While much discussion has focused on how insurance companies are trying to influence healthcare reform legislation, Congress has been turning the tables in recent months—looking closely at how medical coverage decisions and denials of claims are made.
On the Senate side, Sen. Jay Rockefeller (D-WV) sent a letter in August to the top 15 health insurance companies requesting information on what insurance companies do with the premium payments they get from consumers and whether this data is shared with policy holders and potential customers.
And last week, in two days of hearings, Rep. Dennis Kucinich (D-OH), as chairman of the Domestic Policy Subcommittee of the House Oversight and Government Reform Committee, turned the spotlight on how private health insurers make decisions on medical care—particularly what Kucinich called "wrongful denial and delay of healthcare."
"The fact is that in America today, you don't know if your health insurance will take care of your serious medical bills until you become seriously ill or injured," he said during the first day of hearings, which featured several witnesses who had been impacted by insurer decisions on the patient and provider sides.
Some spoke of "life-consuming denial and appeal processes," while others such as Linda Peeno, MD, a physician who formerly worked as a company physician for several health plans, talked about "the abyss between what insurance companies say and what they do."
"The primary purpose of health insurance data collected by the state regulators today is to monitor solvency," Karen Pollitz, a research professor with Georgetown University's Health Policy Institute, told the panel. There is little information "on an ongoing basis to monitor the accessibility, affordability or security of health insurance for consumers."
Pollitz, citing earlier data collected by the full committee, said that when queries were sent out to all 50 state insurance departments, only four states could provide data on the number of rescissions—the process of dropping enrollees from insurance plans—that occurred and only 10 states could provide the number of individual health policies.
For the second day of hearings, Kucinich called for executives with six health insurers—and not their chief medical officers—to testify.
"All of the insurance companies here today wanted to be represented" by their chief medical officers, Kucinich said. "Had we allowed that, their preferred representative would have been consistent with the public image companies like to project, but it would have denied the subcommittee the ability to probe how health insurers work." The panel heard from executives of UnitedHealthcare Group, WellPoint, Aetna, Humana, CIGNA, and Health Care Service Corporation.
Kucinich questioned Brian Sassi, executive vice president and chief executive officer with the consumer unit of WellPoint, about $15 million the company recently paid out to settle claims on charges from the California Department of Insurance that 2,330 members were removed from coverage after submitting expensive claims for medical care.
Kucinich specifically wanted to know what the individuals had in common. Sassi, pressed by Kucinich to answer the question, said that they "medically misrepresented their medical history" on their applications during the time they were applying for medical coverage.
"We need information about how your business model works— because people really need to understand that [you] are not charitable organizations," Kucinich told the insurers. "If your medical loss ratio changes too significantly, Wall Street will punish you. We understand that [but] the question is this business model sufficient to provide healthcare to the American people... There's a collision here and you happen to be at that time and place where this collision is happening."