Guaranteed Healthcare

This essay will help you understand how and why your health insurance claims are denied and why they must be denied for our for-profit system to thrive.

The insurance industry in the United States has a single purpose, to provide a stream of profits to shareholders who own the stock of healthcare companies. Guaranteeing the healthcare needs of the American people is not even an afterthought.  Our private, for-profit insurance industry is a huge, sophisticated and dangerous denial machine.

We pay huge premiums year-after-year, then when we become ill, our claims are routinely denied.

I'm going to take you inside one company which functions exclusively to deny as many claims as possible.  Remember a denied claim goes right to the bottom line.

The first concept you need to understand is the Medical loss ratio.  You and I are losses in insurance industry lingo.

The medical loss ratio refers to the percentage of dollars actually spent on medical care versus administrative costs or profit. The higher the ratio, the more money is being spent on actual delivery of care. Components of the medical loss ratio include payments to physicians, hospitals, pharmacists and other providers of health care.

 For example an unheard of medical loss ratio of 91 percent, means that 91 cents out of every dollar goes to practitioners and providers. This never happens, of course.   Most medical loss ratios are in the neighborhood of 80 - 81 percent. The mission of the U.S.  insurance industry is to keep this ratio as low as possible.  The way they do this is with companies like  TC3 Total Claims Capture and Control which I'm going to introduce you to today.  When the medical loss ratio creeps up, the for-profit insurer turns to TC3 to bring it down.

Let's take a look at this denial machine called TC3.

I've selected this company for some well-deserved scrutiny, but you should understand, there are tons of companies just like this one.These companies sell insurers computer programs and claims management protocols designed to reject as many legitimate claims as possible.  Also keep in mind, that for many, once a claim is rejected, the process of an appeal is so daunting and overwhelming, that many of these claims go unpaid.  This is part of the scandalous business model of the insurance industry.

The regulators have disappeared so I defy you, as an individual, to take on the TC3 Funnel once they have "targeted" you and your doctor for a denial. And make no mistake, TC3 brags to its customer base that "targeting" is how they achieve savings.

Utilizing our proprietary claims management system, the TC3 Funnel, we target $250 billion in healthcare claims overpayments to validate payment integrity and maximize cost savings for our clients. TC3 enables our payer clients to take advantage of multiple state-of-the-art loss control technologies through a single connectivity source to prevent paid claims errors on a pre-payment basis, reducing paid claims by 3-10% annually.

Your doctor is the first person TC3 targets. Your doctor is viewed by this company as essentially a criminal lacking integrity who submits an endless stream of fraudulent claims. This is how  TC3 sells its Provider Integrity Program.

Fraudulent healthcare claims generate a large portion of more than $250 billion in healthcare overpayments. TC³ provides healthcare payers with a highly effective system for healthcare fraud detection .

. . .TC³’s Provider Integrity Program (“PIP”) is a comprehensive provider data analysis and modeling application designed to review healthcare claims that may represent questionable or abusive billing practices. Historically, PIP has provided savings in healthcare fraud detection in the range of 1% - 3% of total claims dollars which are in addition to any identified by internal systems or procedures.

To help detect healthcare fraud PIP examines and flags potential claims daily prior to payment. The review process identifies claims and providers processed by a payer’s system and compares each claim against proprietary databases that are updated daily from ongoing investigations.

If you want to know why your doctor will no longer accept your insurance it's because of companies like TC3. If TC3  "flags" your doctor, then her claims will be subject to endless audits and denials.

The software identifies patterns of unusual behavior and provides a risk score based on the claim's degree or probability of fraud. The scores allow TC³’s seasoned team of fraud investigators to determine which claims need to be taken out of the payment stream for further investigation, and allow the rest of the claims to be fast-tracked for payment.  

And a customer testimonial: TC3 is their "secret weapon".  Are you interested in how the TC3 repricing software works? 

The ODS Companies is committed to providing the highest value products supported by the best possible service.  On October 20, 2003 the ODS Companies entered into a partnership with TC³ Health to assist us in implementing a total claims solution focusing on healthcare costs and customer service.  Strategically, we focused on the areas we felt we could save our customers (both groups and members) money. 

With the assistance of TC³ Health and their suite of products, we have differentiated ourselves from the competition.   We are saving our customers money through TC3's out of network repricing services, enhanced clinical editing services and the provider integrity program.

The individuals we have worked with from TC³ have been extremely knowledgeable and service oriented.   They are a pleasure to work with.  We value our partnership with TC3 and look forward to a long lasting relationship. 

TC³ is our top-secret weapon against fighting the on-going rising cost of healthcare.  

Vice President, Medical Claims and Customer Service
The ODS Companies  

TC3 offers another chilling service, this one revolving around the USA PATRIOT ACT. Does this mean if your doctor treats an undocumented alien who happens to be insured, and then he submits a claim, he'll be reported to Homeland Security?  Again, I ask, why would any doctor want to be in the database of such a company?  This is why more and more doctors are refusing to accept insurance, making healthcare even less accessible.

 Specially Designated Nationals and Blocked Persons (SDNs) that prohibits US underwriters, brokers, agents, primary insurers, reinsurers and US citizen employees of foreign firms in the insurance industry of making or receiving or any contribution of funds, goods or services for the benefit of persons designated as SDNs. Payers are required to screen provider and member data against the SDN master list and to notify OFAC of a match or block the assets. OFACsecure(SM) is an automated screening tool that utilizes TC3's proprietary technology and alerts the compliance office of potential regulatory requirements. OFAC regulations are promulgated under federal law and Presidential Declarations and thereby preempt state insurance regulations.

I urge you to familiarize yourself with this company so you'll understand the full dimension of what you and I are up against.

We are in this fight alone, battling massive denial machines. There are no regulators, and the political class, save for a few like Rocky Delgadillo, the Los Angeles City Attorney,  have turned a blind eye.