November 20, 2000
Councilmember Ruth Galanter Los Angeles City Council Westside District Office 7166 W. Manchester Avenue Westchester, CA 90045
Dear Ms. Galanter,
As a member of your constituency in council district 6, I am requesting your help in holding Blue Cross of California accountable for misrepresentation of coverage. It has come to my attention through denied emergency room insurance claims that several Southland emergency rooms are no longer negotiating physician contracts with Blue Cross of California. Blue Cross of California is therefore denying ER claims, deeming them “out of network.” However, Blue Cross continues to sell corporate and individual policies stating emergency room coverage after a one hundred dollar deductible is paid. This fraudulent activity is not only a gross misrepresentation of coverage, it is a blatant lie.
Dr. Slay, ER Physician Medical Director at Daniel Freeman Marina Hospital informed me that due to Blue Cross of California paying “abysmal reimbursement” to doctors, hospitals are refusing to renegotiate contracts with Blue Cross of California. However, Blue Cross continues to sell policies with emergency room coverage. Blue Cross also continues to collect premiums on existing policies, charging for emergency room coverage which they then refuse to provide. This is clearly insurance fraud. In speaking repeatedly with Blue Cross over the past year and a half, I have been edified by Blue Cross agents with the knowledge that the Blue Cross policy holders, not they, will bear the cost of these contract disputes by being forced to pay out of pocket for ER care. Dr. Slay explained that he receives daily calls from shocked patients who are being billed, in addition to the one hundred dollar co-pay, for ER visits. These patients were falsely led by Blue Cross into believing that they had emergency room coverage as is stated in their policies, unaware of contract disputes beyond their control.
I discussed with Dr. Slay the fact that a Blue Cross agent reprehensibly suggested that the next time my three month old baby is in need of emergency medical care, we should drive an hour and a half to “contracted” Torrance Memorial, and only then will they cover an ER bill, since Torrance Memorial is listed as having contracted physicians. Unfortunately, Dr. Slay informed me that this is incorrect as Torrance Memorial’s physicians are also dropping Blue Cross by refusing to renegotiate a contract. I was then astounded to find that each hospital I called yesterday is dropping Blue Cross by refusing to negotiate contracts including St. John’s Medical Center and Cedars Sinai citing unacceptable reimbursement. We, the policy holders, are all left with no ER physician coverage.
Blue Cross continues to sell and collect premiums with impunity on policies stating emergency room coverage with a one hundred dollar co-pay outlined in their benefits package without disclosing the fact that they are unable to negotiate physician contracts and provide this outlined coverage. I have paid several hundreds of dollars over the co-pay in recent months alone. Dr. Slay and I were lamenting over how tragic it would be if one of your constituents were to be in a major accident and require emergency care. They could lose their home due to lack of insurance coverage, which they falsely believed they had in their erroneous Blue Cross policy.
It is incorrigible that Blue Cross pays, as Dr. Slay pointed out, “less than Medicare” to doctors yet they are not charging the same “abysmal” premiums to their customers. I have a masters degree in clinical psychology and currently work as a client advocate. I will now advocate to ensure that consumers know that their private Blue Cross health policy is considered “worse than Medicare” by doctors and hospitals. I believe that the only way to hold Blue Cross accountable is through generating heat in the media through a public outcry. I have collected several articles from the Los Angeles Times about the Blue Cross negligent denial of coverage and their dishonest, incompetent service. It is obvious that we need much more media attention. I plan to rally those who have been denied coverage and paper Los Angeles clinics, doctor’s offices and emergency rooms with flyers alerting Blue Cross policy holders of their unconscionable service and lack of coverage. After a year and a half of egregious service from Blue Cross it has become obvious that this matter can only be settled through a class action law suit. (After an internal appeals process that took 65 hours of my time, Blue Cross paid an additional $70 toward a claim, refusing to cover the entire claim stating that being brought to an emergency room in an ambulance unable to breathe is obviously not a true emergency. And furthermore, if I wanted to use my insurance the ambulance should have driven to “contracted” doctors.) If every single one of their policy holders, both individual and group, switches to another insurance company and seeks legal action for denied coverage that was guaranteed and paid for, I am certain that needed changes will go into effect.
My husband met with his Human Resources Department in the hopes of persuading them to switch from Blue Cross to another health care provider. Due to multiple complaints, we were guaranteed that they would drop their Blue Cross large group corporate policy and switch to another health care insurance provider by February, 2001. We informed the company’s insurance broker of Blue Cross having costly yet “Medicare equivalent” coverage. Insurance brokers should offer less expensive yet consumer friendly policies to their consumers. Free of Blue Cross in February, I will continue to advocate for patient rights. Armed with the knowledge provided to me by the doctors and hospitals I am speaking to, I am going to my list of human resource department contacts to enlist corporations in Los Angeles and Orange County to switch from Blue Cross to another health care provider who will provide emergency medical care coverage to their employees.
I am requesting a full investigation of the Blue Cross by the California State Insurance Commission Fraud Division. I am in the process of writing letters to every major newspaper and television station in Los Angeles and Orange County. I am contacting Senator Dianne Feinstein and Senator Barbara Boxer to alert them of what Blue Cross of California is doing to their constituents. In this most turbulent time for our country when the question of quality healthcare is on everyone’s mind, we need government to step in and ensure that doctors are adequately paid and policy holders are adequately covered. Policy holders have the support of the physicians and hospitals. It has been my experience that together we can effect change. I am requesting your assistance in this most grievous and urgent matter. Thank you for your continued work and concern for those of us in district 6.
Sincerely,
Colleen Kelly