Doctors Accuse Insurance Companies Of Fraud, Extortion
- From: "georgia" <jwissmille@xxxxxxx>
- Date: 14 May 2005 18:21:35 -0700
TheKansasCityChannel.com
Doctors Accuse Insurance Companies Of Fraud, Extortion
Patients Denied Medical Care Because Of Profits, Doctors Say
POSTED: 8:46 pm CDT April 28, 2005
UPDATED: 12:30 pm CDT April 29, 2005
KANSAS CITY, Mo. -- A Kansas man suffering from cancer can't have a
bone marrow transplant because his insurance company won't allow it,
KMBC's Jim Flink reported Thursday.
Some doctors said it's a scenario that happens all too often --
patients are denied critical medical care because health insurance
companies care only about profits.
Dying Of Cancer
Tracy Pierce, 37, of Shawnee, is dying of cancer and isn't expected to
live another year. He said his insurance company, First
Health-Coventry, is doing nothing to stop it.
Tracy Pierce
"I have no treatment -- three months have gone by and I'm getting no
treatment," Pierce said.
Every time his doctor attempts to treat him, the claim is rejected.
Pierce's wife, Julie, is a health care professional and cannot believe
what's happening.
"Everything the doctor prescribes -- they've shot down," Julie Pierce
said.
Video
Watch KMBC's Report
The family's doctor has written letters to First Health-Coventry,
asking the company to approve payment for two drugs for Tracy: Tarceva
and Avastin. Clinical studies showed that the drugs stop renal cell
cancer in 70 percent of cases.
The insurance company rejected the claim, saying the drugs were not a
medical necessity.
A life-saving bone marrow transplant was also rejected by First
Health-Coventry, even though a donor match was found.
"(Tracy's) youngest brother came back from college, got tested, and he
was a perfect match. They submitted it to (the insurance company) --
they denied it," Julie Pierce said.
The insurance company said the transplant was experimental and could
not be covered.
'Scared To Death'
Tracy Warn is the mother of twins and is worried about a lump in her
breast. For more than a year, her insurance company, Blue Cross Blue
Shield of Illinois, has said it won't pay for an MRI because it is not
a medical necessity, even though Warn's doctor said it is.
Tracy Warn
"I said, 'If I have breast cancer, you're not responsible?' And they
said, 'No.' Because they won't give me an MRI," Warn said. "I think if
the MRI will detect the mass, they should pay for it."
"Do you think they're messing with your life?" Flink asked.
"Of course," Warn said. "I'm scared to death."
Extortion, Fraud And Collusion
It's rulings like these that have doctors fed up. About 2,000 local
physicians have filed several class-action lawsuits charging the metro
area's biggest insurance providers with extortion, fraud and collusion.
Doctors said the insurance companies are putting profits above patients
and are obstructing care.
"We have a barrier between doctors and patients, and it's the insurance
companies," said Dr. William Soper, with Mid-America Medical
Affiliates.
"In essence, they are practicing medicine, which they have no right to
do," said Dr. Bob Gibbons, with the Metropolitan Medical Society.
Doctors said the insurance companies are focused on money, not health.
"There's never been a better time to be an insurance company than right
now," Soper said.
Studies show that insurance companies have doubled profits in just four
years.
Doctors are accusing insurance providers of paying out incentives to
claims adjusters who deny care.
"There's just a huge reward for denying care," Gibbons said.
Dr. James Mirabile said insurance companies go to extremes to meddle in
doctor's care.
"The insurance companies send people in behind us on our rounds to make
sure our patients get sent home within a certain time frame -- sick or
not," said Mirabile, who is one of the doctors filing suit against
insurance providers.
In the lawsuit, doctors allege the insurance providers are in collusion
-- conspiring together with elaborate schemes to make it difficult to
care for patients, such as constantly rejecting medical claims.
"What they're hoping for is that we'll just give up, or that the
patient will just give up, and that we just won't work to get those
tests approved," Soper said.
"It's not every now and then, it's not every once in a while, or even
once a week -- it's every day, all day," Gibbons said.
What To Do?
Meanwhile, patients like Warn and Pierce wonder how they can fight
back.
"To be honest -- I don't know what to do," Warn said.
She said her biggest fear is that the lump in her breast will mean her
twin boys won't have a mom someday.
Doctors for Tracy Pierce said he has less than one year to live.
"This doesn't just affect Tracy, it affects me, our family and our
12-year-old son," Julie Pierce said.
Insurance Response
KMBC contacted two health insurance providers for a response to the
lawsuits.
Humana called them "frivolous."
Blue Cross Blue Shield denied the allegations.
"We categorically deny any participation in, or knowledge of, any
conspiracy with other health insurance companies," said Susan Johnson,
with BCBS. "Our reputation locally as the gold standard in health care
is built upon our passionate commitment to provide access to quality
health care for our members at an affordable price, while at the same
time, we fairly compensate for the services they provide."
Discussion: Insurance Companies And Your Health Care
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