Thursday, January 19, 2006


Finally! Or, the True Moral Hazard of HMO's

The Girl is just over 18 months old. She’s walking, and talking (in her way), and laughing, and feeding herself with a spoon.

I mention that because the HMO finally finished paying the doctor who attended her birth.

I’ve read umpteen analyses/discussions/arguments about our health care system, and I’ve never seen anybody address the glaring loophole in HMO’s. Once you’ve actually been to the doctor, the HMO has no incentive to follow through and pay. None.

This one was particularly bad. (It rhymes with “shoe floss.”) As I posted last year, it initially refused to pay for The Girl’s birth on the grounds that she was not listed on the (family) policy when I joined my current employer a year before she was born. I politely explained that that was because she hadn’t been BORN YET. (I also raised the ontological question of what ‘childbirth coverage’ means if it does not, in fact, cover the birth of a child.) Apologies ensued, though payments didn’t. With the help of a beleaguered and indefatigable unsung heroine in HR, I’ve spent the last year and a half nagging them for payment. In the meantime, it calmly went on earning interest on the money it wasn’t paying my daughter’s doctor.

To recap: you aren’t allowed to have a baby unless the baby is already listed on your policy. You can’t list a baby without a social security number. You can’t get a social security number for a baby until after she is born, which isn’t allowed unless she’s listed on your policy.

This, in the name of efficiency.

Who benefits from this arrangement? I don’t – my credit rating was hanging out there for the last year and a half. The hospital didn’t. The doctor certainly didn’t. Hmm. Can’t quite put my finger on it…

To make matters worse, HMO’s are immune from lawsuits. So I can’t even threaten to sue. They know that, of course, so they take their sweet, sweet time to pay bills, tossing off progressively more ridiculous excuses while quietly earning interest on the money they aren’t paying.

How is that not stealing?

Since most people get their health insurance through their job, they don’t even have the option of ‘exit’ if they get jerked around. I was lucky to the extent that my employer offers a choice of several plans, so I was able (eventually) to switch carriers, just to punish this one. In some companies, I wouldn’t even have had that choice. I have no illusions about the one I switched to – it has the same perverse incentives as any other – but at least it hasn’t jerked me around yet. Then again, we haven’t had another kid.

A modest proposal: if we’re going to go the market route for health care, let’s at least hold HMO’s to the same standard as any other company. Failure to pay for covered services within a reasonable amount of time should be considered actionable breach of contract. If we can’t do the civilized thing and embrace single-payer, instead favoring the open brawl of the market, we should at least make it a fair fight.

In the time it took this multi-billion dollar operation to get around to fulfilling its obligation, a newborn learned to walk and talk. Give me a break.

Hear, hear! HMO's and other insurers are businesses, so it's only fair that we have some recourse and fair practices to rely on. Where to start, though. . .
I've got a PPO instead of a HMO, but in my experience, the attitude is the same. I've had to have "discussions" with their reps because my daughter needs to see a pediatric nephrologist once a year, and they always seem to take their sweet time to pay the Children's Hospital that we take her to for the tests. The thing is, the pediatric nephrologist, who has his office in the Children's Hospital, is considered "in-network", but the Children's Hospital itself is considered "out-of-network".
Our society tolerates, protects, promotes, and rhetorically valorizes so much that is simply villainous. I could stand it if it weren't so smugly hypocritical and cloying. The next time someone mentions health insurance and personal accountability in the same conversation, I....well...grrrr.

I think nowhere in America is the rank wrongness of a policy more evident, more universally hurtful, and more couched in the up-is-down Bizarro rhetoric of the right than health insurance.

My sister-in-law, with whom I never talk politics declared last year (she used to work for Geico and is a financial analyst for a bank) that she "feel[s] bad for insurance companies!" OMG! Good thing I wasn't trying to swallow at that moment.
You think 18-months is bad?

It took my future in-laws *eight years* to pay off a C-section they didn't even need on their second child. I'm not sure if it was due to insurance debacles, lack of money, or both.

I'll definitely check our coverage before I even think of having kids! Yikes.
I found your blog recently and just want to say that I am enjoying it tremendously. I told my husband to read it too, since he's an undergraduate program director at our Univ. Thanks for writing!

That's a good one! Here is another....

When I was hired full time as an instructor last year, I took all the benefits I was offered which included a PPO. My son was covered under BOTH my policy and my husbands. The state required my policy to become the primary because my birthday is before my husbands. Since then, my huband's policy refuses to pay because they are the secondary and my policy refuses to pay because they say everything is pre-existing. And the fun goes on..........
Dawner85 -- I must tip my cap, that one's absolutely amazing. And I'll betcha that every time you remind your insurer of your dilemma, they say it's the first time they've heard of it.

Amber -- that's awful. My (not as serious) variation on that was The Boy's pediatrician's office. Like many, it has about a dozen doctors, and you see whomever is on duty at the time. The HMO only had one doctor's name on file, though, so if you saw any of the other 11 (which we usually did), payments would be denied, and we'd have to go through the we've-told-you-this-before dance.

Peter, Joanna -- solidarity.

botanicalgirl -- 8 years? Sheesh! I got a Ph.D. in less time than that! The discouraging part is that 'checking your benefits' only gives you half the story. Childbirth was a listed benefit on my policy, and it still took a year and a half.

Victoria -- thanks, and welcome!
I know it's totally not helpful but I love Canada. Having lived and dealt with healthcare paperwork under both systems, I know which one I prefer!
As Dean, I would hi me over to HR and strongly suggest that the plan from hell be invited not to participate next year. RHIP
A few days after my heart attack I received a wonderful (gack!) note from my HMO. Seems they'd reviewed my case, and decided I was really ill.

I was certainly impressed.

The really odd thing is that I was treated in the hospital which owns the HMO. At least the paid the bills.
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