Declined Claims and Insurance Fraud

I was disappointed by Dana & Parks’ (local KMBZ radio show) one-sided diatribe against health insurers.  They asked to hear from various people, but pointedly left out those who might defend/explain insurance industry practices.  (It is hard to get comments to them, I had to cut this into 5 separate comments).

Clearly it is appropriate to highlight wrongfully-denied claims.  But we have a lot of insurance fraud; our costs reduce if insurers deny fraudulent claims.  The Anthem BCBS plan to limit anesthesiologist payments was the result of overbilling, which Dana & Parks failed to report.  As noted in #2, you should criticize insurers for paying improper claims as well as declining proper claims.  This would be a more unique contribution, as it is an example of the “tragedy of the commons” (I can explain that principle if you are unfamiliar with it).  Here are examples I have experienced:

1. My insurance covered 80% of dental cost.  When I wasn’t billed for my 20%, I contacted the dentist’s office to pay my share.  They told me it wasn’t necessary.  They had raised their prices 25%.  When my insurer paid 80% of their inflated bill, it covered the dentist’s full intended charge.  Thus, the insurer inappropriately paid my share.  I imagine the dentist had good repeat clientele due to their practice although I never went back again.
2. I drove a person home from a car accident.  He assured me he was fine.  I watched him sprightly walk to his house (his entrance was very recessed from the curb).  I later learned he sued for severe neck damage and was told the insurer knew it was a bogus claim, but he was represented by a known shyster lawyer, and it was cheaper for the insurer to pay the claim than to incur legal costs fighting it.  Insurers’ failure to deny such claim fosters fraud should be exposed..
3. My heart doctor was explaining that my heart test was fine, when we were suddenly interrupted so he could speak with his partner.  Suddenly, I needed a heart monitor installed.  I was dubious; in several years since, my heart monitor has detected no abnormalities.  Doctors prescribe unnecessary treatment to protect against our flawed malpractice lawsuits.
4. I locked my key inside my company car.  An attendant at the garage offered to get into my car.  I agreed to save my wife from having to bring my spare key.  When he jimmied into my car, he broke the lock on the passenger door.  I asked our insurance agency where I might get this problem fixed inexpensively.  They told me to send in the bill.  When I responded that I was going to pay for the repair because I had caused the damage, the person repeatedly urged me to “just send the bill to us”.  It concerned me that he was causing premiums to rise.  I did not send the bill.