Coverage terms like “medical necessity” that are vague and open to interpretation set the stage for disputes, said one former physician executive at a Twin Cities health insurer. This is particularly true for the sickest patients most in need of expensive care, the executive said.
“The consumer gets caught in the middle — that’s probably the main problem,” said the executive, who requested anonymity due to threats against insurers. “And they don’t know their appeal rights well. … All of this plays out in a setting where health care is ridiculously expensive. It’s such a mess.”
Patients can request the contract documents but don’t always know this, Foley said. The details can be hard to understand, ranging from prior authorization requirements to coverage exclusions. And patients find they get tripped up in a bureaucracy where automation can seem like a barrier to common sense.
“It’s often difficult for patients to understand — ‘Who’s really pulling the strings here?’ and ‘How do I make a difference?’” he said. It gets back “to this environment of the little guy versus the elites. … People are probably quite certain that the higher-ups aren’t running into the same types of problems.”
Wisconsin resident Bil Schmidtknecht joined a protest outside parent company UnitedHealth Group’s pharmacy benefits management (PBM) business in September. His 22-year-old son Cole died earlier this year after he couldn’t afford to fill an asthma medication prescription. It’s the sort of tragedy that could be prevented, Schmidtknecht believes, with reforms to the PBM market, in which UnitedHealth Group has a stake.
”Vigilante justice is not the way to do it — plain and simple,” Schmidtknecht said. “Do I have sympathy for Brian Thompson’s family? Well, hell yeah. I just lost my son. … I feel that pain for them, but where’s the pain for Cole and everybody else in this country who’s being affected by the company the guy worked for? That’s how I think about it. I don’t think it’s just, not in any way shape or form. And I’m not happy for it, either, because that doesn’t make things better.”
Source: UnitedHealthcare CEO’s slaying brings criticism of U.S. insurance industry to a boiling
