From the Mailbag: Is that a fact?

As we've mentioned, we get some interesting email here at IB. Recently, aspiring author Doug Perednia, M.D. wrote to us, questioning the veracity of a recent article in US News and World Report. It seems that a Dr Bernadine Healy, whose imagination is surpassed only by her paranoia, penned a rather misinformed screed against health insurance, and the carriers that underwrite it.

Specifically, Dr Doug cited this passage from the diatribe:

"Denials that produce the most disputes are those where insurers judge the care to be unnecessary or unproven, pitting a proverbial sick David against a multibillion-dollar Goliath. What few Davids know is that insurance contracts by law grant companies the legal right to manage a patient's care, including denying it, sight unseen, and give them the final say, if challenged. Unless the state steps in."

Although there's a lot of other misinformation in the linked article, we'll concentrate on the issues raised by Dr Doug. As per SOP, I forwarded the good doctor's email to my (more than) capable co-bloggers, and then proceeded to respond directly.

I replied:

■ insurance contracts by law grant companies the legal right to manage a patient's care

No, that is just silly. Insurers no more manage one's care than your car dealer tells you what kind of air freshener you can hang on the mirror. Insurers cannot, and do not, tell you what procedures or medicines you can utilize, only whether (and/or how much) they'll pay for them. And even these issues are subject to a claims review process, which is included in policies.

■ the most disputes are those where insurers judge the care to be unnecessary or unproven

I would also question her assertion that most claims disputes have to do with medical necessity (which would be the correct terminology). I haven't seen any figures which would support this (although, to be fair, I haven't seen any to refute it, either). I'd like to see some citation(s) to back this up. Perhaps Dr Healy will oblige you on that score; please let me know if she does, because that would make an interesting post, as well.

Bob was even more specific:

There are certainly a lot of goofy statements in that link.

Just to name a few . . .

■ the 17-year-old girl who died before her liver transplant was approved

Not sure if we are talking about the same case or not, but the liver transplant was covered extensively at InsureBlog.

■ the people in California whose insurers canceled their policies retroactively after they got sick

As for the folks in CA with retroactive cancellation, we've also covered that as well.

Quite a few misstatements in the article. But I had to chuckle at this one:

"Andrew Cuomo of New York has launched a nationwide investigation into schemes that low-ball reimbursement and stick patients with bills insurance companies should have paid. "All too often," Cuomo says, "insurers play a game of deny, delay, and deceive." His pursuit is in full throttle and has the advantages of his bully pulpit and his power of subpoena to pierce the opaque veil that patients never can."

This is the same Andrew Cuomo appointed by President Clinton to head up the FHA and authorized the expansion of mortgage lending to low income, and otherwise unqualified loan applicants.

Of course we all know how well that worked . . .

And Mike took issue with this one:

■ insurers judge the care to be unnecessary or unproven

I would only add that "unnecessary" and "unproven" are two very different reasons. Lumping the two of them together does not yield a meaningful statistic. Sort of like saying that more than 90% of deaths in the U.S. last year were the result of the common cold or some other cause.

Since I'd hate to run up the score, we'll leave it at that.