Blue Cross Blue Shield Horizon of New Jersey has contributed an interesting new proposal to the national health care debate: Embarrassment-Based Care™.
A few weeks ago, my friend Biella posted an account on her blog of how BCBS Horizon of New Jersey (hereinafter “BCBS”) was denying a claim of hers on the basis that it was a pre-existing condition. She was staying with me at the time, and we talked about the so-called condition in detail then. Now, I’m just a simple caveman, not a health care lawyer, but BCBS’s rejection sure sounded bogus to me, as it did to Biella. (There’s an appeals process by which such disagreements can be settled, and if the parties fail to reach agreement then the case can eventually wind up in court, a prospect Biella was prepared for, though dreading.) Her interactions with BCBS had been pretty bad up till the point of that first blog post: not only were they continuing to reject her claim, they were doing so in an especially opaque and inconvenient manner — you know, shunting her from one service rep to another, demanding new documentation apparently just for the sake of stalling, that sort of thing. She later called it “some of the worst customer service I have ever received”.
Well, within two hours of making that first blog post, she got a call from the Director of Public Relations for Blue Cross Blue Shield of NJ. He “came across her blog posting” and wanted to see what he could do to assist. This is all described in her second blog post.
Doesn’t it seem a little odd that the Director of Public Relations would get involved in what is essentially a medical determination? I mean, if BCBS really, sincerely believes Biella’s condition was pre-existing under the applicable definition of the term, there’s nothing the PR department could do to change that. On the other hand, if it’s not clearly pre-existing — that is to say, if BCBS has been exercising their discretion all along in a hard-to-call edge case — then you’d think it would make much more sense for them to just change their decision and pay out the claim, without ever telling Biella why, and certainly without the PR Director calling her. Finally, if BCBS itself doesn’t even believe the condition was pre-existing, then naturally they should have paid the claim in the first place and never put her through this.
So I’m not sure where in all this it makes sense for the PR department to get involved… except, of course, that from BCBS’s point of view, her original blog post was a potential embarrassment, and protecting the company from embarrassment is part of PR’s job.
Maybe they ought to consider the possibility that protecting the company from embarrassment is also the claims department’s job… I’m just sayin’.
Often times, the most effective way to get quick reactions out of large organizations like this is to embarrass them. That lesson is not lost on folks that are undergraduates at American universities, for one, these days. Also see the related tactic “I know a lawyer who will threaten probably ridiculous but certainly expensive (for you, the defendant) legal action and therefore it makes economic sense for you to address my complaints now instead of facing a drawn-out legal battle.”
It’s “squeaky wheel” economics. As it turns out, if you deny just about everybody coverage, only a small proportion of the population will contest it. This saves you money. This is why BCBS is currently engaging in an intense argument with my doctor about my menstrual cycle, believe it or not.
Hmm, but then why do they put up such a fight?
True, in order to ensure that most people don’t bother to contest, BCBS would need to put up some fight in each case (otherwise word would get around, and people would start contesting more). But the insurance company wouldn’t need to fight to the degree they are in Biella’s case (and perhaps in yours). At this point, they may well be near to spending more money resisting Biella’s entreaties than they would just paying out her claim, which wasn’t that large by medical standards.
The “squeaky wheel” theory is sort of like those “satisfaction guaranteed or your money back” offers on cereal boxes. If you take the time to clip off the box top and send it back, along with a letter detailing exactly what you didn’t like, and you’re willing to fill out the form letter they’ll send you as a first response, then you will, in fact, get your money back. The know that only a tiny percentage of people will ever bother.
But by analogy, Biella has already clipped her box top, filled out all the forms, etc. If this were just the squeaky wheel treatment, they’d have paid the claim by now. I think some other policy must be in operation here…
Yeah. But I worry about arms races… As more and more people figure this out, the less weight it will have in each individual case.
Nice blog(s), by the way (dannycolligan.com).
I have had nothing but headaches with Horizon Blue Cross Blue Shield of New Jersey. I had to deal with them on behalf of my mother, who had Alzheimer’s, and they were just atrocious. Now my niece who has them as her insurer, is being denied a claim for having her childbirth at home (when they told her it WAS covered). The State ought to look into that company for false advertising. I would LOVE to speak with someone at a stockholder’s meeting and let them what is really happening with this company — I personally feel they are fraudulent in their claims.