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SiCKO "Hitman" Shares Insurance Industry Secrets With Honest Medicine

Posted Sep 14 2008 4:39pm

Leemug Everyone who’s seen SiCKO will surely remember insurance company “hitman,” Lee Einer. Lee is the person whose job it was to keep the insurance company from paying any large bill -- no matter what he had to do. In his “hitman” role, Lee was directed to find ANY loophole -- one slip-up on an application, or a pre-existing condition, anything -- so that the insurance company could cancel the policy or jack the rates so high that the average person wouldn't be able to pay them. Lee’s most memorable (and most-quoted) line in SiCKO: “You’re not slipping through the cracks. Somebody made that crack and swept you towards it. And the intent is to maximize profits.”

Lee worked in the healthcare industry from 1984 to 2004. The time he spent there still stays with him.

In my HonestMedicine review of SiCKO, I quoted Lee. Imagine my surprise when I received an email with the subject line, “I’m with you.” Lee had found my review and liked it!

So began a back-and-forth correspondence that resulted in a wonderful new friendship, and this enlightening, information-filled audio interview.

Below, you will also find "show notes," where I give a sense of the content of this interview.

DOWNLOAD LEE'S AUDIO INTERVIEW HERE.

INTERVIEW SHOW NOTES:

0:00 to 2:00 – Introduction. Lee’s background, from his days working in the insurance and healthcare industry, up to the present. He is now Features Editor of his local newspaper in Las Vegas, New Mexico, as well as the creator of some really beautiful jewelry.

2:00 to 7:00 – Lee describes our healthcare as a “labyrinthine,” for-profit system, where the patient is the biggest loser -- “like a piece of meat in the middle of a sandwich, with the insurance company and the healthcare provider squeezing him.” Lee talks about how, when an insurance company denies a claim, the healthcare provider invariably opts to go after the patient for the money, rather than battling the far-richer insurance company! Lee also worked for healthcare providers, and in that capacity, challenged insurance company denials, and got lots of insurance companies to pay. So he knows it can be done – if the providers would only try. (HINT: It’s a much less complicated process to go after the patient for the money!)

7:00 to 7:30 – Lee talks about the common practice healthcare providers (especially hospitals) use of putting liens on patients’ houses.

7:30 to 8:30 – Examples from SiCKO of several people with insurance, who were either denied treatment, or who got treatment, but still ended up owing huge bills, leading (in some cases) to bankruptcy. Examples: 18-month old Mychelle Williams, who was denied care and died, because the hospital the ambulance took her to was an out-of-network, non-Kaiser hospital. Also, the “fully insured,” middle-aged couple, Larry and Donna Smith, who were forced into bankruptcy because of large co-pays and deductibles. According to Lee, the main point here is that for-profit insurance companies will do everything they can to get out of paying large bills.

8:30 to 11:00 – Lee discusses the practice by which some CEOs and their top officers often get far better care and better insurance coverage from ostensibly the same plans as their employees. Also, how employer-funded (self-funded) plans are not true insurance plans; and how, with these self-funded plans, it’s not uncommon for there to be a separate set of secret (unwritten) instructions for the CEO and certain top management executives. Lee knows about these plans because he administered some of them. He was told that, if it’s for an employee, you pay by the book. But if it’s the company owner, or a certain officer, everything is to be paid.

11:00 to 13:00 – What shocked Lee the most was the degree to which denial of services is an organized affair, and the degree of effort that is expended to sink certain claims. He tells of one instance, when he was working as a medical investigator, when he was presented with a file of a patient who had just been in an auto accident. Told that the bill would most probably top $300,000, Lee was ordered to find any reason for the insurance company to DENY the claims. He was even authorized to HIRE A PRIVATE INVESTIGATOR, if he needed to. Instead, Lee resigned and never worked for an insurance company again.

13:00 to 16:00 – Pre-Existing Conditions and Other Misconceptions. Includes a discussion of a child with a pre-existing sinus condition, whose family was denied coverage for EVERY complication that resulted from the (uncovered) sinus surgery that failed.

16:00 to 17:30 – The Differences Between a Socialized Payer System and Socialized Medicine. Also, how confusing the multi-payer American healthcare system has become as a result of the many different kinds of policies and coverage patients have. In most cases, each healthcare provider has to hire an entire staff to handle all the details of the many insurance plans patients have, as well as to track receivables, and follow up on unpaid claims, etc. Lee says: “The paperwork burden is preposterous!”

17:30 to 20:00 – Lee discusses possible reasons why the AMA is so against a single payer system. He points out that SiCKO showed that many of our other services are government-run, including the fire and police departments and the military. So why not healthcare?

20:00 to 21:00 – The Veterans Administration vs. Medicare. While both are government-sponsored programs, Lee points out that there are many problems with the VA, most especially the fact that it is severely under-funded. The Medicare system is better: You can go to the doctor you want to go to, and they get reimbursed by Medicare.

21:00 to 22:00 – A discussion of why healthcare providers would find a Medicare-like system easier to deal with than what we have now: 1 set of rules, 1 phone number to call, 1 appeals process. Healthcare providers wouldn't need a whole staff (like they do now) to deal with this complicated mess.

22:00 to 27:00 – Insurance Scams and Rip-Offs – An in-depth discussion about the self-employed person’s so-called “insurance policy.” According to Lee, individual policies are the “bottom of the barrel” in the insurance industry, because they can’t really be true insurance. Why not? The concept of health insurance relies on SHARED RISK. Lee clearly explains this concept and why it works – if there is a large enough pool of people in the insurance plan. It’s totally different with self-employed policies, where there is NO shared risk, so the likelihood of these policies actually coming through for you if you become sick is slim. If fact, in order for these policies to be profitable for the insurance company, they almost HAVE to be a gyp, because you don’t have a pool for sharing the risk. If the insurance company is going to make money from you, the premiums you pay in MUST outstrip the amount they pay out for you.

27:00 to 28:00 – Lee discusses how this problem of coverage for the self-employed person is one of the major factors discouraging entrepreneurship in America, because people are afraid of leaving jobs they hate because they’ll lose insurance coverage.

28:00 to 32:00 – Fraud that healthcare providers perpetrate. Examples of some of the more common types of healthcare fraud: (1) upcoding, which occurs most often with equipment providers and doctors’ offices, and (2) unbundling, which occurs very commonly with surgeries and medical supply kits. One example of a possible surgery that is “unbundled” is given.

32:00 to 37:00 – Lee Becomes a Whistle Blower. Lee describes the situations where this happened, and why he felt compelled to report these companies he was working for. He tells about the Qui Tam provision of the Small Claims Statute, the statute under which Lee sued these companies on behalf of the Federal Treasury. Also, exactly how this provision works.

37:00 to 38:00 – How Lee still feels terrible about having worked in the insurance industry. In his opinion, if you're working for an insurance company, you're generally assisting the company in denying payment for things you know people need. He believes that, unfortunately, far too many people who work in the insurance industry do NOT feel at all badly about their behavior.

38:00 to 39:00 – Are Americans really more “me”-oriented than most? Also, a discussion of people who are willing to go public -- like Lee, Dr. Linda Peeno, and Becky Melke (in SiCKO) -- and expose the terrible things they did while in the employ of insurance companies. Lee feels that only 1 in 100 (or even 1 in 1000) people working for insurance companies feel enough concern to go public.

39:00 to 43:00 – Healthcare Waste, which Lee thinks results, in large part, from a for-profit mentality on the part of providers that emphasizes providing services for which you know you’ll get paid, rather than services a patient needs. Lee gives examples of healthcare products being provided to patients who don’t need them, because the provider knows it will get paid. Also, hospital waste, and how he successfully fought this practice when he worked for an insurance company.

43:00 to 46:30: Why we have to act like cops -- because these fraudulent practices are so rampant within our for-profit healthcare system. He thinks the government would do a better job of patrolling this healthcare fraud than is being done now. I ask Lee if it is possible that many healthcare providers don’t want a single payer system because they know that their fraud will be caught more readily.

46:30 to 49:00 – Ways the public can work to help get universal healthcare passed.

IMPORTANT POSTSCRIPT #1:

After this interview with Lee was recorded, I received two emails from people who work with Michael Moore's production company: Amy Cooke and Anna McHugh. Amy asked if I knew of any stories about people who are organizing "SiCKO Events" in their own communities, and Anna wrote to tell me about the "SiCKO Health Care Card," which Michael wants people to carry with them just in case their insurance company denies them coverage -- at which point they can whip out their SiCKO card and say that it guarantees them "coverage" by Michael!

Both of these women are working with Michael Moore to do what they can to help transform the movie into a movement -- so that universal healthcare will become a reality.

So, please feel free to download the "SiCKO Health Care Card," and to share your stories of SiCKO Events you are holding in your community, in the comments section below.

For some ideas from Michael Moore, check out this link. Thanks very much.

IMPORTANT POSTSCRIPT #2:

At the end of my interview with Lee Einer, I mentioned a book by Jamie Court about the insurance industry, but had forgotten the title. I promised to post a link to it in these show notes. The book is "Making a Killing: HMOs and the Threat to Your Health." It is printed -- I believe, in its entirety -- online. It's a great read! Author/activist Jamie Court is President of The Foundation for Taxpayer and Consumer Rights, www.consumerwatchdog.org, and author of another book, “Corporateering: How Corporate Power Steals Your Personal Freedom – and What You Can Do About It,” for which Michael Moore wrote the introduction.


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