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Insurance Fraud Starts at Home
Published on July 1, 2010 By Phil Osborn In Consumer Issues

I just submitted this to the state of California at insurance.ca.gov/0250-insurers/IndHlthRateFilings, in response to an article about Anthem Blue Cross's application to raise rates by about 20% next year.  Note that previously they had insisted that they needed to raise rates by about 40%, due to increasing costs.  However, the parent company, WellPoint*, was audited and somehow, via such standard accounting practices as double-billing, as they admitted, they had lost track of quite a few $billions.  I believe I also saw a story a month or so back to the effect that WellPoint had made $9billion in profits in California this past year.


To Whom It May Concern,

I have been a subscriber to Anthem Blue Shield of California for many years.  What I have been noticing of late, however, is a decline in actual service and a piling on of unnecessary and overpriced procedures, coupled with a failure to collect on billed costs. 

~2012:  As it tuned out, the gluten connection may have been a red herring.  We still don't know for sure what the cause of the problem was, but it recurred a couple years later, with serious abdominal swelling and shortness of breath and blood pressure going through the roof, from my normal 110/65 to over 190/??, as I discoverd after a friend drove me again to the ER.  This time they did pump my stomach and leave a drainage succion going for the next 30 or so hours.   This time, also, they had a new scanner that identified that I had "pseudo-obstruction of the small intestine."  This means that some small section of the small intestine stops the peristalis that moves the food along.  The succion was to take the pressure off the blockage and let it relax and start working again.

Conditions in the hospital were barely better than the previous time.  I think that because I was wearing old work clothes and had a backpack - for my motorcycle - that I must be a street person without insurance.  So, they put me in a duplex with a curtain between me and some high-roller salesman who proceded to have a PARTY in his little area, with a whole crowd of people showing up at about 7AM and singing, shouting and dancing - at one point falling through the curtain and spilling my urine bottle all over my bed.  I never got any sleep in two days.

I was and am taking selegiline for several reasons and it was I who found the link on-line that indicated there was a possiible cause there.  Since then, when the symptoms seem to be coming on again, I just stop eating for a day or two and it always goes away.

In 2009, for example, I went into the ER, complaining of shortness of breath combined with abdominal pain.  The abdominal pain had been ongoing off and on  for several years, with no treatment from any of my doctors, until it spiked and I rushed to the ER.  There, I was almost killed by a crew of young interns who tried to pump out my stomach, even though I told the doctor that this was an ongoing condition - not likely due to anything I had eaten. 

I spent the rest of the night and the next day in a hospital bed pincusioned with IVs, waiting for an actual doctor to examine me, as I had a crucially important meeting scheduled for that day.  By that morning the pain had subsided, but it was impossible to get any rest, due to nurses making completely unnecessary racket throughout the night, and due to the patient - a 90+ year old man clearly on his deathbed who kept urinating on the floor right next to me.  The lady who took his urinal away felt that it was an imposition on her to mop up the pool of urine on the floor.

The cause of the abdominal pain and shortness of breath turned out to be an intolerance for wheat gluten.  The IVs and XRays and attempted stomach pumping were all totally useless.  However, I discovered that on my own.  None of the doctors ever suggested it, even though it is well documented in the literature.

In January of both 2009 and 2010, I suffered injuries from motorcycle accidents, both the other party's fault.  However, when I inquired about compensation for my medical bills, I was told by Anthem Blue Cross's collection unit that they were expecting their costs to come out of any award from my or the opposing party's insurance. 

This seemed only fair to me, so I asked them how I could find out what the total was, so that I could include it in the claim.  They told me that they would not give me that information.  Instead, they would let me guess what the costs were and then bill me for the remainder.  As a consequence, I simply gave up on collecting anything. 

This year, after the 2nd motorcycle accident, I asked my insurance - Progressive - what was going on and how I could deal with it.  The Progressive medical claims expert informed me that due to some quirk in California law, there was no solution for me.  So, I went back to Anthem Blue Cross and their billing company, where I was informed that they would separately bill either my insurance - Progressive - or the opposing party's, but that I could still expect an undetermined bill against any award that I received, in addition.  Thus, I may well end up simply paying out of pocket once again all the co-pays and meds resulting from the accident.

Why would a company that is seeking a massive rate increase be so incredibly lax in collecting known bills that are surely in the range of $2,000 by now?  Why would they pay for all the unnecessary tests and procedures such as I had with the abdominal pain.  These are only two examples of situations in which unnecessary costs are being ignored while patient services suffers.

Could it be that the law's mandated 70% for medical claims is simply serving as an incentive to creatively boost the claims - thereby also the allowable profits?

End of submission:

I have a new doctor, now, as my old one left the area, it seems.  She noted that my white count was low, which is usually the case for me.  It's apparently hereditary and a few years ago my doctor of then sent me to a hematologist to try to discover the cause.  Nothing resulted except a few hundred dollars in co-pays and lost work time.  Ultimately I went to Mexico again and picked up some Isoprinosine, which reliably boosts the white count back into normal range. 

I explained this to my new doctor, and thought that she understood, but then I got a call from her nurse, advising me that she was sending me to another hematologist.  So it goes.  More money down the drain so that Anthem Blue Cross can collect that 30%...

on Aug 30, 2012

I checked your PDF flie.. You have lot of pages on there. Good.