I got stung this time. I was a mark.
Darn it.
My excuse is that this scam was a subtle one. I'd classify it as an occult emergent fraud. It's the third one I've met from Anthem Blue Cross/Blue Shield; health insurance is a breeding ground for these things.
The trick starts with making a "preventive care" or "routine physical" visit a "free" part of a health savings account insurance plan. These are commonly included in HSA plans ...
... A recent industry survey found that in July 2007 over 80% of HSA plans provided first-dollar coverage for preventive care. This was true of virtually all HSA plans offered by large employers and over 95% of the plans offered by small employers. It was also true of over half (59%) of the plans which were purchased by individuals. All of the plans offered first-dollar preventive care benefits included annual physicals, immunizations, well-baby and well-child care, mammograms and Pap tests; 90% included prostate cancer screenings and 80% included colon cancer screenings ...
At first, and even second, glance this looks like a nice benefit. After all, HSAs are all about having individuals feel the true cost of care, so we will inevitably reduce our use of preventive services. Making those "free" seems to make a care plan less harmful.
The catch is, as I recently discovered, is that it can be quite tricky for an adult to get this benefit. The responsible physician has to choose to bill a care episode as "preventive". These visits, however, pay poorly -- they're only cost effective if they can be done very quickly. A physician, meanwhile, is legally and ethically responsible for overall patient health. Any adult over thirty, and many younger, has health problems that can, at the least, be reviewed to confirm all is well enough.
So the physician is biased to doing at least a moderate amount of work, which makes the preventive care payment uneconomical. So these visits will usually be charged as something other than preventive care, which means they come from the general HSA pool -- not the free preventive care visit. (Immunizations and such will be covered, but not the physician fee.)
This should be possible to study. What percentage of adult males, we could ask, actually manage to get their visits billed as preventive care services?
In my particular case I was steamed about being charged a Level III fee when I had worked quite hard to get my "free" preventive care visit -- including confirming with Anthem that it would be covered. I even complained about it to the physician's billing office. It was only when I worked out the angles that I realized I'd been stung, and that I just needed to shut up and pay up. It wasn't my physicians fault, or the fault of their billing office. It was just the way the system works.
I doubt anyone planned this out. It's just a happy coincidence that an expensive (to Anthem) benefit ends up not being used. The emergent fraud aspect is that once an unintended scam like this emerges, nobody will work very hard to fix it.
See also:
- Verizon scam: Emergent fraud earns a fine
- Emergence: how entropy and incentives create scams
- Emergent fraud: Anthem and automatic payment denials
- Memphis mortgages, complexity attacks and long term consequences
- Anthem - Putting the Hell in Health Insurance
- Causes of the crash of '08 - how much fraud?
Update 11/7/10: The "13 month preventive medicine" visit is a variant of this scam. Marketing and legislative presentations will claim a yearly physical is part of a plan. This does not, however, mean that one can schedule a covered preventive medicine visit on Nov 1 and March 3rd. In practice a "year" means "no less than 365 days apart". Many people fall prey to this trick.
3 comments:
I think it is the fault of the insurance companies primarily or clinic CFOs maximizing profits. Some clinics charge for every trivial potential "topic". I tried changing clinics once and what was $115 at one was $300+ at the other. In addition to not being able to actually get a free preventative physical, they are now drastically increasing the HSA 3/6K single/family deductible to 4.5/9K and 6/11K if we will agree to it. I hope Obama or some rational person can get the single payer system for the U.S. and eliminate the middleman so we can stop lining the CEO pockets of BCBS, Medica, HP and United Health. They wonder why small businesses aren't hiring. We cannot afford the double digit annual premium increases of the past decade. And few, if any, employees like the high deductible HSA plans. What young family can afford a 9 or 11K deductible and how will a small business compete with such "benefits".
I had the same problem. At my preventive care visit, the doctor talked about lab results for stuff we'd been monitoring for 14 years that finally moved across the normal value range. He prescribed some medication. I got a bill for $183. The billing dept said because the doctor talked about a "new" event, he could code for a non-preventive visit. After much complaining (and the fact he neglected to run a req'd lab test before prescribing the meds) they credited me for that.
For an interesting take on why only business can save the health care system, read Matt Miller's, The Tyranny of Dead Ideas. Maybe there's hope yet.
It isn't just the insurance companies but doctors who love to add on as many costs as they can get away with. This is fueled by a total lack of what doctors charge for their services and what the bill will be. We should demand that doctors quote the costs of services before they perform them. Lack of transparency and accountability is the true reason for our countries health care crisis.
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