[THS] WellPoint routinely targets breast cancer patients

[The Harder Stuff in news and commentary]

WellPoint routinely targets breast cancer patients
By Murray Waas

22 Apr 2010 22:03:27 GMT
Source: Reuters

* Algorithms launched probes of breast cancer diagnoses

* Many policies were canceled based on flimsy information

* New health care law lacks teeth, according to detractors

* WellPoint lobbied against reforms to end such practices
http://www.alertnet.org/thenews/newsdesk/N20207082.htm

LOS ANGELES, April 22 (Reuters) - Shortly after they were diagnosed with breast cancer, each of the women learned that her health insurance had been canceled. There was Yenny Hsu, who lived and worked in Los Angeles. And there was Patricia Reilling, a successful art gallery owner and interior designer from Louisville, Kentucky.

Neither of these women knew about the other. But besides their similar narratives, they had something else in common: Their health insurance carriers were subsidiaries of WellPoint <WLP.N>, which has 33.7 million policyholders -- more than any other health insurance company in the United States.

The women paid their premiums on time. Before they fell ill, neither had any problems with their insurance. Initially, they believed their policies had been canceled by mistake.

They had no idea that WellPoint was using a computer algorithm that automatically targeted them and every other policyholder recently diagnosed with breast cancer. The software triggered an immediate fraud investigation, as the company searched for some pretext to drop their policies, according to government regulators and investigators.

Once the women were singled out, they say, the insurer then canceled their policies based on either erroneous or flimsy information. WellPoint declined to comment on the women's specific cases without a signed waiver from them, citing privacy laws.

That tens of thousands of Americans lost their health insurance shortly after being diagnosed with life-threatening, expensive medical conditions has been well documented by law enforcement agencies, state regulators and a congressional committee. Insurance companies have used the practice, known as "rescission," for years. And a congressional committee last year said WellPoint was one of the worst offenders.

But WellPoint also has specifically targeted women with breast cancer for aggressive investigation with the intent to cancel their policies, federal investigators told Reuters. The revelation is especially striking for a company whose CEO and president, Angela Braly, has earned plaudits for how her company improved the medical care and treatment of other policyholders with breast cancer.

The disclosures come to light after a recent investigation by Reuters showed that another health insurance company, Assurant Health, similarly targeted HIV-positive policyholders for rescission. That company was ordered by courts to pay millions of dollars in settlements.

In his push for the health care bill, President Barack Obama said the legislation would end such industry practices.

But many critics worry the new law will not lead to an end of these practices. Some state and federal regulators -- as well as investigators, congressional staffers and academic experts -- say the health care legislation lacks teeth, at least in terms of enforcement or regulatory powers to either stop or even substantially reduce rescission.

"People have this idea that someone is going to flip a switch and rescission and other bad insurance practices are going to end," says Peter Harbage, a former health care adviser to the Clinton administration. "Insurers will find ways to undermine the protections in the new law, just as they did with the old law. Enforcement is the key."

In a statement to Reuters, WellPoint said various specified criteria trigger rescission investigations, including certain types of medical claims. The company said it changed its rescission practices to ensure they are handled appropriately after a 2006 review of its policies prompted by public concern over rescission.

WellPoint also said it created a committee which includes a physician for making rescission decisions. The company also noted that it established a single point of contact for members undergoing an investigation and enacted an appeals process for applicants who disagree with the original determination.

During the recent legislative process for the reform law, however, lobbyists for WellPoint and other top insurance companies successfully fought proposed provisions of the legislation. In particular, they complained about rules that would have made it more difficult for the companies to fairly -- or unfairly -- cancel policyholders.

For example, an early version of the health care bill passed by the House of Representatives would have created a Federal Office of Health Insurance Oversight to monitor and regulate insurance practices like rescission. WellPoint lobbyists pressed for the proposed agency to not be included in the final bill signed into law by the president.

They also helped quash proposed provisions that would have required a third-party review of its or any other insurance company's decision to cancel a customer's policy.

A WellPoint spokeswoman on Thursday denied such lobbying took place.

The new law does leave open the possibility of reform in this area, these sources say. The reason, they say, is that much of the new legislation is essentially a roadmap, with regulations to be decided later.

"The lack of specificity doesn't mean that nothing is going to be done," said a senior congressional staffer who has played a key role in the health reform debate. "The law grants HHS (the Department of Health and Human Services) the discretion to promulgate regulations. This is very much a work in progress."

Among other things, the staffer said, the White House could revisit proposing tough new regulations requiring third-party review of policy cancellations.

Victoria Veltri, the general counsel of Connecticut's Office of Healthcare Advocate, a state agency that investigates complaints by policyholders, says she has seen the success of such a process in her home state. One company, Aetna, has voluntarily agreed to engage in the third party review, with what she described as favorable results.

"I haven't seen an Aetna case in our office since they went to the third party review process," she said. "It's a powerful tool to have a third set of eyes required before someone is rescinded."

For its part, WellPoint said it began offering third-party reviews in 2008.

A senior Obama administration official said he remained confident that mandatory third-party reviews of rescissions is not entirely out of reach.

"It might take some wrangling with the insurance industry, some strong-arming, maybe even use of the presidential bully pulpit," he said on condition of anonymity.


http://www.huffingtonpost.com/jane-hamsher/wellpoint-lobbyists-axed_b_548220.html


Jane Hamsher
Founder, FireDogLake.com
Posted: April 22, 2010 02:18 PM

Wellpoint Lobbyists Axed Key Protections for Breast Cancer Patients From Health Care
Bill

Federal investigators have told Reuters that WellPoint, the country's largest insurance
company, is using an algorithm to identify women with breast cancer for the express
purpose of dropping their coverage.

Murray Waas writes that WellPoint "specifically targeted women with breast cancer
for aggressive investigation with the intent to cancel their policies":

The women all paid their premiums on time. Before they fell ill, none had any
problems with their insurance. Initially, they believed their policies had been canceled
by mistake.

They had no idea that WellPoint was using a computer algorithm that automatically
targeted them and every other policyholder recently diagnosed with breast cancer.
The software triggered an immediate fraud investigation, as the company searched
for some pretext to drop their policies, according to government regulators and
investigators.

Wellpoint claimed that these women had made material misrepresentations in order
to justify dropping their coverage, but Waas says they were dropped "based on
either erroneous or flimsy information." Last week, Waas reported that AIDS patients
were being similarly targeted for recision.

The version of health care bill passed by the House of Representatives would've
allowed these women to apply to an "independent external third party" for review
before being dropped. It also would have required Wellpoint to keep their coverage
in place until the board made its determination, and policies could only be canceled
in cases with "clear and convincing evidence of fraud."

Those provisions were not included in the Senate Finance Committee bill, however,
which became the basis for the final health care bill signed by the President. Reuters
says that Wellpoint lobbyists "helped quash proposed provisions that would have
required a third party review of its or any other insurance company's decision to
cancel a customer's policy."

As Marcy Wheeler reported last year, the Senate Finance Committee bill was written
by former WellPoint VP Liz Fowler, who left her position at the insurance company in
February 2009 expressly for the purpose of helping the committee to draft the health
care bill:

picture-132.png
http://www.huffingtonpost.com/jane-hamsher/wellpoint-lobbyists-
axed_b_548220.html

And when Max Baucus did a "victory lap" after the health care bil passed, he
expressly thanked Fowler for her work:

I wish to single out one person, and that one person is sitting next to me. Her name
is Liz Fowler. Liz Fowler is my chief health counsel. Liz Fowler has put my health care
team together. Liz Fowler worked for me many years ago, left for the private sector,
and then came back when she realized she could be there at the creation of health
care reform because she wanted that to be, in a certain sense, her profession lifetime
goal. She put together the White Paper last November-2008-the 87-page document
which became the basis, the foundation, the blueprint from which almost all health
care measures in all bills on both sides of the aisle came. She is an amazing person.
She is a lawyer; she is a Ph.D. She is just so decent. She is always smiling, she is
always working, always available to help any Senator, any staff. I thank Liz from the
bottom of my heart. In many ways, she typifies, she represents all of the people who
have worked so hard to make this bill such a great accomplishment.


Susan Bayh, wife of Indiana Senator Evan Bayh, is on the WellPoint board. Bayh
threatened to join Joe Lieberman in a filibuster of the health care bill if a public
option was included, something that would very much threaten WellPoint profits --
which have soared in the past year. Susan Bayh's compensation for her role on the
WellPoint board includes valuable stock options.

Before the health care bill passed, Harry Reid promised Bernie Sanders that there
would be a vote on the public option "in the coming months," and anonymous "hill
aides" said that they were looking to use the reconciliation process, such that only 50
Senate votes were needed for passage. In exchange, Sanders offered to give up on
his plans to offer a public option amendment. A public option would mean that at the
very least, breast cancer and AIDS patients who were unfairly dropped from private
insurance plans had some place to go for medical coverage.

But the Senate budget committee is marking up next year's budget right now, and
according to the Hill, there are no plans to include reconciliation instructions for
health care. Which means that for the next year, any plan to "fix it later" would
require 60 votes in the Senate -- but the public option doesn't have 60 votes. Which
means Reid punk'd Sanders, Jeff Merkley and other progressive Senators to secure
their votes.

It's shameful that Wellpoint lobbyists were successful in keeping key protections for
those with breast cancer, AIDS and other serious illnesses out of the Senate bill. But
it's even more shameful that Harry Reid has no intention of keeping his promise to fix
the health care bill any time soon -- and that members of the Senate with serious
conflicts of interest will profit handsomely as a result.