Oops, Shame On Insurance Companies

Oops, Shame On Insurance Companies


Are you one of those who have Aetna insurance and went “out of network”? Were you one of those left with a large bill to pay the doctor or emergency room even though you paid your monthly premiums? Well, it seems you were not the only one.

Insurance premiums are high as it is. I have known families paying one third of their paycheck in order to have insurance for their families. Obama Care is designed so that everyone will have insurance and health care. I’m not sure that Obama Care is the answer but may cause a slow hidden problem that people aren’t yet seeing. In order for everyone to have the insurance, someone has to pay for it. It may be the job employer or the client themselves. The IRS will be the “police” to make sure we will have mandatory insurance, but who will be the “police” to make sure the insurance companies aren’t getting richer off the people?

Last month, December 2012, Aetna agreed to a proposed $120 million settlement with organized medicine, plaintiffs in a class-action lawsuit, and Aetna beneficiaries, concerning rates paid out-of-network providers.

The American Medical Association (AMA) and ten state medical societies, accused Aetna of systematically underpaying those who were out-of-network providers. Such providers are entitled to be paid the lesser of either their billed charges or the “usual, customary, and reasonable” fee for the particular service given. When a patient stays in the network, the health care provider must accept the insurer’s reimbursement rate as payment in full. However, if one is on vacation and needs to go to an “out-of-network” doctor, the doctor is free to bill the patient for the balance of their charge after subtracting what the insurer paid.

The plaintiffs like the AMA were not challenging the contract terms, but were challenging the artificially low levels at which Aetna was paying. The lawsuit alleged that Aetna lowballed their fees using a database called Ingenix that was developed by UnitedHealth Group. UnitedHealth Group settled a case similar to this in 2009 for $350 million. Class-action lawsuits have been filed against Cigna and WellPoint dealing with the same issues and are pending.

This is one of the reasons why I am worried that Obama Care has not been completely thought out. I do not feel making everyone have mandatory insurance is the answer to good health care. We need to go to the root of the problem. Our health care itself has fallen and we need to try to regain our compassion for healing the sick and doing a good job rather than just trying to make money.

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