I don't typically complain much about health insurance. The insurance companies have to decide what conditions and treatments to cover (or not), and sometimes those decisions mean that patients have to pay for some of their own care. It's part of doing business. And insurance companies have to limit what they'll cover if they have any hope of staying in business.
But I do have a problem with insurance companies scamming consumers on legitimate health care costs that they promise to pay in their insurance contracts. Thankfully, Mary Jerome stood up to UnitedHealth, and many of us will benefit from it. She personally owed $46,000 in medical bills related to treatment for ovarian cancer... even though she had insurance through UnitedHealth.
How did those costs accumulate? Whenever a patient gets treatment "out of network" (with a doctor or facility that doesn't have a contract with the insurer), the insurance company only pays what they determine to be "usual, customary, and reasonable" expenses. Can you guess what's coming next? UnitedHealth said they determined these "reasonable" costs based on independent research. The truth is that Ingenix, a company owned by UnitedHealth, came up with the numbers. And not-so-coincidentally, the rates they use costs patients hundreds of millions of dollars.
Of course, UnitedHealth denies any wrongdoing, yada, yada. But let this be a lesson to all those dealing with insurance companies: Don't take no for an answer. Carefully check your bills. Dispute items when necessary. And if you think an insurance company has done something wrong, don't be afraid to report them to the appropriate regulatory body. We pay lots of money for health insurance, and we should get the benefits we're entitled to under our contracts.
Tracy L. Coenen, CPA, MBA, CFE performs fraud examinations and financial investigations for her company Sequence Inc. Forensic Accounting, and is the author of Essentials of Corporate Fraud.
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