A health insurance whistleblower told News 5 Investigators what health insurance companies are getting away with is “outrageous.” In this “Cost of Coverage” report, you’ll hear what he said about how the industry works.
You’ll learn from an expert what you should do when you face insurance problems, and what health insurance industry representatives have to say about the criticism.
“I’m in pain daily. It’s not horrible, but it’s wearing me out after three years,” said Dave Cunningham, 60, from Norton. He’s been suffering from digestive problems.
He said getting insurance on the Affordable Care Act or ObamaCare Marketplace is frustrating, especially with the two health insurers he bought into. “I was told I was buying one product and when I went to use it, I had another and it was very subpar,” said Cunningham.
He told us it was difficult to understand the 139 plans offered, with their many different premiums, co-pays, and deductibles. Then, he found out the insurance he did purchase wasn’t helpful.
“Why? Just to confuse it, to muddy the waters?” said Cunningham. “To make money, it’s got to be to make money. There’s got to be money at the end of the rainbow. That’s what’s going on.”
“Reward their shareholders. That is what is most important to these companies,” said Wendell Potter who worked as a health insurance executive for a major company. He explained one of his roles during that time. “To help plan public policy campaigns or propaganda campaigns or lobbying campaigns to try and keep any legislation from being enacted that might hinder our profits."
He got out of the industry and has since written extensively about it.
He’s even testified before Congress about what he said he saw big insurance companies doing to patients that led to more people being uninsured and more patients getting denied including for life-and-death procedures.
“That is outrageous and we have allowed that to continue to be our reality,” said Cunningham.
He did tell us that not all blame should be placed on insurance companies.
“Our employer has not been watching this enough…I think they’re complicit in this,” said Cunningham. “As are policy makers in Washington and state capitols.”
But even when politicians passed ObamaCare and stipulated that 80-85% of patient premiums had to be spent on actual care, Cunningham said insurance companies got around that.
“They’ve been buying physician practices and clinics,” he told us. “And getting involved in the pharmacy business in ways that they are now getting more money from pharmaceuticals than, in many case, than drugmakers. It’s just been ridiculous what they’ve been able to do.”
“We hear a lot of frustration, and frankly, it’s been getting worse annually,” said Caitlin Donovan from Patient Advocate Foundation, which provides free medical case management and help for patients navigating the insurance system. “It’s not that people want a free ride,” said Donovan. “They just want to be assured that if they’re paying for health insurance, that in return, they’re receiving coverage. And that they don’t have to jump through hoops to get it.”
If you find yourself in a fight with insurance, she suggested you don’t pay the first bill.
“Assume that any medical bill that you get has a mistake in it. We see about half of them do,” Donovan told us.
When you receive your explanation of benefits, don’t ignore it. See exactly what the company says it will pay. Donovan said always to file an appeal if you are denied coverage.
“Almost 50% of the appeals that we go through get overturned. So, it is really worth your time to go through the process,” she told us.
People like Donovan said obstacles are put in place on purpose, bringing additional consequences. “Patients dealing with these types of barriers all the time leads to distrust not only the insurance companies but with the medical system overall,” said Donovan.
It’s fair to say that Cunningham has that distrust now and told us he feels hopeless about healthcare.
“I think maybe my best option is to wait until something snaps or breaks and hope it doesn’t kill me before I get to the hospital to get it fixed,” said Cunningham.
News 5 Investigators asked for an on-camera interview with AHIP, a national association representing companies in the health insurance industry. It denied us that interview but sent a statement saying:
“In the fragmented and heavily regulated health care system, health plans, providers and drugmakers share a responsibility to make high-quality care as affordable as possible and easier to navigate for the people we collectively serve. Health plans are working to protect patients from the full impact of rising costs while connecting them to care that is safe, evidence-based and coordinated.” – AHIP
It also said that caregivers make many mistakes when filing claims, and the health care system is highly complex.
Here is a link to the Patient Advocate Foundation’s resources to help you through your questions.
The News 5 Investigators are dedicated to helping you with your insurance issues during our Cost of Coverage series. You can email us at InvestigatorTips@wews.com or call our tip line at 888-WEWS-TIP.
