looked more like an internal cock-up, since once I pointed out the mistakes, the submissions were usually reprocessed correctly.

The next ratchet down occurred in 2009 or so, when Cigna would simply not process 20% to 25% of my claims. This pattern continues to this day, although the percentage that goes “poof” now is more like 15%. And mind you, I am very healthy. Even with my low premiums, Cigna makes money on me on an annual basis, so it isn’t as if I’m seeing a ton of doctors and they’ve put me in some sort of “medical service overuser” category (not that they are allowed to do that either, BTW).

Previously, every single claim led to a letter back with the usual results, either a payment or credit against my deductible, or some explanation as to why they thought the service wasn’t covered. Suddenly, a large proportion of my claims appeared to go directly into a Cigna trash bin. And since none of my other mail (including payments of Cigna premiums) was going missing, this failure to process claims can’t be attributed to the US Postal Service going rogue. I had to start recording the date of every time I submitted a claim to Cigna, the provider name, date of service, and dollar amount and following up.

We’ll skip over some chapters to get to the most recent incidents. The latest looks like a textbook case of insurance fraud, meaning failure to honor a valid claim, and I will be sending a letter into New York State on this occurrence when I find time.

Drug claim rejection. I sent in some recent prescriptions. I pay those in cash and then send them in for reimbursement. I submitted the same paperwork that the drug store has provided for the last ten years and Cigna has heretofore accepted.

Cigna sent a letter back. The reason for not processing the claim was “Claim is missing detail charges.” They included copies of the drug store prescription information that I had sent in, which was fully legible, and included the usual information, such as the date the prescription was filled, the name and strength of the medication, the Rx number, the doctor’s name, the dollar amount.

Thus per what they sent back, there were absolutely no “detail charges” missing.

When I called Cigna, I got an astonishing run-around from the rep, who told me that Cigna had not scanned the drug store information (if they had a scanned image, I could simply demand that the claim be reprocessed) but that he could look in my records and see past prescription claims and he could see it was identical in form to the ones that had been rejected. <strong>How could he see it was the same if there were no scanned images?

Now this situation isn’t (in theory) as difficult to remedy as others, but you can see what is going on here. This looks like an effort to delay payment, and for other people who encounter the same run-around, some may not resubmit their claims before Cigna’s time limit for submission expires, so Cigna will get away with not making payments that it was required to make. (Note that Cigna has recently imposed time limits, which in theory should not apply to me, since this is a change in terms and Cigna did not comply with the state-mandated procedures for making that change, but I haven’t had time to get around to that fight).

Bloodwork runaround. I’ve get a lot of blood tests every year since 2001 for reasons not worth discussing. Until this year, Cigna reimbursed it all.

This year, it refused to pay on half the tests, claiming they were preventative in nature and hence not covered. I called Cigna and referred them to my most two previous years of bloodwork, which Cigna paid in full. Every time, the rep agreed that 1. My policy has not changed since 1991; 2. It does not differentiate between preventative and therapeutic care (the “preventative care” concept is absent from the policy) and 3. They saw no reason for the claim not to be paid.

6 reps (including a supervisor) submitted the claim to be reprocessed. That means I as the customer should get some paperwork back as of a date certain (the customer service staff would typically tell me when the letter ought to go out).

I never received anything from Cigna, which again strongly implies that the customer service reps are just for show and claims processing is simply trashing claims they don’t like.

In addition, Cigna has the usual automated prompt system you must navigate in order to speak to a live person. One of the things they ask is whether this is the first time you’ve called about this matter, and if this is not your first time, how many times you have called previously. I also learned in this process that if you respond with a number 3 or higher, your call will be disconnected when it is supposedly transferred to a customer service rep more than 50% of the time.

Doctor visit Catch-22. I saw my regular MD earlier this year. I paid via credit card even though she is a Cigna network doctor and prior to this year, I’ve had her office handle the “deal with Cigna” hassle and submit the claim. I decided to pay because my reading of Obamacare (and I’d welcome expert input) is that if the provider accepts the patient’s insurance, the medical records transfer to the insurer is seamless. If the consumer pays, my understanding is the insurer has the right, as before to ask the doctor for records if it needs them to process a claim, but is not automatically given access to them (as in their rights to my records are the same as before, as opposed to increased under Obamacare).

This usually results in some hassle with in-network doctors, since I pay the rack rate, and then Cigna tells them what the discounted rate is and reimburses me only based on the discounted rate. Then I have to go back to the doctor to get a refund. That normally goes pretty smoothly.

In this case, the doctor’s office was not willing to issue the refund. I went back to Cigna, since in those rare cases when that has happened, either Cigna needs to reimburse me based on the non-network rate or tell the doctor to issue the refund. I spoke to two reps who looked at my policy, agreed this was screwed up. Each put in the claim to be reprocessed. I even got reference numbers and dates certain when I should expect a response from Cigna.

Again, nothing came back. I called a third time. This representative maintained, contrary to what the two previous ones said, that my doctor was not a Cigna doctor. I said that wasn’t right, but if so, that meant my claim should be reprocessed at the rate I had paid for services. He tried to maintain that the “Multiplan” discount, which is a network discount calculated by a third-party vendor, was the “ordinary and customary” rate, which is utterly ridiculous (the fee for the visit was normal for NYC standards and the discount was shockingly large, 63%).

I then called my doctor’s office and told them Cigna told me that my doctor was not in the Cigna network. Outrage ensued. They then passed me back to a person in their billing department who told me that even though the doctor had been with Cigna since 2001, Cigna had said the same thing with respect to some other patients. She had submitted paperwork twice with Cigna to get it fixed, once in May and again in June and it clearly was not resolved.

What These Experiences Say About Cigna

I’d very much like to get input from readers on what has been happening here, since I’m not in the same position as most customers, given my unusual policy terms. But the flip side is that it’s well documented that when insurance customers have hospital bills, they often find numerous inexplicable and invalid charges, as well as too often have a huge uphill battle in getting a significant portion of valid charges paid. I may be running into the same treatment at a much lower level simply because I have a non-standard plan that they regard as inconvenient to process. In other words, this may be another version of what Lambert calls “code as law”. Either I accept having terms that are not in my policy imposed on me, like not having preventative care covered, or they’ll do their damndest to harass me into submitting.

And an addendum: earlier this week, after I discovered the Catch-22 problem, I received a call from an independent marketing service asking me to rate the quality of my last customer service call and tell them whether I’d recommend Cigna to a friend. The call not only allowed me to give the expected low ratings but allowed me to leave some 30 second comments. Presumably as a result of the low ratings, the service asked me to leave a number so a Cigna representative could contact me. Needless to say, no one has called, confirming my experience that Cigna’s customer service is all hat, no cattle.

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  1. geoff gray

    you have a non-standard plan. insurance companies for years have issued all kinds of plans to customers they could not effectively service. your antiquated plan is a big outlier. it doesn’t fit into a problem resolution slot–too much complexity–so your problem is disappeared. same thing kind of thing happens with comcast. if the problem is non-standard, the call gets disconnected.

    1. Garrett Pace

      I wonder about agents disconnecting deliberately if they know it will be an unusual problem, as that will harm their call time and resolution rate.

  2. John

    Here in Europe we have a hodgepodge of health insurance plans. But what is common is there is strong government intervention on allowable costs from drug makers, GP pricing and clinical care.

    Like in the US insurance is generally tied to employment. Your company pays for your plans. In Belgium we have non-profit insurance exchanges which you become a ‘member’ of. When you have a claim you file it and they pay a portion of it. Yes, you do have a deductible but nothing like what Cigna would charge, for instance. And you don’t get the run around. You do pay full amounts for elective procedures.

    Those same scamming drug companies pilfering American wallets pay premiums to European governments usually at the end of the year — usually in the millions of euros. Drug companies pay this premium in order not to be penalized for governments selecting other drug makers. The drug premiums are passed onto the public in lower costs.

    Clinics are heavily subsidized so your deductible is (usually) low. Your insurance pays the rest. If you see a specialist for out-patient care, you are not going to be taken to the cleaners.

    Of course, things are slowly changing. With austerity we are seeing more out of pocket expenses for health-care. Some countries have gone kleptocracy with their heath-care systems.

    The American health-care sector is overwhelmed with the profit motive. CEOs see only this: 30-60-90. In other words, revenues must exceed the previous period. Europe on the hand have kept the profiteers out of the health-care sector out for the time being.

  3. Bryan Sean Mckown

    One of the things you purchase with your health care insurance premium is claims administration. Whether it is Cigna, some other carrier, CMS for Medicare, health care Providers or your local doctor’s office, there is an industry wide trend of forcing the patient to become an unpaid claim admistrator, unpaid quality control officer or unpaid attorney when you uncover systemic unfair health care business practices. Don’t dance with them. Impose cost on them by going straight to appeal often an entirely different department. Deploy contract law, state or Federal collection law in your jurisdiction, or stiffer claims where fraud is uncovered. When you are dealing with an “In-Network Provider” that provider is bound by their own contract with the health insurance carrier. The patient is a third party beneficiary to that contract. Police that contract – no billing to the patient beyond contractual limits. Read the Privacy form the receptionist has you fill out – it may contain an assignment of insurance rights adverse to your health. Recommend NC start a new topic – “Health Care Billing” – a large and growing part of the economy.

  4. Skeptic

    Wow, you really need a Health Care Consultant to take care of all those details and ins-and-outs. Love the one about the Phone Dump, happened to me many times. There is certainly one big book in that tale. Good on you for keeping after the deniers. (There should be a penalty for a business that denies a service which is then proven to be due, That would solve a lot of this obfuscation.)

    I have found that Modern Life consumes a lot of time just getting ordinary things done. The Government and Sidekicks Corporadoes make things so obtuse and difficult that large swaths of time are unnecessarily consumed. Most of it is deliberate and calculated on their part to increase profits.

    A friend of mine had a son working in “Customer Service” at a telcenter. This fellow did well initially and was sent for advanced training. After the course, he quit the job telling his father that he could not engage in the manipulation and deception he would be required to do at the advanced level.

    My one steadfast rule of Modern Life: limit your transactions/involvement with Government/Corporadoes as much as possible wherever you can. Get the service/product from and independent/non-1% business if possible.

    (One Government Tale: I file my income tax manually, believing that electronic filing is more easily audited. This year they just lost one of my papers and just did not enter the numbers in the puter. So, the usual back and forth, and I now wait for a considerable amount of cash. Deliberate, you bet! They just do not want any manual returns or to fork over any loot.)

    1. John Zelnicker

      You are mistaken about electronic filing versus manual. I am an Enrolled Agent representing clients before the IRS and preparing tax returns. The issue with manual filing is the error rate for clerks doing manual inputs. For manual returns the rate is about 8-9%, for e-filing about .0005%, just as you discovered when a form of yours was lost and your refund is now delayed. No returns are picked for audit before they are input, so your manually recorded return looks no different than any other when the audit picks are made. With the loss of your form, there are now several people looking at your return in order to fix it instead of it quietly sitting among the millions of e-filed returns that haven’t been seen by human eyes. Also, one of the methods for picking returns to audit is a screening process that looks for deductions that are out of line with norms based on income, such as charitable deductions. If the manual input misplaces a decimal, you could end up being audited due to their mistake. Another factor is that budget cuts to the IRS have resulted in too few employees to do the job with adequate care and concern. More crapification, although I have to say that every IRS employee I have dealt with is dedicated to providing the best service they can.

      1. zapster

        After several years of running the e-file for-profit scam gamut that is allowed to piggyback on the IRS, I went back to filing paper returns in sheer protest. I am completely disgusted with the deceptive click-bait nonsense it entails.

        1. John Zelnicker

          You can e-file for free through the IRS website if you meet certain income requirements ($55,000 annual income IIRC).

    2. diptherio

      I wonder if the NY Insurance Commissioner could subpoena the underlying code for the Cigna’s voice-prompt system. That shouldn’t be a “trade secret” should it? I’m guessing that there might be more than one piece of incriminating code in there.

    3. Banger

      We exist as food for the corporate oligarchs–they have nibbled a little at us and are now planning a bigger feast in the next few years–something has to give.

  5. Jim Haygood

    A neighbor new to Medicare asked my help in parsing out a multi-page statement from the Medicare administration, accompanied by a $180 check. Nowhere did the statement show how the $180 was derived.

    Forensic accounting revealed that:

    1. The four pages, each with several lines of billing codes, covered two different claims, XXXXXX-070 and XXXXXX-080. Claim 080 was randomly sandwiched in on page 3 of 4, then claim 070 continued on page 4.

    2. Columns headed ‘Amount billed by physician’ and ‘Amount paid to you’ appeared on every page. A comparison revealed that the latter column was 80% of the former, evidently corresponding to a 20% copay. Nowhere was the copay percentage actually stated or explained.

    3. Each page had a subtotal at the bottom. Manually adding the subtotals from each of the four pages equaled the $180 amount of the check. Reconciled!

    4. The front page stated ‘you have satisfied your deductible,’ but contained no reference to when, or on which earlier statement this might have been documented.

    Medicare is often cited as a potential example, but this statement was a model of obfuscation and non-communication which completely flummoxed the beneficiary, a college grad.

    Crapification, comrades: not just any idiot can do it. It takes a village.

      1. Jim Haygood

        Not sure whether you’re /sarcing, but the statement was from the Medicare administration (gov), not one of the private supplemental plans.

        1. pdooley

          Medicare administration is done by “private” contractors. The lowest bidder, no doubt.

          1. Farishtah

            Yes. I was inexplicably told by my eye doctor that when they called the Medicare “provider number” to see if I’d met my deductible, they could find no record of a Medicare account associated with my name or birth date. Hmmm. I’ve had Medicare for 3 years and this was my first claim, but even so…. To make a long story short, I got my doctor’s office, Medicare and Social Security together on a conference call to straighten out an internal housekeeping issue in a matter of minutes (!). In the process, it was confirmed that, yes, Medicare outsources a lot of administrative tasks to private contractors.

    1. Abe, NYC

      I’m on group insurance (Blue Cross/Blue Shield). A few years ago I had a hilarious story. I went to a doctor complaining of muscle pain in my shoulder and he offered to get some routine bloodwork done in addition to addressing my complaint. So I had it done.

      Then a few weeks later I started receiving checks from my insurance company. The lab was out-of-network, and they were paying me 80% of the amount they considered appropriate, for me to settle with the provider.

      So I received checks in my name in the amount of US $3,000 total (Three Thousand United States Dollars). To remind, this wasn’t a surgery or even a DNA test, this resulted from two vials of my blood taken casually at a doctor’s office. I was outraged and was waiting to receive a bill from the provider. But the bill never came, and I never took the checks to the bank (still have them, long expired).

      Then a couple of years later (!) we had a phone call from a lab complaining of some missing payments. We told them to screw off, we never had any unpaid bills. Only much later did I realize this was the bill they must have been talking about. They never took any further action.

      My regret is that I was also too lazy to get to the bottom of this and cancel the payments. As a result, the amount on the uncashed checks was almost certainly pocketed by the insurance company, rather than returned to my employer one way or another.

    2. Janie

      Medicare contracts with insurance giants to process claims. When Medicare was introduced, the cry of “COMMUNISM” echoed. Social Security (Medicare) establishes eligibility. So, all claims are processed twice – or were when I worked in the medical industry. Dealing with the insurance company was just awful; SSA was better. Most government employees do their best in my experience, but I can’t say the same for industry.

  6. LAS

    Ezekiel J. Emanuel has written about 6 mega-trends in healthcare (“Reinventing American Health Care”). The first of his trends is that within the next 10-12 years, insurance companies as we know them are going out of biz. He argues that they will either become integrated delivery systems – contracting effectively with hospitals, physicians and other patient service providers — OR — they are going out of biz. I would classify Cigna as one that’s going out of biz – slowly – so they can collect premiums for as long as possible from you before you understand the trend.

  7. cnchal

    The banks profit from fraud, and it isn’t even fraud anymore if the Police look the other way. The insurance companies are left in the dust by the banks so they want to catch up.

    I recall a post from almost a year ago about bullshit jobs, and this comment by lee that stuck in my mind.

  8. DH

    New reader here. Forgive me if my comment is just repeating something said previously.

    Your theory of crapification is spot on. Things are deteriorating, but only in drips and drabs. Monetary inflation is the culprit and crapification is the byproduct.

    Starting simply, ice cream used to come in 1/2 gallon packages. A few years ago the packages decreased to 56 oz. Today they are commonly 48oz. Prices are relatively constant with the distant past or maybe a little lower, but not proportionally to the 25% decrease in quantity. This is an example of crapification that probably doesn’t show up in any CPI.

    You’re absolutely right about quality deterioration in clothing. I have some old items that are still in style. If they were replaced with identical pieces, those pieces would be hard to find and likely quite expensive now. This is another example of inflation being expressed as crapification.

    Services are price competitive and corner cutting is a tried and true way to lower costs. Crapification is another word for corner cutting.The methods of crapification are only limited by the creativity of the crapifier and the tolerance levels of the crapifiee (customer).

    Although, to some with influence, crapification is only noise, I suspect. It should be ignored while more attention should be paid to the rising prices of financial assets due to crapification of the money supply.

  9. Noni Mausa

    Living here in Canada, the word that comes to mind is “horrified.” How do really ill people cope? Where are the class-action suits?

    I moved up here from Minnesota in 1974, and so have missed the long descent of US medical into malicious lunacy. When I visit back home, nice but clueless Americans ask me when I will be moving back to the greatest country in the world. I generally tell them I can’t afford it, and the medical insurance system is the chief reason. I have a small but decent pension, but health insurance, even under the ACA, would whittle that down to the cat food bracket in no time.

    I wonder how many valuable potential immigrants steer away from the US for just that reason?


  10. Anarcissie

    Your experience with crapified medical insurance is about the same as my entire experience with all kinds of insurance, including medical, going back to the 1970s. The dominant principle was and is avoid payment. An insurance company is in business to collect money, not hand it out. The techniques of disappearing claims, improperly rejected claims, long delays at every stage of the process, dropped calls, unanswered letters, and deep bureaucratic obfuscation are standard-issue. I think it is a matter of very simple economics.

  11. jfleni

    RE:Cigna: Crapification or Insurance Fraud? –
    Barry Buttkisser and Eric the equivocator and the whole corrupt crew have promised the insurance company “contributors” the moon. Of course they cannot possibly do it, and the chickens come home to roost eventually.

    Until we get Medicare for All with an insurance-company free and regulated and fair payment system it will continue. Other people do it as a matter of course, but the scam-central USA cannot and will not!

    1. Gerard Pierce

      Medicare for all is a worthwhile goal. Most people do get better service than they would receive from private insurance companies. What is not obvious is the effect that reimbursement rates have had on the quality of care. It’s hard to determine whether medical care was crapified on it’s own, or whether low reimbursement rates led to a crapified system.

      There are situations where a person is thrown out of a physical rehabilitation program because they have exceeded the maximum allowable number of days. In some cases the patient is transferred from Medicare to Medicaid. Service is then provided – with the costs supposedly taken out of the patients estate. But the transfer to Medicaid is not automatic and may not happen at all.

      It would take a thick book to describe the number of gotchas built into Medicare/Medicaid. Much of Medicare reimbursed medicine has already been privatized. Everything from skilled nursing through Hospice care has a corporate constituency. I would guess that half of the rules were implemented to keep corporate providers from pillaging the system, and the other half of the rules were implemented to help corporate providers in their attempts to pillage the system,.

      It intrigues me how much Republican outrage there is against Medicare when you consider how much of Medicare costs are actually corporate welfare.

  12. Roy

    The different European systems all work much better than in the US for illness. But it is just the opposite if you have big hospital bills because you were the victim of an accident caused by someone else. It can take 2 or 3 years before the hospital has been paid in full, whereupon the hospital turns your bill over to a collection agency and your personal credit is ruined for the maximum statutory period which is typically 5-10 years. Even worse if the accident occurs in the US where the hospital charges are typically triple the European maximum (Switzerland) and fuve or six times the European average. Sometimes the insurance companies insist on getting the American hospital to write down its bill (putting you in the middle) and to fill out lengthy forms that have to be translated and whose legal implications are unkowable in litigious America. European insurance companies routinely deduct around $5,000 from the final settlement knowing that no lawyer will take less than that up front for bringing a law suit.

  13. Banger

    I have decided to, mainly, forego medical treatment and use alternative remedies. The whole system is rotten from the unexamined assumptions that underlie the medical model of human health and illness to what is, basically, a state mandated extortion racket. I objected to Obamacare precisely because I saw it as giving people who have already been proven to be extortionists a few fig-leafs to try and mine even more revenue out of the population to feed their hunger for large boats, trophy wives, car collections and a higher-grade of call-girl to show off to their friends and colleagues–really, that’s how thos f-ckers actually think–cause I’ve been around them.

    1. cnchal

      It’s even better when “ feed their hunger for large boats, trophy wives, car collections and a higher-grade of call-girl to show off to their friends and colleagues” is tax deductible. A little icing on the money cake.

  14. SWOD

    As you’ve mentioned, healthcare is not health insurance. I think by design all discussions about the ACA try and conflate the two, even with the use of the pejorative “Obamacare”, which includes the term “care”. I think you should begin referring to all things ACA as “Obamasurance”. It will highlight the requirement to purchase an insurance product from a for profit company as opposed to any kind of healtcare.

  15. Generalfeldmarschall von Hindenburg

    Bang on, Banger.

    It’s astonishing to me how much administrative work it requires to simply exist within the United States as anything other than a homeless person.

    The Canadian commenter reminded me of the problem attendant in resolving this issue. Amer’kins are so thoroughly trained to bark at anything their pastors and bosses say is “socialism”. The only alternative to being defrauded and run through the wringer is, to the masses of working class people a gray Stalinist world of bureaucrats in Mao suits with pinched faces stamping a big “no” on your papers despite your hard work, while some other type of unworthy usually severely tanned person who just lazes around all day gets treated like royalty. That’s the picture they have in their minds.

    1. Grand High Pontiff Q Salisbury Steak

      I just don’t get how we’re not already living in that world, frankly.

    2. jrs

      They probably think socialism is like their experiences in public schools. Gray and bureaucratic indeed. But the corporate world isn’t much better.

    3. cripes

      As a result of working several years in homeless service organizations, i can assure you that the administrative and documentation requirements imposed on homeless people are substantial. But the facilities (not) provided for them to secure their documents insure they must acquire them over and over again, and suffer denial of basic services as a result (think food, etc) it is not unusual for homeless people to shuffle around lugging huge binders of paper, only to accomplish conveying a scrap of paper from one government agency to another.

  16. Greg

    When it came time to sign up for ACA I went to the Washington State exchange to check it out. It asked me what my income was which was zero because I quit my job six months before and am living off of savings. I haven’t had insurance before believing it was a scam and have always gone to cash only doctors after discovering that most regular practices were charging me top gouge for paying cash and accepting reduced amounts from the insurance carriers. The ACA system decided I was poor, which was fine with me as I am, and sent me a Medicaid Card which was fine because I didn’t have to use it. Now it appears I’m on a deadbeat list. The two times I tried to make appointments with an endocrinologist and then a cardiologist were not successful. I would call to make the appointment then told that they had to have a referral so after I had my doctor of 30 years do that nothing would happen. Id call again and was told that they needed the clinic notes, for what they were worth, and after receiving them they would call me but nothing would happen. I would keep calling the office and would be told they were still waiting for the information. On both occasions I received a letter 2 weeks later indicating I was now cleared to make an appointment. Too late and since I didn’t expire after all, not needed, thanks anyway, not.

  17. R40

    I visited the doctor for the first time in 5 years and BCBS denied it even though it was a preventive visit covered 100%. Appealed = Denied. Am now pursuing External Appeal. All of this with a 6-month lag as BCBS has refused to hire new reps and only pays the ones they hire $24,000. A clear profit extraction strategy.

  18. Jim Shannon

    Insurance Companies are about to be exposed! You can help do something about their tactics, all used to shift the cost of your medical care, back to you. When you give up fighting for your covered benefits, they win, exactly what they all do to keep your money. Your experience is Standard Operting Procedure, all set in motion by the ERISA act of 1974 which destroyed ALL health care and pension rights for non-government employees, exempted as a matter of LAW!
    Go here and set change in Motion! Pass it on, your words are read by many!

  19. Littletoot

    That is a good timeline to make a comparison. Service companies rely on short memories – gradual crapification of service, otherwise, is almost unnoticable. ‘Promoting the weakness’ is such an effective strategy – promise more and give less.

  20. mike

    Unfortunately I am not sure your theory is exactly right. We have a daughter with a very pernicious case of Crohns. Both us and her Gastroenterologist’s office seem to spend a small lifetime fighting for the coverage we are entitled to under any of the policies we have been covered by (Aetna, United Healthcare/Oxford/BlueCross either as company plans or individual policies). It really boils down to their business model is to deny coverage/payment until you enter a battle of attrition with them under the premise that you will surrender first. In fact, when critical surgery was denied we were actually told that their internal policy was deny everything over a certain dollar amount then make the insured fight for it. My brother in CA, covered by Kaiser, was pre approved for a MRI. It took two years of fighting to get reimbursed. So it is not about deteriorating service but about trying to prevent you from receiving what you are entitled to. Lastly, there was an article a couple of years back in the NY Times about United Healthcare purposefully lying that NYU Medical Center was not in the approved list as a way to reduce payments to insureds (99% I have mist of the facts correct). As is usually the case they payed a nominal fine.

  21. Benedict@Large

    Please note that ObamaCare is written to encourage employers to drop healthcare coverage for employees earning less than average incomes (less than ~55K). Obviously, these employees will be forced into individual coverage, which in addition to paying less (75% MER instead of the 80% MER for group), provides (as you have noted here) far lower levels of service; levels often approaching fraud. These employees can least afford to pay more for their healthcare, and are least equipped to deal with claim payment hanky panky. This is RATIONING by income. The working poor under ObamaCare are considered less worthy of medical care than the top half of the income schedule.

    1. Lambert Strether

      “The working poor under ObamaCare are considered less worthy of medical care than the top half of the income schedule.” You say that like it’s a bad thing!

    2. jrs

      Yes and if you want to actually know how people who lean conservative think about this – they think the whole ACA is a government mistake or fraud to drive people into crappier plans that is being imposed on us by Big Lefty Socialist Government taking away our good employer provided plans (FWIW the employer provided plans are often pretty good) for people who work for a living. Being that government can’t work and socialism can’t work according to them, no wonder it’s such a mess, government meddling. That it’s actually not socialism …. that it was all backroom deals with insurance companies all along …

      If you want to give socialism a bad name, call the non-Affordable Crap Act socialism.

    3. jrs

      FWIW employer plans are deteriorating of course. For everyone even those not forced on the exchanges, it’s all becoming HMO etc..

  22. R Foreman

    Maybe they’re getting progressively less and less experienced people to review and approve claims. You know the classic cost saver is lay off the long-term people and hire new ones who cost much less. Just a thought.

  23. Schtubb

    It may already have been said, but if you have the means, record your calls to your insurers.

    My wife and I live in a state where we do not have to notify that we are recording, and do so reflexively when dealing with any financial/health/etc by phone. We recently had trouble receiving a timely $10K+ refund that we were due from our health insurer. After two months, we notified the state insurance regulator, included a CD with the recorded calls, and provided a transcription of the relevant segments.

    That did the trick. The relevant rep called us contritely every day to ask if we’d received the check until we finally cashed it.

    We should not HAVE to do this sort of thing. Correspondence should suffice. But so much is done by phone now, we feel we have little choice.

  24. Oregoncharles

    Makes me glad I’m on Medicare – did without insurance for years before I qualified. I and my wife were lucky.

    Now: I know this is off-topic, but I’m concerned that you’re getting multiple medications when you describe yourself as very healthy. I suspect over-medication. The reasons are none of my business, but I suggest you re-examine those prescriptions.

  25. ian

    Yves, I wish you would explore ‘crapification’ more.
    One thing (and sorry this is a bit off topic) – why no connection with inflation? For example – we see something from 10 years ago, a toaster, say, whose prices hasn’t risen. But as happens so often, it’s the same toaster in name only – stuff that was metal is now plastic. It seems to me (of course, I’m not an economist) that when prices are steady, but stuff is getting shoddier that this is an insidious form of inflation.

    1. jrs

      I don’t mind calling it inflation as it’s a reverse hedonistic adjustment, but I think the causes are bigger.

      I think crapification is always a risk in a market where you can hide the fact you are selling a lower quality product and price is used in buying decisions. That gives every incentive to cut corners. Notice I don’t even blame capitalism at this level because some of that could exists in non-“capitalist” marketplaces. The degradation in food quality can be explained by that alone. Then consumers can be more or less informed on how to judge quality, consumers unable or untrained to judge quality (like for instance be able to inspect a piece of clothing and tell how well it’s made), are ready marks for crapification. I think that describes the current situation. But before I get accused of victim blaming if there is also ever increasing inequality and poverty and decline in real wages, even when people CAN judge a well made shirt (not something they are trained in now – but even if they could), if their wages only allow them to buy cheap crap then buy cheap crap they will, a cheap crap shirt being better than no shirt afterall. Of course hopelessly opaque markets like health insurance add to the inability to judge quality in the first place.

  26. Alan

    Have BCBS…at least in this state, it still works.
    Sister has cancer. Just received her immunotherapy meds; cost $7790, scratched out by pharmacy, $100 copayment written instead by hand. Covered by insurance, no hassle.
    Patients with Cigna….dealing with Cigna is usually much harder. Same with Aetna.
    No idea where it’s going.
    Remember, Obama’s first act in establishing “Obamacare” was to call in the corporations, not the experts. Been DOA from the start.

  27. LAS

    Affordable insurance does not even begin to address our problems. There were whole sections of the ACA intended to address real health care problems. Congress has not fully funded these provisions, which is going to be a growing problem for the whole US population. Except for the northeast, we have a shortage of primary care health workforce in this country that is going to get worse. It’s causing problems already and is about to worsen over the next years. Some of us will in the future be cared for by a nurse rather than a doctor. If you want to be seen, that’s who may see you. You may be happier with this situation (some people are) … but it is not what we’re used to expecting. Doctor education is likely to change. Some academic medical schools are going to experiment with a shorter education and more time in clinics rather than in hospital settings. I think these might be good changes (less student debt and more primary care experience) but there’ll be some polemics/complaints about the changes, like the way people have divergent opinions of electronic health records.

  28. TimR

    I know somebody who works at Blue Cross. Also somebody who worked in the billing department of a large hospital chain.

    From what I gather talking to them, I would not so much call it crapification (although I’m sure it’s that too) as the Gamification of Healthcare.

    All of the players involved — the insurers, the hospitals, the government (and their sub-parties) — are trying to game their particular part of the system. Not necessarily primarily from venal motives, but if only as a matter of self-defense.

    Doctors, for example, have to come up with the right “code” (referring to which procedure they use) in order to get reimbursed by the insurance company (which is obliged to pay for some “codes” and not others.) Everything has fit neatly into these “codes,” no matter how messy the reality, in order for money to flow.

    I’m sure someone closer to it could be more exact, but that is the general impression I get from talking to those doing it.

    It is a result of lack of trust, IMO, and lack of honest human relations among the parties. They have been forced to become bureaucratic cogs, to compensate for our inhuman society. Which imposes an enormous economic cost on us all, to support all this “non-productive” (gaming) work.

  29. Dan

    I spoke to my Doctor about his ACA experience. He told me some thing you mention in this article. He was listed on the NYC Insurance Exchange as being a member of various insurance company networks and his patients purchased insurance based on this information. After Jan 1, when bills for these patients were processed, the claims were denied. It turns out several insurance companies have cut him – and other doctors – from their networks with no explanation. It took until April or May to get the insurance exchange / provider information updated. These doctors have also been told there is no way they can become part of certain insurance groups. No explanation has been provided by the insurance companies. The assumed reasons is the insurance companies can no longer reject clients based on pre-existing conditions, so, they’re targeting doctors with high cost patients as clients. I was told there are several lawsuits in progress.

  30. jan

    I don’t know if your problem is medical necessity (does the diagnosis match up with or support the care you want them to pay for according to their guidelines) but just in case you might want to take a look at it.

  31. onwee

    Two points:

    1) One consternating factor of this story is that we must believe in competence from the incompetent. We take it as a truism that competence at the cubicle level in America is very low. We experience it every day. Clerks who do not think, they just ply a groove that gets them to quitting time (yes, exceptions exist but we note them in their rarity). It would be an interesting management task to design a system of screwing the customer base that required competence from the incompetent to succeed. Moreover, to get it done without leaving a trail of thousands to testify to the system for the AGs would seem impossible. While I agree wholeheartedly that the OP’s treatment is shoddy in the extreme, I suspect in the end 90% of the problem is incompetence/indifference and 10% design.

    2) There are only so many afflictions we humans can have. Let’s ask the government to designate universal billing codes for every one of them. Get rid of the tower of Babel of medical billing codes and save systemic costs.

  32. John Spek

    “and is an indemnity plan”

    that would make it not compliant to ACA

    “I paid via credit card even though she is a Cigna network doctor and prior to this year, I’ve had her office handle the “deal with Cigna” hassle and submit the claim. I decided to pay because my reading of Obamacare (and I’d welcome expert input) is that if the provider accepts the patient’s insurance, the medical records transfer to the insurer is seamless. If the consumer pays, my understanding is the insurer has the right, as before to ask the doctor for records if it needs them to process a claim, but is not automatically given access to them (as in their rights to my records are the same as before, as opposed to increased under Obamacare).

    This usually results in some hassle with in-network doctors, since I pay the rack rate, and then Cigna tells them what the discounted rate is and reimburses me only based on the discounted rate. Then I have to go back to the doctor to get a refund. That normally goes pretty smoothly.”

    So – pay full price, then add paperwork to try to walk all of that back,

    pay full
    then submit a claim
    for reimbursement

    an insurer has to then go verify services with the doctor’s office

    the insurer also has to match the doctor’s office account number for cash payments that is on the bill you sent to the insurer (hence the not in network)
    with the actual provider I D number

    the dotor’s office has to verify the service date to the insurer

    the records office that the doctor sends records to has to send records to the insurer

    then at the insurer
    the records of the visit and the records of the services and the claim refund request all have to connect
    under the corrected provider I D

    the doctor’s office has to back out the full price
    correct the billing to the insurer rate
    “bill” the insurer to correct the books
    create a “fake” insurer credit on the books
    marry the insurer credit to your bill
    discover a payment differance
    and refund it

    and it’s expect it to go smooth?

    1. Yves Smith Post author

      In the past, Cigna did not attempt to impose the network discount on the doctors. I’m not sure Cigna is actually entitled to it with my plan. I’m perfectly happy to pay the rack rate and pay my co-pay on that. I have even written the New York State insurance department, because I’d rather not get the discount and have this work as it did before.

      Re ACA compliance, there are ways to deal with that and my accountant (who has serious tax chops) has already handled it.

  33. sharonsj

    Crapification can also be ascribed to the stupidity of the average human (especially Americans) and the fact that the mainstream media is useless. And please remember what happened before and after Michael Moore’s “Sicko” came out–the insurance companies, the drug companies, and the right-wingers did everything they could to discredit him.

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