Cover America: Denied insurance because of a medical coding error

With all manner of high costs, limited protections, and confusing fine print, it’s tough going it alone in the health-insurance market. It’s all the more intimidating for those whose health history is being quietly tracked by a little-known insurance-industry group called MIB.

Few people realize MIB, formerly known as the Medical Information Bureau, has a file on them. Like a credit-reporting agency, MIB monitors virtually every aspect of a person’s health care. When someone applies for individual health-care coverage, the application is routinely run through MIB's huge database of health and medical information. Insurers effectively use the MIB data for health-insurance applicants like they use motor-vehicle administration records for auto-insurance applicants, adjusting premiums or even denying coverage based wholly or in part on what is in a person's MIB file.

Consumer Reports Health's Cover America Tour realized the impact of MIB when we visited Sheila (above) in Gulfport, Miss., the day after her 50th birthday. She and her granddaughters welcomed us in and shared some leftover lemon cake from the previous day's celebration.

Sheila was surprised when she was rejected for an individual health-insurance policy by three different companies. She was even more shocked when she learned why: Her record with MIB listed her as having a history of Chronic Obstructive Pulmonary Disease (COPD). Sheila does suffer from asthma, but COPD is supposed to be used to indicate more severe diseases of the lungs, such as emphysema or severe bronchitis. No company would insure her with this damaging mark on her record.

Sheila eventually traced the problem to a coding disparity at her doctor's office. She says letters and phone calls to both her doctor and MIB have been to no avail, and the problem remains uncorrected on her record, effectively blocking her from obtaining individual health coverage.

So just who is behind MIB? Well. That would be the nation's insurance companies. The more than 470 insurance companies that are members of the group provide the medical information that MIB plugs into its huge database.

MIB in turn uses the information to protect the insurance companies "from proposed insureds who knowingly or unknowingly omit information about their insurability on their applications," according to its own Web site. MIB says it saves insurance companies $1 billion a year from fraudulent applications and claims.

That's nice protection for insurers—an exotic form of self-insurance for them, really—but what about people such as Sheila, who through no fault of their own are being denied health coverage in whole or in part because of faulty MIB information?

Sheila now spends most of her time looking for a job and watching over her granddaughters. She realizes perhaps her only shot at getting decent medical coverage is by finding a job that comes with health insurance. But the job prospects in this Hurricane Katrina-battered community are not good.

"I am not even close to retirement age, so my future looks grim at best," she told us.

—Meagen Bohne, campaign organizer

Visit Cover America Tour to see more videos of the people we're talking to across America, and to share your own health care story.

Comments

[e-Patient Dave]

btw, Jennifer (medical coder) - what sort of legal action is possible in case of coding error? Do you go to the state Attorney General for Coding Errors (just kidding) or the local cops or is this just a liability lawsuit?

[Jennifer]

As a Certified Professional Coder, only going on the limited documentation she provided, that she should actually look into legal action in regards to her MIB. As an Instructor of Coding I warn all perspective coders to be careful because you don't want to code something that the patient doesn't have. I don't necessarily know whether this is a coding error or if there is a documentation/physician error in the medical record. Therefore, I think before titling this "coding error" one should clearly understand what the infers-

[cchiovitti]

No kidding. Our family alone has had to "fight" our insurance company 3 times in the past 2 years due to coding errors. It truly is a nightmare, especially since it often takes weeks or months to get the correct code recognized and by that time the insurance company likes to say "coverage denied - not submitted in a timely manner". I have come to the conclusion that insurance companies essentially do anything possible to deny coverage and save money - especially for large families which use their policy a lot.

[e-Patient Dave]

As I understand it, what's actually happening here is that ***physician error caused her this extreme financial difficulty and it’s her problem to fix it.*** Is that an accurate assessment?

I don't know if it was a diagnostic error or a clerical / coding error. I do know that the story says this woman is being harmed by someone else's mistake.

So I'm wondering if the mistake-maker is doing anything about it. Has the doctor been asked to correct the error? If so, did s/he do it? Is the MIB required to fix errors immediately?

This sounds a lot like the need to examine one's credit bureau data. I just went to their site http://www.mib.com/html/request_your_record.html and requested a copy of my MIB record from their robot. (4 minute interview plus 3 minutes of intro.) They say I'll get it in 15 days.

Errors do happen - a report in my own hospital's radiology records identified me as the wrong gender.

I wonder who pays for any penalties she might incur from draining her 401(k).