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Hi, my name is Joan, and I'm your instructor today. I'll be covering the introduction to working in the health insurance industry for you new employees. It is very important to keep in mind that you have signed a non-disclosure agreement. It you go public with any of the negative policies of this or any insurance agreement, by mutual agreement among all major insurance industries, you will never be able to buy insurance again. That means you won't be able to drive, because you can't meet state requirements to have insurance. You'll never be able to buy a home, and Lord help you if you or your children ever get sick. There are lesser penalties for helping people navigate the system efficiently. This includes things like telling the client the correct form to fill out, or regulations that the insurance industry is required to meet. These and other lesser infractions will just be penalties levied against your paycheck.

Keep in mind you are working for a business, who like any other business is trying to make a profit for its stockholders. Our ability to pay your salary is based on us making a profit, not on providing service to the people who pay for insurance. Some of you will be working in the large claims department. The sole purpose of that department is to scrutinize any large claim and find a way to cancel the policy or at the minimum not pay the claim. An example would be if somebody lied about their weight on their initial application, we can cancel their policy after the fact. Another example would be like the young lady who developed bone cancer in her face, six months after signing up for a policy. A quick thinking agent got the parents to admit there was a bump on her chin. Their failure to include that fact in the application was enough to cancel it.

Those of you in the programming department will be fine tuning and maximizing our "downcoding" procedures and our payment delay protocols. In this area, we are increasing profits at the expense of the doctors rather than the people buying insurance. There is a code for every procedure and test the doctor's do. When they submit a claim, they include this code. What the computer does is change the code on their form to a less expensive procedure. For instance, a doctor send the patient for a CAT scan, which costs thousands of dollars. The computer system downcodes that to an X-ray which costs hundreds of dollars. If by chance the doctor's office catches the downcode, the process to get it fixed should take so long that the doctor will settle out of court for a smaller amount of money. You have to be very subtle about this. In September of 2002 over eight thousand doctors sued every major HMO in the country for carrying out this practice for the preceding twelve years. In general, even on procedures that are not downcoded, the system should drag out the repayment time, to allow our company to make interest on the money at the doctor's expense. Aside from the benefit of the direct increase in profits, this policy puts pressure on the doctor not to order expensive procedures, that they know they will have a hard time collecting on. Again, be careful how you implement this profit maximizing technique. The government used the RICO act for conspiracy to punish big companies like CIGNA, Humana, Aetna, Prudentioal, Wellpoint and others.

Those of you going to the retro-cancellation department have the best chance to help increase our profits. This is done by retroactively rescinding an insurance policy on an expensive procedure. Even though we have agreed to have a procedure done, once the bill comes in and we find it to be too high a cost, we refuse the pay the bill by retroactively cancelling the policy and then bill the insured for all medical cost we paid previously. This department has to be especially vigilant. The California regulatory commission, many hospitals, and doctors have joined a class action suit file in December of 2006 against Blue Cross/Blue Shield. The court has fined Blue Cross $200,000 for a single infraction, and they say there may be hundreds if not thousands of other cases. So cover your ass.

In closing, remember we try to collect as much money as possible and pay out as little as possible. A "zero-payout" policy is the best objective for our company. To help you with this, we are paying our HMO doctors a cash bonus for not ordering test or procedures their patients need. So remember to do anything in your power to confuse and frustrate people actually wanting insurance companies to pay for the service they bought!

 

 

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