Tuesday, November 18, 2008

Coventry Health Care Inc of Bethesda MA False Promises

Before commencing with today’s blog, it’s important to share a few behind the scenes maneuverings of Coventry attorneys. Within the past few weeks Carelink attempted to silence my blog. They did not succeed and it will be the blogosphere that will continue to support my efforts to reveal the truth about Coventry Health Care, Inc. of Bethesda, MA.

While West Virginia State Court Judge, Martin J. Gaughan, who will preside at my upcoming civil lawsuit against Carelink Health Plans, Inc. and Patrick Dowd, recently denied Carelink’s motion, I was asked to refrain from speaking about potential witnesses in this blog and to try to keep my reflections to facts.

I have great respect for the law. There will be a shift in focus for future blogs. We will turn our attention to the “facts” reported on the internet about Coventry Health Care, Inc of Bethesda MA, the parent company of Carelink Health Plans Inc of West Virginia and to primarily developing tirades from this information, at times supported by the facts of my case.

News like the following:

July 10, 2007 news: Fitch Places Coventry Health Care's IDR of 'BBB' on Watch Negative After Acquisition Announcement
June 19, 2008 news story: Coventry Healthcare tumbles after cutting forecast.
June 20, 2008 Managed Care Matters: What happened at Coventry?

Note: Visit unitedforjustice.blogspot.com for links to these articles.

Tuesday’s Tirade
False Advertising or bull shit?

“Genius - the ability to produce fantastic amounts of equally fantastic bullshit that all makes perfect sense” ~Jason Zebehazy

Many may describe Mr. Zebehazy as crude and unrefined. Others may look more kindly upon him and understand the depth of his anger and outrage towards those who choose to deceive.

The internet is bursting with hundreds of websites from Coventry Health Care, Inc. of Bethesda MD, the parent company of Carelink Health Plans, Inc. of West Virginia, my former HMO. Additionally, there is a deluge of printed material describing Coventry’s mission and policies.

Is Coventry Health Care deliberately deceitful in the promotion of its services? Many reasonable people might agree with me that this corporation’s actions do not always match their words. So deceitful that one might describe many of its publications as a “fantastic amount of equally fantastic bullshit.” It’s pretty scary. Take notice.

When one is dealing with a life threatening health problem, it would be comforting to know that the doctors in one’s health plan have the depth of understanding of the procedure that would approximate that of a specialist. Carelink’s Medical Director is a DO. While MDs and DOs have similar training, Osteopathic medical schools emphasize training students to be primary care physicians, those who are the first doctors contacted by a patient, a gate-keeper, of sorts. Because the scope of a doctor’s knowledge greatly varies and may be limited, it is critical that one’s specialists contribute to the process of making the decision about health care coverage, especially in a life and death decision.

Doctors Make The Decisions

Media reports about managed care can be confusing. We want you to know that at Carelink our medical directors, who are doctors, make health care decisions together with you and your doctor. These decisions are based on making sure you get the appropriate care. Carelink prohibits any programs that would give doctors or utilization management professionals financial incentives to deny care. Through our Quality Improvement initiatives, at 1-800-348-2922. We monitor the volume and appropriateness of the care provided to all our members. Your health is important to us. If you have questions about how your doctor is paid, please call us.
~Carelink’s Living Well Magazine, spring 2004

In May 2005, my surgeon, Bernard J. Costello, DMD, M.D., Chief, Division of Craniofacial and Cleft Surgery, UPMC, was denied his request for medically necessary surgery on the spot and without Carelink’s stated policy that they provide consultation with specialists and me. During the internal appeals, Dr. Costello’s written appeal (Link to copy that supports the complexity of this issue) was never reviewed in a speedy determination of my appeal on July 29, 2005 ,by the Medical Director in Charleston West Virginia. Carelink did not provide a peer-to-peer review conversation as internal policy regulates.

You have read what Carelink states is their policy; here is the reality:

A doctor requests a medical procedure on behalf of the consumer. The authorization department, sometimes only a nurse, looks over the request, consults the consumer’s contract to determine if the procedure is for a non-covered benefit, a plan exclusion, and, likely, many times denies the request on the spot. The physician does not have an opportunity to discuss the medically necessary designation.

After the initial denial, the consumer has the right to request an internal appeal. Without the designation of medical necessity at the time a procedure is initially reviewed, the case goes immediately into non-covered benefit status. Appeal denied. No questions asked.

Carelink’s Appeals Department took less than an hour to deny my appeal on July 29, 2005. No one reviewed Dr. Costello’s evidence. (Note that the West Virginia Insurance Commission later agreed and issued Final Order 06-AP-024.) Carelink's doctor did not speak with Dr. Costello. Carelink did not provide my doctor with peer-to-peer consultation.

This is not a fabrication. I have written notes of many conversatoins with Carelink personnel who described this process.

“Do Doctors Make the Decisions?” at Coventry Health Care, Inc., the darling of wall street, whose CEO earned a $32,000,000 salary package in 2004?

One hundred and five words scripted eloquently by Coventry proclaim that doctors do make the decisions. Is what happened to me being repeated over and over in the other Coventry Health Plans? How shameless.

Judge Jack DeBolt, Examiner, West Virginia Insurance Commission, has another word to describe the behavior of my former health plan: egregious”

conspicuously and outrageously bad or reprehensible; "a crying shame"; "an egregious lie"; "flagrant violation of human rights"; "a glaring error"; "gross ineptitude"; "gross injustice"; "rank treachery"

The health care system is in crisis. Any wonder?

Tuesday’s Tale
Lorraine Summer sues Carelink Health Plans, Inc. of West Virginia

Lorraine Summer is not unlike you and I. When we are sick, we need treatment right away. Our belief is strong: our health care plans are ethical and fair. The reality is far from this the stated rules of governance.

Yes. We have our rights under our health plans. It’s all in those articles of governance and ethics. But actions do not always follow words. What is not known to many is how convoluted, lengthy a process it sometimes is to secure ones' health benefits. Practically impossible, I believe.

While my persistence is beginning to pay dividends, there are too many others who have been crushed by an unjust, sometimes ruthless, industry. Against these powerful forces, we rarely win.

Visit unitedforjustice.blogspot.com for the account of Lorraine Summer’s fight against Carelink.

I leave you with an interesting thought: I have interacted with hundreds of peole about this issue. Honestly sharing my thoughts and feelings. Will not one of them have the courage, outrage and moral fortitude to come forward and be a witness at my lawsuit against Carelink?

It's what I expect.

It's why I write and plant seeds in many places thruoghout our great country.
With perseverance, boldness, and determination, we will continue to win.

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