26 September 2007


From The Consumerist (via the Great Orange Satan):

"Blue Cross Blue Shield Calls Miscarriage 'Elective Abortion,' Denies Claim"

Click through the link for the story, but the headline pretty much sums it up. The patient, explains in her own words:

"I just got off the phone with the hospital and was told that the claim was not miscoded. The billing clerk told me that the wording clearly stated that I had had a spontaneous miscarriage and not an elective abortion. I was also informed that this is common practice with BCBS of Kansas City to deny miscarriage clams as an "elective abortion." [...] Mind you we have had Blue Cross and Blue Shield of Kansas City for less than three months, they have denied every claim we have submitted to them. EVERYONE!"

This is the problem with for-profit health insurance. They have a motive to engage in practices which minimize the amount of claims actually paid. It's well-known in ER billing circles that insurers use computer filters to automatically deny a certain fraction of claims, knowing that some consumers won't bother to appeal (or lack the sophistication to navigate the byzantine appeals process), and those denied claims are pure profit for the insurer. Any claim that isn't a "clean claim" -- meaning submitted in accordance with each insurer's idiosyncratic rules and procedures -- is automatically returned to our billing office denied, usually with minimal explanation, forcing us to research why it was denied and resubmit. Maybe 5% of our claims are denied in this manner -- but we see over 120,000 patients a year. And if some of those denied claims get lost in the shuffle and never are resubmitted? Pure profit for the insurer.

Contrast that with Medicare: claims filed electronically, paid quickly and without hassle, funds electronically deposited in our account. Sure, it's not perfect -- the Medicare compensation rate is about half that of the typical commercial insurer, and Medicare can audit us and send me to jail on a technicality. But forgive me for sometimes wishing Medicare was the only payer I had to deal with.


  1. There is money to be made with this. Bad Faith in the auto insurance claims made many an plaintiff's attorney a millionaire.

  2. My mother was diagnosed with uterine fibroids (sp?)which were small enough to not require treatment. Years went by and they never caused her any problems. I believe a large percentage of postmenopausal women have fibroids (you docs out there can confirm or deny that better than me) A few years ago, after she had switched (unfortunately) to Blue Cross Blue Shield of Kansas City, the fibroids began to grow, and her doctor recommended a hysterectomy. BCBS refused to pay for it, saying she had a preexisting condition, and my parents picked up the tab to the tune of (i think) about $25K.

    My opinion is that her fibroids were a preexisting condition in the same way that someone with a genetic predisposition for, say, breast cancer has preexisting condition. Yes, she did have a slightly higher probability of needing a miscarriage than your average woman on the street, but since she had never been TREATED, how can it be considered a pre-existing condition?

    maybe I'm just whining because this happened to my mom....does it seem to anyone else that this was wrong?

  3. I think any kind of automatic preexisting condition exclusion is wrong. Like it's so bad for people to get themselves into a position where they would get better health insurance because they - horrors! - have a need for health care? And in most cases it's not even that, it's just changing jobs and the change in insurance comes along with it.

    That said, we have switched insurance many times in the last ten years, and not once have we been hassled about preexisting conditions, of which there are some in our family. Does it depend on how long the interval between leaving one plan and joining another, or maybe it's been outlawed in some states? I'm lucky not to have needed to find out, I guess.

  4. When you go from a group plan to a group plan (like most large employers offer) there is usually no or only a limited pre-existing condition exclusion.

    When you want an individual plan, or a small group plan, then the exclusions become more common and onerous.


Note: Only a member of this blog may post a comment.