LOS
ANGELES, CA — Attorney General Jerry Brown is investigating how the
state’s top insurance companies, including Kaiser and Anthem Blue
Cross, review and pay claims. Brown said the "public is entitled to
know whether wrongful business practices are involved" in the
"dysfunctional" insurance system, in which major HMOs are denying from
28 percent to 40 percent of claims.
"This inquiry is needed
because there were reports that HMOs are denying claims of up to 39.6
percent," Brown’s spokesman Scott Gerber said.
"The inquiry
is just getting started, so we don’t have any details of what kinds of
claims are being denied. But in the coming days our deputies will be
reviewing records and speaking with a broad range of people."
The
Los Angeles Times reported that 2009 rejection rates range from 28
percent for Kaiser and Anthem Blue Cross to 39.6 percent for
PacifiCare.
Judy Dugan of the Santa Monica-based advocacy
group Consumer Watchdog said one of the primary reasons for the HMO
system’s dysfunction is its for-profit emphasis that puts patient care
on the back burner.
"They (HMOs) seem to be happy to take
care of slightly healthy people, but their dollar alert goes up when
it’s expensive," Dugan said. "They don’t have any huge interest in
figuring out what effective care is and isn’t and sometimes it seems
random when they deny something as not medically necessary."
In
the never-ending quarrels between doctors and insurance companies over
who will pay for care, Dugan says patients are left with the bill.
"Doctors
don’t want to deal with it, so they’ll lay it on the patient, because
the patient is the weakest link," Dugan said.
"The Doctors Association
in California has continuously beaten back legislation that would
require insurance companies and doctors to work this out."
Dugan
said Consumer Watchdog tries to help patients publicize their horror
stories, but people often won’t do it, for fear of retaliation from
their HMO.
"These things happen to people who are just frantic," Dugan said.
She
cited a recent case in which a woman who had severe intestinal cancer
was denied treatment from a specialist because it was outside of her
HMO plan.
"She was in a very strict, mini-HMO, and they just
wanted her to go to a small hospital they had a contract with that had
no specialist or surgeon for her disorder," Dugan said. The woman
refuses to go public with her story. "People won’t share their stories
because they’re just frightened to death of the insurance companies,"
Dugan said.
