What do health insurance corporations do?

GCTMT · Jun 8, 2009

Well, I don't think anyone has answered the question directly so, to put it simply health insurance companies (most of them anyway) are a business, and a business needs to make a profit. So, if a business wants to maximize profit the best the way to do that is to recruit more customers and avoid giving them services (in this case, paying medical bills) as much as possible.

:twocents:

Ginger's Person · Jun 24, 2009

I have family members who work for a small health insurance company, which I would argue is relatively un-evil. From what I can tell, a lot of employee hours, in this company anyway are spent...

- Building and maintaining a network of providers statewide in order to have a sizable base of providers for clients and to comply with federal regulations for 3rd party Medicare payers. This involves a lot of visits to remote counties, talking to PCP's and specialists and convincing them to sign up and remain affiliated with the plan, and then filling out a lot of paperwork to submit to the gov't to demonstrate this work and to appeal unobtainable requirements (for instance, in a county with zero cardiologists, there is no way they can contract with the minimum number of cardiologists per capita in that county)

- On a similar note, negotiating with hospitals and providers for fees. The bigger companies often have more bargaining power with hospitals, so those companies may get better prices for some services.

- Keeping up sales. This company in particular only sells to groups via employers and to medicare enrollees. So, they have a sales staff that maintains good relationships with companies to maintain and grow their customer base, and another sales staff to find new medicare enrollees

- Health promotions and cost reduction campaigns... so they have a staff of actuaries and nurses and physicians and other types of professionals figuring out how to maximize efficiency of care. Are there docs who are prescribing new and expensive drugs when older cheaper ones would just as well or even be safer? Are there things employers could do to promote employee wellness so their medical costs will be lower? Of new technologies on the market this year, which should the company cover? Are there hospitals they contract with who have lots of nosocomial infections? Do members need better access to health information and their medical records online? They look at these questions and try and come up with solutions.

- Customer service... pretty obvious. A lot of people sitting at the phone or at a computer helping frustruated people figure out how to fill out and submit their paperwork, and figure out what's covered and what's not.

- Legal stuff... they have lawyers figuring out the extremely complex and rediculous rules for health insurance companies in general and for medicare providers specifically to make sure they've filled out all their paper work and are following every rule to the letter. If you want to go to law school and get experience with these types of regulations, you could be very well paid to do this extremely frustruating job. Other legal stuff involves defending the company against lawsuits placed by frustruated clients (although this happens very rarely at this company... I think the big ones have pretty big staffs for this job). Also, occasionally placing lawsuits against other companies, hospitals, or government agencies acting in illegally in bad faith.

- Claims processing. When health care providers spend time filling out paperwork to submit to companies, someone on the other end is approving it, rejecting it, and filing it away. This would also involve considering appeals etc.

At least, that's what it seems like to me. I'm sure I'm missing lots of other stuff, and maybe slightly mischaracterizing something, but for this most part this is the work I hear about from my family.

allnurses Guide · Aug 22, 2009

joe scarborough is shocked, yet awed by single-payer logic

mr. weiner asked some simple, direct questions that no politician, much less obama or hhs secretary kathleen sebelius, has managed to pose:

what is an insurance company? they don't do a single check-up. they don't do a single exam, they don't perform an operation. medicare has a 4 percent overhead rate. the real question is why do we have a private plan?

http://www.youtube.com/watch?v=5tumuk-jldo

in part two he gets it. - http://www.youtube.com/watch?v=toxqgsqiwp8&feature=related

lamazeteacher · Aug 24, 2009

Well, I just saw this topic today, and thought the responses very interesting. They reflect the opinions with which the proponents and opposers of reform of health care, have dug down, with little possibility of those opposing revision, changing their view.

The health care bill has been pummeled, and lost some of the main advantages its proponents wanted for so long. If it loses the public program for healthcare, all the concerns about uninsured and underinsured persons will be lost, and the insurance industry's fat cats will continue to be paid exorbitant amounts + bonuses for bilking the country of billions of dollars!

This will be known as the era of exploitation of anyone who is not in the realm of the highest paid members of its society, since representatives in government have not won the support needed to save most of humanity here, from the clutches of big business.

StNeotser, ASN, RN · Aug 25, 2009

I also really wonder how much this whole "customer service" BS is wholly detrimental to patient care. Nobody really says in a lawsuit "oh, your nurse was so busy attending to the rude loud annoying family who brought their infant children along and bothered the nurse for cokes and snacks so while she was doing that your family member was going south" They just blame the nurse as if she was filing her nails for the whole time the family member was going south.

If hospitals quit acting like businesses, you'd see a lot of the BS out the window. Does your local fire station or police station have a marble fountain in the lobby? Doubt it, but when you call 911 you get three services, only one of which is not paid through local taxes. Why?

elkpark · Aug 25, 2009

I also really wonder how much this whole "customer service" BS is wholly detrimental to patient care. Nobody really says in a lawsuit "oh, your nurse was so busy attending to the rude loud annoying family who brought their infant children along and bothered the nurse for cokes and snacks so while she was doing that your family member was going south" They just blame the nurse as if she was filing her nails for the whole time the family member was going south.
If hospitals quit acting like businesses, you'd see a lot of the BS out the window. Does your local fire station or police station have a marble fountain in the lobby? Doubt it, but when you call 911 you get three services, only one of which is not paid through local taxes. Why?

My local police department and fire station don't have to spend money trying to convince me to call them when I've been mugged or my house is on fire instead of calling one of the three (or seven, or twelve) other police departments or fire stations in town ... If the hospitals weren't competing with each other like they're chain restaurants trying to lure customers in, if we as a society just made sure that there was a sensible system in place that ensured that everyone could get the care they needed in a reasonably prompt and efficient manner, that would probably reduce a great deal of the money spent on healthcare now just by itself.

I don't see why more people don't think of healthcare the same way they do other public services -- we all pay taxes, and we all have roads, police service, fire-fighting services, public primary and secondary education, etc., available when we need it. Healthcare is also an essential service in order for society to function -- why isn't it handled the same way? (We all pay taxes to make sure we can all get the services we need when we need them. It seems to be working for every other industrialized nation on the planet ...)

RN4MERCY · Aug 25, 2009

While I agree that in theory this could be a great good for the citizens of the united states, in practice it goes against many of the core ideals that this country was founded upon:
1) It creates a good for one class at the servitude of another. Providing health care for one group is not more just than taxing another to get it.
an example: If I needed a car, would you feel it was right to be forced to pay for my car?
2) Giving the central gov't the power to supply the money for everyone's health care is a stone's throw away from full control. It will give the gov't the impetus to control how health care is delivered and later to whom. Never before in US history has the gov't been given such power over the life and death of ordinary citizens. This is a disconcerting possibility that we are facing.
Perhaps when it is first created there will be none of these dooms day problems I worry about but allowing your rights to be slowly chipped away will surely lead us there.

Providing public transportation, roads, clean water, parks, libraries, schools, police and fire protection is not a "stone's throw away from full control." How can you reason that health care services are any different? Cars? C'mon. At some point we'll all need access to healthcare. Reform isn't rocket science and it's not too complex to understand. What's so complex about ordinary equality and the government's role to protect and defend it? If our right to healthcare isn't assured, it's folly to think that any of our other cherished rights are guaranteed.

"Power over life and death?" Let's remove that power from the hands of insurance company bean counters. Once in awhile, an industry insider gets conscience and blows the whistle on an inhumane practice. Wendell Potter is the health insurance industry's worst nightmare. He's a whistle-blower. Potter, the former chief spokesperson for insurance giant CIGNA, recently testified before Congress, "I saw how they confuse their customers and dump the sick--all so they can satisfy their Wall Street investors." And before him, it was Dr. Linda Peeno, testifying before Congress, and featured in the documentary, SiCKO.

One thing's for certain, we shouldn't be throwing any more "cash for clunkers" money at the health insurance industry. Their products are defective in terms of providing access to affordable medically necessary care, controlling costs, and preventing financial ruin for people who suffer from illness or injury. Faux "reform" proposals that would amount to a financial windfall for these insurers are tax credits, medical savings plans, and other subsidies that are next to meaningless to people without jobs or money. What good is an income tax credit if you don't have an income? And why, for that matter, is universal insurance presented as such a bright shining promise, when, more and more, people who do have insurance continually have to jump through hoops to get the coverage they pay for? Most of us that still have insurance through our employers are only an illness or injury or job loss away from losing it. It makes more sense for those premiums that we pay to go into a single universal publicly accountable risk pool so we don't lose those precious healthcare dollars into the pocket of a wealthy investor. Let's make sure they're available to pay for actual care.

The most effective weapon against the pharmaceutical industry and health insurance companies would of course be a single-payer system, which would give the government clout in negotiating prices with the drug companies, and render the insurance providers obsolete. :up:

Jstand · Jul 17, 2010

While I agree that in theory this could be a great good for the citizens of the united states, in practice it goes against many of the core ideals that this country was founded upon:
1) It creates a good for one class at the servitude of another. Providing health care for one group is not more just than taxing another to get it.
an example: If I needed a car, would you feel it was right to be forced to pay for my car?
2) Giving the central gov't the power to supply the money for everyone's health care is a stone's throw away from full control. It will give the gov't the impetus to control how health care is delivered and later to whom. Never before in US history has the gov't been given such power over the life and death of ordinary citizens. This is a disconcerting possibility that we are facing.
Perhaps when it is first created there will be none of these dooms day problems I worry about but allowing your rights to be slowly chipped away will surely lead us there.

Your posts display the core problem with the Republican argument in this debate. You are very eager to run down the solutions that have been proposed to fix the problem, but you don't offer any solutions. If you don't think that the solutions on the table are the correct ones, why not offer up your own solution to the problem and then explain why it would work better than those of your opponents?

lamazeteacher · Jul 17, 2010

Providing public transportation, roads, clean water, parks, libraries, schools, police and fire protection is not a "stone's throw away from full control." How can you reason that health care services are any different? Cars? C'mon. At some point we'll all need access to healthcare. Reform isn't rocket science and it's not too complex to understand. What's so complex about ordinary equality and the government's role to protect and defend it? If our right to healthcare isn't assured, it's folly to think that any of our other cherished rights are guaranteed.
"Power over life and death?" Let's remove that power from the hands of insurance company bean counters. Once in awhile, an industry insider gets conscience and blows the whistle on an inhumane practice. Wendell Potter is the health insurance industry's worst nightmare. He's a whistle-blower. Potter, the former chief spokesperson for insurance giant CIGNA, recently testified before Congress, "I saw how they confuse their customers and dump the sick--all so they can satisfy their Wall Street investors." And before him, it was Dr. Linda Peeno, testifying before Congress, and featured in the documentary, SiCKO.
One thing's for certain, we shouldn't be throwing any more "cash for clunkers" money at the health insurance industry. Their products are defective in terms of providing access to affordable medically necessary care, controlling costs, and preventing financial ruin for people who suffer from illness or injury. Faux "reform" proposals that would amount to a financial windfall for these insurers are tax credits, medical savings plans, and other subsidies that are next to meaningless to people without jobs or money. What good is an income tax credit if you don't have an income? And why, for that matter, is universal insurance presented as such a bright shining promise, when, more and more, people who do have insurance continually have to jump through hoops to get the coverage they pay for? Most of us that still have insurance through our employers are only an illness or injury or job loss away from losing it. It makes more sense for those premiums that we pay to go into a single universal publicly accountable risk pool so we don't lose those precious healthcare dollars into the pocket of a wealthy investor. Let's make sure they're available to pay for actual care.
The most effective weapon against the pharmaceutical industry and health insurance companies would of course be a single-payer system, which would give the government clout in negotiating prices with the drug companies, and render the insurance providers obsolete.

The post above tells it like it is, but left out a little known law enacted many decades ago, that allows veterans' healthcare programs to negotiate the prices of drugs, and disallows civilian healthcare programs from doing that. Of course it was the lobbyists and sleazy pharmaceutical companies that got that one through, with minimal notice given it, so that civilians couldn't hurt that abominable piece of legislation.

I believe that an incredibly large amount of money spent for the healthcare of all Americans, would be saved if both delivery systems of healthcare would be combined. Having veterans' and civilian and military health care providers in the same facilities, would add considerable staff to them without the expense; and having veterans in contact with civilians would enhance mutual understanding and awareness of the human costs of wars. There would be fewer pieces of new medical equipment needed in the same geographical area, and costs for greater numbers of whatever is used in hospitals would go down due to higher amounts needed.

Civilian personnel as well as military health care professionals would be able to access the same educational programs, to both their benefit, and we'd all be "on the same page" as far as knowledge of the latest techniques and treatment modalities is concerned. It would also save money if civilian physicians and nurses earned salaries according to the military guidelines. No military professional has voiced complaints about their earned amounts that I know about, so perhaps the earning capacity of some (elitist) health care professionals could use moderation efforts and oversight. It is just obscene that some physicians earn over 8 million dollars a year. That is what stressed the civilian system unsustainably.

lamazeteacher · Jul 18, 2010

Well, I don't think anyone has answered the question directly so, to put it simply health insurance companies (most of them anyway) are a business, and a business needs to make a profit. So, if a business wants to maximize profit the best the way to do that is to recruit more customers and avoid giving them services (in this case, paying medical bills) as much as possible.

Having worked for Wellpoint (the parent company of Blue Cross/Shield/Anthem, et al) as a "Disease Manager", I'd like to share that the "customer" as defined by them, is the employer (payer of premiums) of those who are covered by their policies.

Their profit depends upon keeping those people out who will cost them the most. That's why many employees are made to leave their jobs after reaching the age of 55, as coverage for them costs a considerable amount more that other employees. Anyone with a predisposing diagnosis also gets the "boot".

Katie82, RN · Aug 15, 2010

Please tell me what constructive and/or useful things health insurance companies do.
I see they own large buildings throughout the country. What is getting done in there?

I know insurance companies get a bad rep, and often deservedly so, but they also offer services to their enrollees in the form of health education and wellness programs. I worked with a lot of insurance companies when I was a Practice Administrator in a Family Medicine practice. I received constant reminders from insurers that patients needed screening tests and preventive healthcare. Most offer educational programs, case management, and disease management. I realize that promoting education and wellness will benefit the company, but it also benefits the enrollee and sadly, few folks take advantage of it. I suppose the biggest advantage of having an insurance company is that they do cover the majority of costs. Try taking the premium you pay (even add your employer contribution) and covering your healthcare costs. I now work in Utilization and Quality Assurance (not for an insurance company). Getting more and more difficult to cover the costs, especially when a lot of patients see an insurance card as a carte blanche to pay for a lot of things that are not needed.

lamazeteacher · Aug 16, 2010

I know insurance companies get a bad rep, and often deservedly so, but they also offer services to their enrollees in the form of health education and wellness programs. I worked with a lot of insurance companies when I was a Practice Administrator in a Family Medicine practice. I received constant reminders from insurers that patients needed screening tests and preventive healthcare. Most offer educational programs, case management, and disease management. I realize that promoting education and wellness will benefit the company, but it also benefits the enrollee and sadly, few folks take advantage of it. I suppose the biggest advantage of having an insurance company is that they do cover the majority of costs. Try taking the premium you pay (even add your employer contribution) and covering your healthcare costs. I now work in Utilization and Quality Assurance (not for an insurance company). Getting more and more difficult to cover the costs, especially when a lot of patients see an insurance card as a carte blanche to pay for a lot of things that are not needed.

The costs are high, because insurance companies pay overblown charges of physician, pharmaceutical and diagnostic companies, because of their need to please those entities to collect the high premiums. I never used what was paid (all by my employers) years ago for my health insurance, when I was young and well. I had to go 10 years without medical insurance after I was 55 years of age, because my employment was terminated (several times) because of the dramatically higher monthly premiums ($1,000+) charged employers for employees over 55 years of age.

My last job was at Wellpoint (the parent company of Blue Cross/Blue Shield/Anthem, et al), as a "Disease Manager for their Obstetrical patients across the USA. They made me adhere to a script that contained many untruths/errors, and the real purpose of their "preventive" programs, was to weed out subscribers that had health problems.

The goals were to call as many people as possible, and prizes were awarded to those nurses who called the most "members" (the employer was the "client"). It didn't matter how well I listened, what I said, other than to uphold what they told the "managers" to say. I certainly never called a doctor to advise him/her to order tests for patients, but I'm sure that it was to cover the company's and physicians' behinds, when that's done.

I can't say anything positive, as I know insurance companies stand between people and their receipt of good health care. They make obscene amounts of money as do the doctors and labs, etc. Patient wellbeing just isn't an objective with them or the physicians. :devil: