HMO as (bad) doctor

By | May 15, 2006

My wife and I each recently received letters from Blue Cross Blue Shield of Massachusetts, our health insurer through my employer. These letters introduced us to a program being run by BCBS which, to put it bluntly, is wrong, wrong, wrong.

Here’s what the letter said:

Blue Cross Blue Shield of Massachusetts and Blue Cross Blue Shield of Massachusetts HMO Blue(R) are pleased to offer our Blue Care(R)Connection programs, which are designed to help our members and their families manage certain conditions that may adversely affect their health. These programs provide individualized, enhanced support for members who may be at risk for, or have been diagnosed with, certain chronic conditions. We would like to work with you in support of your physician’s treatment plan by providing you with care management support and educational information. Your physician will also receive information about the program and your participation.

Blue Cross Blue Shield of Massachusetts is working with Healthways, Inc., to administer this program. Healthways is an organization with over 20 years of experience in providing chronic disease management support to people and their doctors. Please be assured that Healthways adhere to the same important confidentiality guidelines as Blue Cross Blue Shield of Massachusetts.

What You Can Expect

  • We provide the enclosed materials, designed to help you monitor your condition; assist you in establishing personal health goals; help you keep track of your medications, tests, and reports; and develop exercise and action plans.
  • A Blue Care(R)Connection program representative will call you at (___)___-____ to introduce you to the program and review these materials with you in greater detail. if this is not your current phone number or if we did not list a phone number for you, please call us toll free at 1-877-301-1430, Monday through Saturday, between 8:30 a.m. and 8:30 p.m. (multi-language translation services are available) to give us your correct phone number.
  • Throughout the year, you will receive care calls and other important health information, including reminder cards and newsletters, to help you better understand and manage your condition.
  • Based on recommendations from providers, selected members suffering from heart failure may receive a scale and blood pressure monitor to measure their daily blood pressure, weight and pulse.

What You Can Do

  • Review the enclosed materials and keep them for future reference.
  • Confirm that (___)___-____ is your correct phone number.
  • If you have questions, if you want to begin participation immediately, or if you choose not to participate in the program, please call us at 1-877-301-1430, Monday through Saturday between 8:30 a.m. and 8:30 p.m. (multi-language translation services are available). Hearing-impaired members may call 1-866-291-0605 (TTY/TTD).

Please note your participation in these programs is entirely voluntary and is available to you while you are an active Blue Cross Blue Shield of Massachusetts member. If you choose not to participate, your eligibility for benefits will not be affected.

Thank you for choosing Blue Cross Blue Shield of Massachusetts. We wish you the best of health.

Accompanying each copy of this letter was an “action plan” for a chronic condition from which Blue Cross or its agent Healthways had decided each of us suffered, based on our insurance claim data in their databases. Yes, you read that right, they diagnosed chronic medical conditions for my wife and me based on our insurance claim histories.

The chronic condition for which they diagnosed me is one from which I may very well suffer, although none of my doctors have, as far as I recall, explicitly told me so. In contrast, the condition for which they diagnosed my wife is one from which she does not suffer, has never suffered, and has never been diagnosed as suffering by any of her doctors. If she actually did suffer from this condition (which, again she does not!) it could interfere with her ability to get a job or insurance coverage in the future. It should be obvious that having her medical records indicate incorrectly that she suffers from this condition could cause the same problems.

My wife immediately contacted her primary care physician to discuss the letter she had received. Her PCP was at first amused (“If I had a patient with that condition, I think I’d know about it!”), then appalled. She said it was outrageous for a health insurance company to be sending letters to patients telling them they had conditions that they didn’t have. She also said that she thinks it might actually be illegal, both because (a) diagnosing a medical condition constitutes practicing medicine, and it’s not at all obvious that the people who generated and sent out these letters are licensed to practice medicine, and (b) there are legal issues with even a licensed practitioner to diagnose someone with whom s/he does not have a formal doctor-patient relationship. After being amused and appalled, she was concerned, and she warned my wife that she’d better contact the insurance company ASAP to make sure that they don’t have something in her records claiming that she has a serious chronic condition that in fact she does not have.

Health insurance companies should not be diagnosing patients. This is true whether or not their diagnoses are correct, but it is much more outrageously wrong for incorrect diagnoses. Prior informed consent from patients to allow the insurance company to look at their records and make such diagnoses might make the program OK, but it is certainly not OK to run patients’ medical data through computers and send them letters of this sort without such prior concent.

Before contacting the insurance company as recommended by my wife’s PCP, I decided to speak with my employer’s Vice President of Human Resources directly about what had happened. He agreed with me that the program was ipso facto inappropriate and that it was outrageous that my wife received a letter about a severe chronic condition which she does not have. He said he would contact the insurance company immediately, and that he might ask them to contact me to discuss it further.

A few days later I got a call from a woman at BCBS. She informed me that the letter my wife received had been sent in error, as a result of an error in the logic used to determine which customers should receive letters about that particular condition, and she apologized for the “error.” She said that other people had received erroneous letters about the same condition, and that as a result, that portion of the application had been shut off and no further letters would be sent out about that particular condition until the problems with the logic were fixed.

In response, I informed her that while I appreciated her apology, my complaint was not with the specific letter that my wife received, but rather with the entire program, i.e., with BCBS diagnosing customers based on claims histories, quite possibly in violation of the law (she professed no knowledge of such a possibility, and I suggested that she might want to look into it). She tried the old, “No one else has every complained!” canard (this is what companies that are wrong tell everyone who complains about a particular issue until somehow the lid gets blown off how many people are actually complaining), but obviously didn’t get very far with me on that one. Then she tried, “This is a service that we’re providing to our customers that many of them appreciate,” to which I responded, “The only reason you have to provide such services is because you pay the doctors so little for their services that they have to see thirty patients a day to break even and don’t have time to pay enough attention to any of them.” She refused to acknowledge that it was ridiculous to assert that now that they’d turned off the logic for this one condition, there weren’t any other incorrect diagnoses being made by the computers. I didn’t seem to get through to her when I explained that just as they didn’t know there were problems with the logic for this particular condition, there was no way they could know whether there were problems with the logic for other conditions as well, unless of course they felt it was OK for them to send letters to patients with incorrect diagnoses until someone bothered to complain about it. In short, according to her, BCBS doesn’t think there’s anything wrong with this program and intends to keep running it.

She had a similar conversation with our VP of HR with a similar outcome. He’s planning on raising the issue with our insurance broker and trying to get them to turn off the program completely for all our employees. I’m planning on filing a complaint about the problem with the Insurance Division of the Massachusetts Office of Consumer Affairs and Business Regulation, as well as running this by the health reporters at the Boston Globe and Herald to see if I can get them to pay some attention to it. We’ll see what comes of it.

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15 thoughts on “HMO as (bad) doctor

  1. George Orwell

    I cannot believe that this can happen. I am disappointed in blue cross blue sheid of massachusetts. My perception of the healthways company is that it is a very deceptive way of obtaining information from unsuspecting people using trained telemarketers.

    Reply
  2. Patience

    First, thanks for the site, I just received the “we’ve been calling you, is this your number…you’ve got one foot in the grave…call us” Healthways letter, dated on 4-3-2008, received on 4-18-2008. I guess it was sent by wagon train!

    Has anyone not called these people back? Why would Blue Cross Blue Shield of Massachusetts think I would want to deal with a “subcontractor” in Morrisville, NC? Blue Cross is $150. more than Harvard POS. Is Healthway what I’m paying the extra money for? It’s open enrollment time, it’s almost enough to make me switch insurance companies.

    Reply
  3. William R. Barnett

    I wanted to add some more things to the “disease management” process. Some other reasons why one could be “flagged” may be due to just not sending in any claims for several years. Another reason could be due to processing a claim for care, procedures, medication, etc. that is used frequently with another medical diagnosis. These are ICD-9 codes or DRG numbers that correspond to a disease classification. It doesn’t mean you have the disease, but the claim history may show it’s consistent with others.

    Also, the best thing to do in the case of getting phone calls or mail is to respond to it. The easiest thing to do is just to decline a program and that should stop the phone calls until the next claim is flagged. Usually it’s 6-months apart between declines. If Healthways doesn’t hear from you after so long, they move on to the next batch, but may come back to call you weeks or months later, if they don’t have a decline on file. To be honest, if you continue to carry the insurance, then you are potentially eligible to be called.

    Reply
  4. William R. Barnett

    I came across your site and decided to add a little to the “conversation”. First off, I used to work for Healthways. Actually, I was a health advisor for a company they recently acquired, which is responsible for administering a disease and lifestyle management program. One insurer I worked with was BCBS of MA and BCBS of KC and I did so as a third party.

    My understanding of contacting potential clients is through insurance claims data. Of course, many people get a little antsy about their “private information” being shared. Still, this is well within the HIPAA standards. What ends up happening is when someone processes a claim that “flags” an individual for a “program”, it’s Healthways job to contact the patient to see if they are interested in the service. For instance, someone may be sending in claims for that are coded for congestive heart failure or COPD. Every time these claims are sent through the system, the patient would be eligible for the program. Remember these programs are completely free to you and are still voluntary. Sometimes individuals are given an incentive to participate, such as discounts on insurance or monetary compensation for their time. These health education services are a great service to people that want to help manage their chronic health conditions and not designed to replace a physician, but serve to augment healthcare.

    Enough about the pleasantries of Healthways and it’s associates. The reason that I have left this company after 1-1/2 years was because it’s nothing more than a sweatshop where enrolling people is money and they do so at the cost of the employee. Healthways is a very anti-union, discriminates against minorities, low-balls wages, and promotes based on favoritism.

    I you have any furthers comments or questions, then you can reach me via e-mail at [email protected]. I hope my reply was helpful.

    P.S. This site popped up on a search for complaints with Healthways. Since I have filed numerous labor and civil charges against my former employer, I wanted to see what “dirt” was out there.

    Reply
  5. jik Post author

    You just go ahead and email Richard Kelliher and tell him that I’m “using a taxpayer paid for server” and see what he says.

    Before you do that, however, you might want to actually acquire a clue about how the “.us” domain works. I’ll even start you off… Your assumption that only servers controlled and paid for by the Town of Brookline can have host names beneath “.brookline.ma.us” is laughably incorrect.

    Reply
  6. Anonomous

    I wonder what the Town of Brookline would have to say about you using a taxpayer paid for server? Hmmmm…where did I put Mr. Kelliher email addy…

    Reply
  7. Louisa

    Thanks for posting this so it can be found by others in this situation. I am familiar with several employees of these companies and the activities described continue to this day. Don’t stop your efforts.

    Reply
  8. someone

    i received this same letter as an automated phone call (and have received it now 5-6 times), but have not responded yet. thanks for having this page available on the net!

    -someone

    Reply
  9. jik Post author

    I received a letter from the Division of Insurance on January 28, 2007, in which they enclosed a copy of a letter to them from Blue Cross dated June 12, 2006. Why it took the Division of Insurance over six months to mail me a copy of this letter, I have no idea.

    In any case, in this letter, the Blue Cross misinterprets my complaint that their Blue Care program could be illegal as an accusation of violating the HIPAA privacy regulations, and then rebuts an accusation I didn’t make by explaining that their fine print allows them to share data with contractors, a fact which I never disputed.

    In fact, my complaint was about the fact that diagnosing someone with a chronic medicine constitutes practicing medicine, and doing that by computer may violate the law for two different reasons: (1) computers are not licensed to practice medicine; (2) it may be illegal for anyone to diagnose people with whom they are not in a doctor-patient relationship.

    The Division of Insurance examiner who handled my complaint of course completely missed the point and indicates in his cover letter, “This matter should be resolved.”

    The biggest difficulty in ever getting any department of government to do their job is, of course, finding someone who cares and has a clue. *sigh*

    If I had more time, I might tilt at this particular windmill more, but my heart just isn’t in it.

    Reply
  10. jik Post author

    My wife and I received this letter from Healthways last week:

    Dear Mr. and Mrs. Kamens:

    It has come to my attention that despite your request for removal from the Blue Cross Blue Shield of Massachusetts Blue Care Connection program on June 8, 2006, you still received a letter about the program in late July of this year. I also understand that after receiving the letter, you attempted to contact Healthways using the phone number provided, and the line did not successfully connect.

    I would like to offer both of you my sincerest apology for any frustration this situation may have caused. It is my intent — and the intent of everyone here at Healthways — to provide you with the best possible customer service, and to strive for improvement at every possible opportunity. This situation reflects one of those opportunities.

    Please rest assured that you have both been removed from our disease management programs, and should not receive any further phone calls or letters. If you do receive any additional communications, please call me directly at (___) ___-____.

    If at any time, you should ever need or want to participate in any of our disease management programs, we would be happy to include you. Until then, we wish you good health.

    Sincerely,

    _____
    Director, Care Management

    It’s a good letter, certainly about the best they could do under the circumstances.  And I can’t honestly say that I blame them for the whole thing, since they’re just doing what Blue Cross paid them to do.

    Reply
  11. jik Post author

    I got this response from the Division of Insurance on August 22. This is after they called and left me a message on my voice mail and I called back and told them to send me email, because I really didn’t have time to play phone tag with them, because I can deal with email on my schedule whereas phone conversations must happen on theirs, and because I wanted everything in writing. In addition to this email, I also received a second voice-mail message asking me to call.

    Mr. Kamens,

    Please accept my apology for the late response to your e-mail. Unfortunately, we are having staffing issues here at the Massachusetts Division of Insurance. So my response time has been limited greatly, with that being said, I have received a response from Blue Cross and Blue Shield of Massachusetts, Inc., regarding your letter of complaint to our office on May 19, 2006. If at all possible, could you please call me here at the Massachusetts Division of Insurance. My direct telephone number is (617) ___-____, the reason for my request is to guarantee that you understand the response that I have received from the insurance company.

    I do understand that you would prefer to have this information sent to you in the form of an e-mail, however, the length of the company’s response and the details of the information provided by the insurance company, is something that I would like to relay to you via a telephone conversation.

    Please accept my apologies for any inconvience that this may cause you.

    Sincerely,

    ______
    Senior Insurance Compliance Analyst
    Consumer Service Section
    Massachusetts Division of Insurance

    I just responded:

    Mr. _____,

    I received your voice-mail message and your email.

    I do not understand why you think you need to speak with me on the telephone. You said on your voice-mail message that you had a two-page response from Blue Cross Blue Shield of Massachusetts, and you felt it was important to read the entire response to me. Why can’t you simply photocopy it and mail it to me or fax it to me at 617-___-____? Surely that would be even more accurate than reading it to me over the telephone, and it would take less of your time and mine.

    In any case, quite frankly, I don’t much care to hear their response. I imagine that they say nothing in it that I haven’t already heard from them directly. I reported the problem to you not because I wanted you to “mediate” for me, but rather because, as I said in my letter, I believe that what they are doing is wrong and perhaps even illegal, and I believe that the Attorney General should be investigating what they are doing and taking action against them to make them stop doing it. You don’t need anything more from me to do that, unless you need me to testify against them.

    I am exceedingly busy. I know you are as well, but I imagine that you probably get to leave your job at a reasonable hour and go home until the next morning, whereas in my job I’ve been working 60-hour weeks for several months, and when I’m done I have to go home and help take care of four young children, not to mention various volunteer activities which take up a great deal of my time. I don’t have any more time to waste corresponding with you about my complaint. I’ve done my duty by bringing to your office’s attention what Blue Cross is doing. I hope you take action against them because of it. Feel free to mail or fax me their response if you wish, but other than that, please don’t contact me again unless it’s for an active investigation rather than pointless mediation.

    Sincerely,

    Jonathan Kamens

    Reply
  12. jik Post author

    Here’s the letter I received from the insurance division at the end of May (haven’t had time to post it before now):

    Dear Mr. Kamens:

    Kindly be informed that the Consumer Service Section received your complaint on May 30, 2006.

    Your complaint has been assigned to me to review. At this time, I have forwarded a copy of your complaint to Blue Cross and Blue Shield Of Massachusetts, Inc., and requested that a detailed, documented response be submitted to my attention.

    Because the Consumer Service Section is committed to conducting a thorough review of the issue(s) raised by your complaint, please be advised that my review may take some time. In addition, as part of my review process, I may need to contact you to discuss your complaint and/or ask you some questions.

    Once my review has been completed, I will contact you and inform you of the results. In the meantime, please do not hesitate to contact me at (___) ___-____ or, in the alternative, at [email protected] with any questions or concerns.

    I haven’t heard anything more from them about this. I’ve just sent email to the address given in the letter asking for the current status of my complaint.

    Reply
  13. jik Post author

    The day I read Paul Maybury’s comment above, I came home to discover that my wife had received the same letter in the mail. I tried calling the phone number in the letter, with the intention of making it clear to them in no uncertain terms that neither my wife nor I wants anything to do with the “Blue Care Connection program” either now or at any time in the future. The phone number doesn’t work — it rings twice and then goes silent. According to the letter, “Healthways is a national organization with over 20 years of experience in providing chronic disease management support to physicians and their patients.” Over twenty years of experience, and they can’t even get their phones to work!

    I have asked my employer’s VP of HR to (again) complain to Blue Cross about this program.

    Reply
  14. Paul Maybury Jr.

    I began being harrassed by The Blue Care Connection people several months ago, however, all the calls were in an attempt to reach my spouse. I told them I did not wish to recieve any more phone calls, and my wife was not interested in thier “care”. The caller out and out refused to discontinue these harrassing calls, and I eventually lodged a complaint against them with the federal Do Not Call registry. I don’t know if this had any effect, although it should, because I have no direct link with their organization, and have never had any business with them. At one point, I became so irritated with their frequent calls to my home, that I tried to call back the number on my caller ID. Instead of reaching them, I reached a very snotty young man who claimed to be a “customer service” representative, but he said in very uncaring tones that he could’t identify the company that was calling me by thier phone number, “his company represented so many” and “he had no way of finding out.”
    However, they did stop calling my wife eventually, but today I received a letter addressed to ME, calling me “Dear Blue Care Connection Program Member” and stating they had been unable to reach me at my phone number, an obvious lie, and asking me to call them. If anyone knows how to stop these interfering and nosy insurance agents, I would like to know what must be done. I’ll be watching this blog.

    Reply
  15. jik Post author

    I’ve sent news tips about this to the Boston Globe and the Boston Herald, sent a complaint about it to the Insurance Division, and sent a pointer to the Privacy Rights Clearinghouse (http://www.privacyrights.org).

    Reply

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