The health insurance industry has dug itself a hole so deep that even our standard five-shovel award doesn’t cover it. So–I hereby award the health insurance industry their own excavator.

I am not even remotely a fan of either of the bills in the Senate and the House.

However, as someone who spends an inordinate amount of time fighting with health insurers to properly provide contracted benefits, I am very much on the “reforms badly needed” bandwagon.

It isn’t just the insurers that are the problem, however. It’s also the employers who decide for employees what benefits are to be provided, in what fashion, and by whom.

Example: yesterday’s mail contained within it an “Explanation of Benefits” (EOB) statement for a recent medical event. The insurer doesn’t require pre-authorization. Care from facilities and providers within plan are covered at a certain percentage of total; care from providers outside the plan are covered, but at a significantly lower percentage.

Prior to the visit, we had spent three hours of our time on the phone with the insurer to assure that we were going to a covered provider, for a covered event.

We were.

Apparently not, according to the EOB. Not only did the insurer claim in the EOB that the provider was out of plan, they also claimed that the plan paid nothing for out-of-plan events.

Can you hear me thudding my head against a wall? Actually, I don’t dare do that, as it might necessitate medical intervention, which would require even more hours of our lives sucked into the ever-spiraling black hole of correcting insurance coverage errors.

I lay part of the problem flatly at the feet of the employer through which this coverage comes. The employer, which has moved its home office to a different state, decided to switch its insurance policies for certain classes of employees to be a plan that provides coverage within a state in which the employees don’t live.

Got your head around that? It means that if we hadn’t screamed “foul” when the new policy first appeared a few years ago, that we would be paying for coverage that would never pay for anything but out of plan events at best.

Under this policy, I don’t recall having a single claim that has been processed correctly yet.

This is just one of a plethora of problems we encounter on an on-going basis in dealing with our insurance.

The employer’s response? “It’s not our problem. We only provide the benefit.”

That would be the benefit that we have no choice over, in any form whatsoever, that the employer holds the contract for and negotiates as to provider, coverage, details and costs?

Mmm hmm. That benefit.

The current health “reform” bills in Congress don’t address the core of the problems we’re having.

So, here’s just one thought about the kind of reform that might have some teeth in fixing insurance plan problems.

Make insurers–and employers that contract for the plans–accountable for their errors and obfuscation. Every time an insurance company makes an error on a claim (incorrect denial of coverage, etc.), penalize the company and the employer by making the insurer pay not only the claim, but also pay an amount equal to the claim directly to the insured as damages. And make the employer responsible for part of those damages, say a negotiated percentage between 30% and 50%, to hold their feet to the fire too in how they select who they chose to do business with on behalf of their employees.

Set up an independent ombudsmen board, through State Commissioner of Insurance offices, to represent claimants and require binding resolution within 180 days of the insurer sending out an EOB.

The beauty of this is that insurers who are responsible corporate citizens, who work hard and well to be both efficient and accurate (and yes, there are insurers out there who already are this way) get rewarded. They spend less, as they aren’t paying penalties, leaving more for profits, and are more competitive because they can offer the same coverage at lower costs than their inefficient and sloppy competitors.

If insurers and employers aren’t accountable for their actions–and the reality for the insured for all practical purposes currently is that they aren’t in these sorts of day-to-day operations–there isn’t a “reform” plan in the world that’s going to work that cuts costs and provides us with insurance that really works.

Just sayin’.