The Evolution Of Insurance Claims – How UHC Changed The Way It Listens

OK, right from the start I admit that this one is going to attract very few people for its excitement value, but it’s a very big deal if you can grasp the significance of these changes. For full disclosure, I state here that my health insurance carrier is United Healthcare, and that they will be providing coverage for my cancer treatment. This situation should be considered in weighing possible bias on my part regarding United Healthcare.

As you all know by now, I have cancer. PMP for short, Pseudomyxoma Peritonei if you’re into the long version. Cutting to the chase, dealing with this cancer has already meant a string of doctor visits and tests, and will involve at least one major surgery and a bunch of chemotherapy. There are all sorts of factors to consider in this sort of thing, but one of the big worries is what it costs, financially, to survive cancer. And a big part of that worry is the cost of medical care. One of my fellow patients with PMP revealed that her hospital stay produced a bill in the amount of roughly $280,000. You know, that’s a big number in anyone’s book, and enough to send the average household right into bankruptcy.

Now, as it happens I have health insurance, through United Healthcare. The policy in general says they will cover 80% of accepted charges after the annual deductible is paid. That’s fine when we are talking about paying for a short stay of a well-known condition, but PMP is not well-known, and everyone I have talked to says that the hospital stay will be for several weeks, followed by several months of recovery. And even if UHC agreed to cover the hospital stay, the projected bill could easily result in me being responsible for $57,000. I do not have that kind of money, and I could not realistically pay that kind of cost out even if someone gave me years to do it.

OK, roll back to the mid-1980s. One big and common complaint about major insurance companies, was how hard people had to fight to get claims covered. From 1994 to 2000, I worked for a third-party claims administrator and I can tell you that there was a lot of difficulty. Sometimes it was fraud, but as often by the provider or the patient as it was from an insurer, but a lot more often there was something missing or misunderstood in the information and communication. This happened the most often when a claim was very large, or the diagnosis was controversial or complex. Things only got worse during the Clinton Administration, because in its zeal to protect the patient, the administration often made insurance companies out to be the villain. Imagine you run a business, but you are not allowed to control your costs. This was how many insurers saw the trend in government management of Healthcare. At that same time, the strong rise in medical malpractice suits and the subsequent jump in premiums made providers feel that they were being pinched; they were being forced to accept standardized reimbursement for medical services, but which did not rise in proportion to their operating costs or sense of risk. And patients continued to complain that valid needs were unmet, and legitimate claims denied purely for financial reasons. As recently as 1998, the matter seemed impossible to resolve.

I cannot speak for every insurer, but United Healthcare examined the issue, considered its options, and made changes. So far, that sounds like something any company would do, but in the case of UHC, the first changes were not towards patients or providers, but in the quality of information UHC had to use to make decisions. Speaking at the 11th Conference of the National Comprehensive Cancer Network (NCCN), Dr. Lee Newcomer, the Business Leader of Oncology Services for UHC explained that “it can be difficult to separate human error from system error”, meaning that the data sources had to be evaluated, and for that, UHC needed to hear – directly – from providers and patients. Participation in medical conferences like the NCCN Roundtable was one way to find out information, but UHC also opened queries to doctors and clients about their satisfaction with UHC. UHC also conducts clinical research in cooperation with laboratories and doctors, especially on those conditions with little established data. UHC also began to release Clinical Profiles, a program to coordinate doctors’ practices with other programs and to establish national benchmarks for medical care. In 1999, UHC followed this with the start of a Care Coordination program, which connected the different services, medicines, and treatments that patients needed for extended and serious conditions. And somewhere along the way UHC examined the numbers and determined an Out-of-Pocket Ceiling that any client would be expected to pay in any year, and UHC eliminated lifetime limits to medical care for most clients. In my case, this means that while my surgery and the associated costs will be expensive, they will be within predictable limits and in general the level of worry I will have from my insurance claims has been greatly reduced.

It remains to be seen how the promise will meet up with the reality, but I have read accounts from other PMP patients with UHC insurance, and the response has been very favorable. True, a lot of this depends on doctors and their staffs following through with the insurance company and all the paperwork, but it should be noted that at least some of the insurance companies have remembered that the patients are real persons, and they respect us in accordance with that truth.