Thursday, March 12, 2009

HEALTH INSURANCE FUND MANAGER'S MOMENT

By : Ms. Priscilla Puggett-Hartmann, B.S. (Hotel Management), Senior Adjuster and Health Fund Manager, U-Sick-U-Pay Insurance Company, Inc. (a Delaware Corporation; DOW: USUP).

At U-Sick-U-Pay Insurance Company, Inc., we are pleased to provide competitive insurance products to individuals, businesses and local governments. Through effective asset management and prudent decisionmaking, we ensure that all our customers receive timely, efficient medical attention from physicians in our professional network. We believe in cost-effective solutions that work. For over 17 years, our company has provided medical coverage to millions of Americans. We are proud to keep America healthy. We believe that we are living proof that America’s health care system is not broken: At U-Sick-U-Pay, we make sure that our customers see a doctor when they need one; provided it is an in-network doctor (See individual policy for details; restrictions apply).

Despite our positive outlook, unemployed people with cystic fibrosis really piss me off. As a health insurance fund manager, I need to constantly evaluate whether to pay medical claims. Some medical treatments are more expensive than others. When I certify a claim, that means money goes out. Management does not like it when money goes out; they like it when money comes in. In that light, I hate paying claims. When I pay too many claims, I get yelled at. Meanwhile, my colleagues win praise when they deny claims. I would much rather deny a claim to avoid heat from management, but then I risk getting scolded by consumer protection advocates, insureds and even lawyers. Sometimes it makes more sense to just pay a claim than to deny one and face the legal hocus pocus. In any event, I try my best to deny claims. I won’t lie: It is a hard road, no matter how you slice it.

But people with cystic fibrosis piss the living hell out of me. Do you know how much it costs to keep these wheezing, mucus-filled people alive? Do you know how much it costs to suck out all that disgusting fluid from their lungs every day? Do you know how much it costs to hook them up to respirators and give them oxygen? You have to keep them in the hospital, and hospital stays cost money. You could be talking about a $1,000,000 claim within 5 days. Sometimes they even need lung surgery. That’s open-chest; we’re talking big money now. After surgery, you have to let them rest in the hospital under a doctor’s care. Plus they get meals. Then they get therapy. All the while, you need to constantly suck out that nasty shit from their lungs, and that means A LOT of money. In the industry, we call people with cystic fibrosis “high-risk insureds.” I call them a fucking pain in my ass.

My job is hard enough without having to worry about someone with cystic fibrosis. It gets really bad when some guy’s son or daughter has cystic fibrosis and they try to squeeze the little brat under daddy’s health insurance policy. When that happens, I roll my eyes and say: “Oh, no you didn’t! Oh, no you didn’t!” In most cases, I can disallow coverage because daddy did not disclose the fact that his kid had cystic fibrosis when he signed the policy. But in some cases a guy actually tells us his kid is sick and he pays the premium every month. Next thing you know, the kid is in an ICU getting snot sucked out of her 24 hours a day. And the little fucker just doesn’t die; she hangs in there and amasses a $4,000,000 bill. You think I want to tell my boss about that one? Hell no, I don’t. You try talking to my boss. When you spend one dollar over the monthly operating budget, you know you’re not going to have a good day. Anyone who says being a health insurance fund manager is easy doesn’t know what they’re talking about.

Still, it is not all doom and gloom at U-Sick-U-Pay. There are ways to maximize customer satisfaction while advancing company interests. For example, there is the conservative approach: Only handle healthy insureds in their 20s who have jobs. These people are excited about working and paying their bills. They never fail to pay their premiums and they never get sick. Occasionally the males get injured at bars or in gyms, but generally speaking, their treatment does not cost much. Maybe a few stitches here and there, a cast or maybe a sling. In any event, they usually don’t have cystic fibrosis, cancer or HIV. After all, those things don’t just spring up overnight; you need to tell us about them before you get insurance. Put simply, health insurance professionals who take the conservative approach make money for the company without paying much out. On the downside, young people do not pay much for their health insurance, so if you take the conservative approach, you will not be making huge amounts. And management wants more than just a money tinkle; they want a money flood.

So how does an insurance fund manager generate a money flood? Simple: The aggressive approach. Under the aggressive approach, health fund managers sell insurance to high-risk customers who must pay big premiums. The risk is obvious: The high-risk customer comes down with Parkinson’s and winds up costing the company millions. But a good health insurance fund manager knows how to navigate risks. To effectively implement the aggressive approach, health fund managers must know their policies inside out. They must know every procedural rule. They must use a lawyer’s craft to convincingly deny claims. And they must anticipate objections. This requires the ability to scour medical histories and sniff out frauds. If a high-risk customer “mysteriously” suffers kidney failure two months after claiming that he had no “pre-existing kidney conditions” on his premium application, a good health insurance fund manager will scrutinize the medical record to prove the applicant lied. In so doing, the manager saves the company from spending $5,500,000 on a kidney transplant operation AND gets to keep the customer’s premium. That is the aggressive approach. It generates a “money flood,” not a “money tinkle.” The best fund managers use the aggressive approach. As we like to say: “No risk, no glory.”

I receive complaints every week from angry customers. They say I do not care about their medical problems and that U-Sick-U-Pay gladly takes their money, but never spends it on them. They complain that I treat their health like a commodity. Well, I certainly do; but what is wrong with that? U-Sick-U-Pay is a private health insurance company. You may purchase our products for your health, but we are not in this business for our health. We are here to make money; why else would be listed on the New York Stock Exchange? You may think that health insurers want to guarantee your health, but you are wrong. We simply want to take in more money than we pay out. We pay when it would be less costly than refusing to pay, but our principle is profit, not your health. Profit dictates that we take any measures necessary to avoid quarterly losses. That means refraining from expending more money in one month than we take in during the same period. To that end, we have many ways to deny your claim: We can say you did not pay your premium on the agreed date; we can say you had a pre-existing condition; we can say your treatment was not covered under the provisions of the policy you purchased; and we can say that your treatment falls under an exclusion to coverage. In short, we have ways to make our profit. Our detractors simply do not understand that we do not hold their interests at heart. We have our own interests at heart.

Yet this is not an easy job. Even with all our methods, at times we cannot deny claims. Sometimes we have to bite the bullet and pay for surgery. Of course, we do all we possibly can before paying a dime, but we cannot always find an exclusion or a fraud. And customers sometimes pay their premiums on the correct date. When that happens, we have no choice but to cover treatments. If we are lucky, the treatment may only be a colon cleansing or a doctor visit. We can handle that. But if some asshole gets cystic fibrosis, or if some woman has a difficult childbirth, it can really ruin my goddamned week. When customers send me $3,300,000 hospital bills every month, I sit at my desk and shake my head. “What am I going to tell my boss?” I say to myself. “I can’t deny this claim, and I need to ask him for a reimbursement check. Fuck, he is going to tear my head off for this.” Damn, this can be a hard job.

I have worked long and hard for U-Sick-U-Pay. I have had my ups and downs. I won Claim Denial Awards in 1996, 2000 and 2002. I was even promoted to Senior Fund Manager in 2004. I am proud to work for such a great company and to help Americans stay healthy. But I still hate customers with cystic fibrosis, chronic asthma, bowel dysfunction, diphtheria, long-term cancer and everyone who needs costly surgery. You sons of bitches make my life a living hell. And you cost our company a lot of money. Our shareholders don’t like you, either. If it weren’t for you, we all could have gotten a raise or a dividend. But because you required us to pay out $15,000,000 for your stupid bone marrow transplant, we’re still stuck at $145,000 annually, with a smaller bonus than last year. So you survived cancer. So what? I’m still living in the same condo as last year. Screw you and your wife. I’m glad you’re happy, because I certainly am not. You’re lucky I didn’t deny your claim, you bastard.

I need to get back to work. Come to think of it, I need a vacation.

1 comment:

SteveW said...

Our broken health care system is coming to a day of reckoning. The European system is going bankrupt and is likewise coming to a day of reckoning.

I think we should nationalize all serious conditions (cancer, transplants, open heart surgery, etc. etc.) and privatize everything else about the health care system. We should allow insurers to configure their products to meet real risks, rather than forcing them to build insurance that covers maintenance issues.

We're at the pregnant moment at the end of the Butter Battle book - "Grandpa, what's going to happen to our health care system?" ... "we shall see, we shall see"