From the Seattle Times:
Health plan fined for denying claims
By Kyung M. Song
Seattle Times staff reporter
Kaiser Foundation Health Plan has been fined $65,000 for denying claims from 299 policyholders in Southwest Washington who received care in emergency rooms during 2003 and 2004.
Insurance Commissioner Mike Kriedler announced Friday that Kaiser violated a state law that requires insurers to cover emergency treatments if a prudent layperson would reasonably believe that an emergency exists.
The fine was sparked by a complaint from a female patient whose claim was denied by the insurer. The state then asked Kaiser to review other rejected claims. That internal audit turned up 229 cases in which claims had been illegally denied by a Kaiser physician reviewer, said Beth Berendt, deputy commissioner for rates and forms.
“We found out that the Kaiser doctor was imposing his medical judgment on the claim as opposed to the prudent layperson judgment,” Berendt said.
For instance, a person would still be covered if he went to the emergency room with chest pains but it turned out to be indigestion.
Kaiser has paid all the disputed claims and has changed its claims-review procedures to avoid rejecting qualified claims for emergency services, said Gail Mathabane, a Kaiser spokeswoman.
Related:
I wonder if other states have laws like these?
Also, I wonder how this effects ER policy? Is the person with chest pains, but no Kaiser coverage, turned away because it “might” be indigestion? My understanding is that Kaiser cheated the statistics to get a lower heart attack mortality rate by excluding people who die before they get to the ER…
No one is supposed to be turned away with chest pains without being evaluated but it does happen. Years ago in Las Vegas I remember a homeless man was turned away from an ER and he keeled over and died on the grass outside of the hospital two minutes later.
Kaiser breaking the law again is hardly surprising. What is really telling is that a law like this has to exist in the first place. There are no real ethics remaining in health care.
$65k divided by 299 patients is only $217 per person. It costs more than that to walk in an ER door. It’s a lame punishment and hardly a deterrent to more hanky panky. Kaiser only gets caught for a small percentage of its illegal antics and will always see cheating its members and breaking the law as a cost saving strategy IMO.
Waiting with baited breath for the DMHC to announce the fine for the kidney transplant debacle.
It’s a sad day when we have to blame an entire organization for what appears to be a simple error in judgement by an employee. I would think that paying the fine and correcting their practice would be enough, rather than acting like Kaiser is out there screwing over the public.
Funny, not five minutes before that last comment was posted by someone with a Kaiser Permanente IP address, someone else said Kaiser would scapegoat the individual physician and pretend it had no idea this was going on. Oops!
I’d like to see an audit of ER claim denials in all Kaiser regions. Would a pattern emerge?
Regarding Kaiser screwing over the public, we’re not acting. Did you take a look around?
Interesting, illegally denying emergency claims also happens in Hawaii. It was a battle appealing my husbands E.R.claim denial. We thought it was a heartattack he was having, when it turned out to be a bad reaction to a diet pill. Which may sound petty, but it was serious enough symptoms to be referred by a Kaiser advice nurse to go to the E.R., but yet later they tried to get out of paying?! Our E.R. doctor told us it was the right thing to do to come in like we did and because he is at an outside urgent care hospital contracted with Kaiser’s after hours treatment of members, he had no trouble backing us up. We were really fortunate. Ridiculous I tell you…Kaiser is dumb.
Kaiser Hawaii has been losing money (and members) for awhile, so they are scrambling to cut costs. They tell the reporters that patients won’t be affected by the penny pinching, but to put it bluntly: they are lying.
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