Tuesday, April 14, 2009

Health Care Reform and Regulation

Tuesday’s Tirade
Masked Justice by Insurance Regulators

According to a new national survey conducted by researchers from the Kaiser Family Foundation and the Harvard School of Public Health, health care reform is a top concern of 43% Americans. This priority is third, following the priorities of the economy and fighting terrorism. While reformers look at different facets of reform, I ask, “Who is regulating the health insurance regulators?”

West Virginians live in a very dangerous place today. Statistics show high obesity rates, major abuse of smoking, poor overall health, depression and high suicide rates. But the real evil behind some of these statistics is the widespread fraud, collusion and corruption within West Virginia that my four year investigation of West Virginia health insurance revealed.

Rather than perpetuating “good government,” state officials like Jane Cline, West Virginia Insurance Commissioner, ignore the plight of those in need of quality health care, ignore the very codes that are the law in West Virginia.

Article III Bill of rights.
Government is instituted for the common benefit, protection and security of the people, nation or community. Of all its various forms that is the best, which is capable of producing the greatest degree of happiness and safety, and is most effectually secured against the danger of maladministration; and when any government shall be found inadequate or contrary to these purposes, a majority of the community has an indubitable, inalienable, and indefeasible right to reform, alter or abolish it in such manner as shall be judged most conducive to the public weal.

On December 14, 2006, Insurance Commissioner Jane Cline, signed Final Order 06-AP-O24, a thirteen page order that was drawn from evidence provided at a six hour administrative hearing, Christine Stenger v. Carelink Health Plans Inc of West Virginia, before WV Examiner Judge Jack W. DeBolt on August 10, 2006. Judge DeBolt, in examining the voluminous evidence, cited Carelink’s “egregious deeds” as reason to order Carelink to “thoroughly review” all future incoming requests for benefits before making a determination.

On February 26, 2007, Insurance Commissioner Jane Cline denied Carelink’s request for a rehearing. Cline cited that there “are no new issues or procedural errors to justify a rehearing.”

On April 4, 2007. Consumer Advocate Frank Hartman, who represented me at my hearing, described the importance of my win:

First and foremost it is important because consumer victories against insurance companies are few and far between. Think of all you have gone through, from the physical suffering of your illness to the treatment you received by Carelink representatives. The long drawn-out process is emotionally draining and extremely difficult. The vast majority of people quit long before this. You have survived. Simply by being here and fighting you have won.

Next, the case is significant for the far-reaching implications about how HMO’s must do business in the state of West Virginia henceforth. As a result of the Commissioner’s Order, HMO’s must evaluate all reasons for the coverage determination of a requested procedure and make a more thoughtful and accurate initial decision because they will be bound to that decision throughout the appeals process. They can no longer deny first and determine a rationale later only to subsequently change the stated rationale yet again.

Link to Hartman’s letter:

West Virginia Code: §33-25A -17a. Quality assurance. (1) The commissioner may suspend or revoke any certificate of authority issued to a health maintenance organization under this article if he or she finds that any of the following conditions exist: … The health maintenance organization has violated a lawful order of the commissioner.

Why is this order so important to the health of West Virginia citizens? My three different providers have documentation that verifies that Carelink denied benefits without thorough investigation as is mandated by Final Order 06-AP-024. How many thousands of West Virginia citizens have found the same fate since December 14, 2006?

The Insurance Commission never thoroughly investigated my claim in September 2007. The Commission spoke directly with and only with Carelink representatives and reported that Carelink had no record of one denial, that Carelink never received another request for service, that Carelink reported that no request for another service was received, and there is nothing in Carelink’s system that relates to the gynecological matter that related to a requested benefit.

Why did the investigation not include contacting my physicians? Maybe it is because of the rule that for the Insurance Commission to begin an investigation there must be a request for services. Carelink had no records of ANY of the three requests. Is it likely that Cline did not want an official hearing? Is it likely that Cline does not want to hold Carelink accountable?

The West Virginia Insurance Commission never publicized Final Order 06-AP-024. It has never been enforced though Commissioner Jane Cline signed and reaffirmed the order at a later date.

Cline continues to display an arrogance and disdain for the law. We hurt in West Virginia, hurt real badly sometimes, as Cline closes her eyes to insurance fraud and acts as if she will never be held accountable. Unfortunately, as Jane Cline reigns over her fiefdom, ignoring blatant fraud of health care providers, the consumers’ anger grows. We are discovering our voice and that voice is no longer still and small.

Tuesday’s Tale
Polishing the Bottom Line

Health insurance plans are businesses. Bottom lines rule. Denying benefits is just one way health plans increase the bottom line. There are many more. Link to 8 Stupid Things:

Friends call me “Queen of the Internet.” Give me some time and a computer and I can locate information about anyone, even where former Coventry CEO Dale Wolf lives and where his children go to school.

In early 2006, following an emotionally difficult period, I returned with renewed determination to learn the real truth about Coventry Health Care, Inc. of Bethesda, MD, parent company of my former HMO Carelink Health Plans Inc of West Virginia. Something gnawed at me. I am no financial wizard but I had just read the book ENRON, and I wondered. As Coventry bought more and more health plans, I wondered. As more and more people within Carelink ignored Coventry’s governance practices, I wondered.

It was in 2006 that I first discovered a phenomenon I lightly speak of as going “AWOL.” Have you ever googled a topic and tried to link to the original document and it was not there? Typically what appears is a message that there has been an error and the page is missing. Or maybe it states that this page is no longer available. What’s to hide?

Today I uncovered the partially completed rating by US News and World Report’s ranking of Coventry Health Care of Delaware as 79th on the Report’s Best Health Plans. 79th? Who is fooling whom? Not only is there no accreditation given Coventry, their reported ratings identify a lot of problems, problems that might send a lot of other institutions to the bottom of the barrel. Given that parent company Coventry Health Care Inc of Bethesda MD is fighting to survive according to analysts, how does a questionable document like this get published?

Is this not fraud? It appears US News and World Report does not care about the integrity of the work it publishes. So why should we care? Because real people are suffering needlessly while others grow wealthy. Simple as that in my eyes. Simple enough to stir the emotions!

No comments: