Doctor tells Congress all, about Health Care Denials

Doctor Linda Peeno, a renown expert in the field of “Managed Care”, explains to Congress the dirty little secrets behind the Business of Health Care Denial:

Doctor Linda Peeno, a renown expert in the field of “Managed Care”, explains to Congress the dirty little secrets behind the Business of Health Care Denial:

THE REAL DEATH PANELS: Insurance Companies That Deny Care…

Linda Peeno, M.D.

In the spring of 1987, as a Physician, I denied a man a necessary operation, that would have saved his life. And thus caused his death. And I’m haunted by the thousands of pieces of paper, on which I have written that deadly word: Denied.

Hat tip to: Ad Watch: Union-Sponsored Group Casts Insurers as ‘Death Panels’

Linda Peeno MD, testifies…

For a Shorter Clip, of same testimony without the subscripts, and Michael Moore’s commentary, etc.

Linda Peeno:

Former Humana Insurance Medical Examiner

Former Blue Cross/Blue Shield Medical Director

I’m here today to make a public confession. In the spring of 1987, as a Physician, I denied a man a necessary operation, that would have saved his life. And thus caused his death.

No Person, and No Group has held me accountable for this. Because in fact what I did, was I saved the Company a half a million dollars, for this.  And furthermore, this particular act secured my reputation as ‘a Good Medical Director’, and it ensured my continued advancement in the Health Care field.

I went from making a few hundred dollars a week, as a Medical Reviewer, to an escalating 6-figure income, as a Physician Executive.

In all my work I had one primary duty, and that was to use my medical expertise, for the financial benefit of the Organization for which I worked.

And I was told repeatedly that, ‘I was not denying Care, I was simply denying Payment’.

I know how Managed Care maims and kills patients. So I’m here to tell you about the ‘dirty work’ of Managed Care.

And I’m haunted by the thousands of pieces of paper, on which I have written that deadly word: Denied.

Michael Moore:

How did we get to the point that Doctors at Health Insurance Companies, actually being responsible, for the Deaths of Patients?

Who Invented this System?

How did this all begin?

Where did the HMO’s start?


[Back in 1971, Nixon’s aid explains Kiaser’s legislative proposal for new HMO’s]

All the incentive are towards less medical care. you see the less care they give them, the more Money they make.

Nixon: So the incentives go in the right way.

[The next day, in 1971: Nixon arranged to pass a bill, to enabling Kaiser to set up a Managed Care system.]


National News Reporters:

While the Health Insurance Companies became wealthy, the system was broken.  

37 Million Americans are without protection against catastrophic illness.

The losers are the Poor, who may now postpone urgently needed Health Care, until it’s too late.

Lest you think being an Insurance Industry Whistle-Blower is easy — think again! Speaking the Truth to Power, always comes with a price tag, in today’s world where Human Well-being and Misery are simply another Commodity, to be exploited, and profited from:

Retaliation Against Physicians – Linda Peeno, MD

Dr. Linda Peeno, who quit her job as the medical director of an HMO to become a whistleblower and expert witness for patients, said that she is on the “hit list” of a managed-care industry that regards her with “sheer hate.”

Her first threatening phone call came after she appeared on Dateline NBC …


And for those wonks among us, who would like to ‘read em and weep’ …

The Confession of a Managed Care Medical Director

As heard by a Congressional Subcommittee, May 30, 1996

My name is Linda Peeno, and although the witness list does not reflect this, I am a physician. I am a former medical director and medical reviewer. I did the job that was referred to repeatedly in the first panel as a physician manager for three health care organizations.


For me, the ethical issues were born in the trenches and pit of the pain that I have come to realize that I cause. And if I am an expert here today, it is because I know how managed care maims and kills patients.

So I am here to tell you about the dirty work of managed care and this is the kind of straight talk that I wish Ms. Ignagni [President and CEO of the American Association of Health Plans] could hear now.

Now, let me explain to you the ways that I was a good medical director. I was regularly consulted by marketing on ways to change expensive benefits or change the language to give me loopholes to make denials when requests came.

For example in one plan, we were able to structure our investigational language exclusion so that I was often able to use it to deny almost anything that was expensive, and particularly out-of-network requests.

I turned preexisting exclusions into a game as I tried to connect almost any prior medical complaint or visit as a reason to deny payment.

There are many more thing that I could tell you about, but, ultimately I was only as good –and I put that in quotation marks — as the doctors in my network, for it was their numbers that I needed to prove that I was doing my job.

That meant that I did whatever it took to control them: intimidation, hassling, humiliation, I have done it all. I have used inadequate and inaccurate data to create reports to get doctors to make their numbers better, in other words, decrease their usage.


This might go unnoticed for simple needs, like a regular office visit or a bout of the flu, but I can tell you that when something unexpected or expensive happens, it is like a bucolic pasture turned battlefield. The land mines will start exploding everywhere.

And somewhere in every coverage booklet for every managed care plan is a claim that establishes the plan as the final authority for medical necessity. What that means is that there is some physician at some plan doing what I did.

That person rarely is continuing a clinical practice. They are sitting behind a desk making decisions about a patient they will never see or touch, completely removed from the consequence of their decisions. They are getting paid by someone to make decisions for the benefit of the plan and not for the benefit of the members.…

This is not just ancient history, the Care Denial Business, is alive and well, to this day. Although the same, probably can not be said, for the victims of these “behind the scenes” Death-Panel-Deciders:

HMO claims-rejection rates trigger state investigation

By Lisa Girion, LA Times — Sep 4, 2009

California Atty. Gen. Jerry Brown is joining state regulators in scrutinizing how HMOs review and pay insurance claims submitted by doctors, hospitals and other medical providers.

His announcement came Thursday as regulators said they had stepped up scrutiny of the payment practices of the state’s seven largest health plans in response to complaints from physicians and hospitals.

The increased attention also comes on the heels of a first-of-its-kind report issued this week that said the California health insurers reject 1 in 5 medical claims.

Six of the state’s largest insurers rejected 45.7 million claims for medical care, or 22% of all claims, from 2002 to June 30, 2009, according to the California Nurses Assn.‘s analysis of data submitted to regulators by the companies.

The rejection rates ranged from a high of 39.6% for PacifiCare to 6.5% for Aetna for the first half of 2009. Cigna denied 33%, and Health Net 30%.

Anthem Blue Cross, the state’s largest for-profit health plan, and Kaiser, the state’s largest nonprofit plan, each rejected 28% of claims.

Where is the ‘Good Housekeeping Seal of Approval’ for these guys?

Health Care and Profits do not mix. Never have, Never will.

The Private Insurers, left with little Oversight, will focus on achieving one of those Goals, while ignoring the other — 3 guesses, about which one, the Insurers will always Maximize, when left to their own devices, and given the arena of No serious Alternatives?

When Insurance ‘Experts’ get bonuses, and raises, from Denying us Care — something is definitely Wrong with our system.

When 1 out of 5 Health Care Claims get denied proper Payment — something is definitely Wrong with our system.

Some might even say the System’s Broken:

Barack Obama on Health Care…

The People don’t need 5 more years, to know there is something wrong with the Health Insurance system. The Insurers may need such a Time Trigger, but the People DON’T — The People have NEEDED Real CHANGE, FOR DECADES, now!

We don’t need a little more Time, to know that Private Insurers and HMOs don’t work; that they will put their own Profits above paying for Treatment, when ever they can. Murphy’s Law kind of “insures” that will happen!

Since they can Choose to Deny us care, so systematically, We simply need a minor System “Tweak”, that lets US Choose to Deny THEM, their ‘routine and customary’ payments, of our ever-increasing Health Insurance Premiums.

And giving us a Choice of Public Payment Plan, no fuss-no muss, similar to Medicare, (aka the Public Option), does just that! Having a strong Public Option, would LET US CHOOSE, a different Health Management ModelOne based on providing “Healthy Results”, NOT one based on providing “Healthy Profits”!

And isn’t that what Health Care SHOULD be all about, “Healthy Results”?

Giving the Profiteers, 5 more years to straighten up and “Clean Up their Act”, with a vague threat of a Public Option THEN — Solves Nothing, NOW! Especially considering the Quarterly Profit business “drivers” and all.

Profiteers will always cut corners, and they will look for Loopholes, to cut costs, and to increase Profits — ALWAYS!

It’s what Capitalism is ALL ABOUT!

WELL, Somethings should NOT be Capitalized — especially those things which are needed to provide for the “General Welfare of the People”.

The only real solution is to take extreme Profits OUT OF the Human Health Care Equation. Providing a strong Public Option, similar to Medicare, is one small step in the right direction.

Giving People a Choice to SAY NO TO THEIR DENIAL PROFITS, should make the bean-counter Profiteers, sit up and take notice. If the PEOPLE could say NO to THEM, they just might HAVE TO change their Business Model, to ACTUALLY provide a Quality Service — to cut the Red Tape, to scrap the fine print, “that makes their Decisions the Last Word” — as Doctor Peeno put it!

It might make them, clean up their Act, in other words. Maybe …

I’d give them, say 5 years, give or take, to see, if those Denial Rate percentage, can shrink to 0-2% range, where they belong!

And if NOT, well, there’s is always Regulatory Oversight, that could “force them” to “serve their customers”. Linda Peeno, MD may know a few folks, eager to sit on such a Regulatory Board, don’t you think? … And maybe, Micheal Moore, could sit as Czar of the Cabinet position of ‘Corporate Accountability’?  Wouldn’t that be sweet?

But alas, such Justice, is NOWHERE to be found, in our Modern Corporate-Lobbyist-Congressmen driven world What’s in it for THEM?

Sadly, THAT is, Always, the Question.

And the People are left to struggle, with whatever fallout, that results, from their myopic and cowardly rulings,  … Such is Life, in modern-day America.

The People are Always the Last to be Heard. … and the First to to feel the brunt, of our Deciders ‘compassion’ and ‘wisdom’.

also posted on dkos


    • jamess on September 5, 2009 at 21:04

    Tips for FINALLY FIXING, our Broken System —

    may it happen, in our Life’s time.

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