Can Anyone Tell Who Has the Highest Medical Claim Rejection Rate?

[Zeb_Carter]

I'm curious. Was it Aetna? Humana?

A chart showing the major carriers and how Medicare compared to them in the study follows: Get the info here.

http://i739.photobucket.com/albums/xx40/mmatters/DenialsByInsurer2008.jpg

Well, well.

The Medicare denial rate found in the study was, on a weighted average basis, roughly 1.7 times that of all of the private carriers combined (99,025 divided by 2,447,216 is 4.05%; 6.85% divided by 4.05% =1.69).

You would think Medicare's sheer size might enable it to have smoother procedures with its providers that would enable it to turn down a lower percentage of claims. But no, this is the government we're talking about.

So who's the most "heartless" now? And why should Americans accept the idea of gradually being forced into a government-run system when, based on documented government experience, they will be more likely to see their claims denied?

And I didn't even get to the idea of refusals to treat in the first place, something that is present to some degree in virtually every state-run system, but is currently against the law in hospital emergency rooms in the U.S.

mmmm...

 

[Zeb_Carter]

What...no response? No scathing remarks? No..Zeb your a weeny?

ETA: I did find one thing about the report...where's Blue Cross/Blue Shield's numbers? Completely lacking.

 

[cloudy]

One thing you may want to consider: insurance companies make money by denying claims...as I'm finding out right now as the victim in an auto accident.

 

[bronzeage]

What...no response? No scathing remarks? No..Zeb your a weeny?

ETA: I did find one thing about the report...where's Blue Cross/Blue Shield's numbers? Completely lacking.

It's sort of a vague statistic, "Denied Records".

There are quite a few people in Federal Prison for filing false medicare claims. Each of those would be a "denied record."

What exactly is being denied? Are people dying in the hallway, waiting for an appendectomy, or is it the 100 hours of physical therapy for a man who hasn't left his nursing home bed in 2 years?

If the table you posted proves that one insurance company is better or worse than another, you will need to elaborate.

 

[JAMESBJOHNSON]

It's sort of a vague statistic, "Denied Records".

There are quite a few people in Federal Prison for filing false medicare claims. Each of those would be a "denied record."

What exactly is being denied? Are people dying in the hallway, waiting for an appendectomy, or is it the 100 hours of physical therapy for a man who hasn't left his nursing home bed in 2 years?

If the table you posted proves that one insurance company is better or worse than another, you will need to elaborate.

Exhausting lifetime benefits. Medicare benefits are not open-ended without limits. Much of this involves chronic psychiatric admissions.

 

[xssve]

Right, when your Medicaid runs out, you're magically cured.

Truth is, Medicaid is a bureaucracy, and like most bureaucracies, saying no is matter of policy; they almost always turn you down the first time. You often have to apply more than once, and the same goes for payment, if there is any hitch in the paperwork at all it can take years and repeated appeals to get them to pick up a bill.

 

[penandpaper]

What...no response? No scathing remarks? No..Zeb your a weeny?

ETA: I did find one thing about the report...where's Blue Cross/Blue Shield's numbers? Completely lacking.

I think it's a good bit of information you posted. I do think it needs elaboration though. Also, I'm surprised to see the numbers compared to other insurance companies. What it tells me is that since they've had huge profit margins the past couple years and not all the business, then the insurance companies will have no problem staying in business if government opens a public option.

But, I still am against part of the plan - forced insurance. It just feels very wrong to me.

 

[Liar]

ETA: I did find one thing about the report...where's Blue Cross/Blue Shield's numbers? Completely lacking.

Quoth Wikipedia: "The Blue Cross and Blue Shield Association (BCBSA) is a federation of 39 separate health insurance organizations and companies in the United States."

So I guess the answer is, it's not one insurance company but several. One of them is Anthem, and the others are probably smaller individually than the ones on your list.

 

[Liar]

Question: Could it be that Medicare and the commersial insurance companies handle different categories of clients with different types of claims? Routine checkups vs major surgery. I'm not in the US health insurance system, but do patients file commersial insurance claims for everything? Like your yearly "say aah" visit to the local doctor? Or just for the really costly stuff?

 

[Zeb_Carter]

Question: Could it be that Medicare and the commersial insurance companies handle different categories of clients with different types of claims? Routine checkups vs major surgery. I'm not in the US health insurance system, but do patients file commersial insurance claims for everything? Like your yearly "say aah" visit to the local doctor? Or just for the really costly stuff?

Actually the doctors file everything for you unless they don't take any kind of insurance then you have to file. So if you in an HMO or PPO or POS plan every time you visit the a doctor within you network they file the paper work. You usually pay a co-pay up front, around $20 to $40 dollars, sometimes higher. I haven't filled out a claim form since 1986.

Medicaid and Medicare are the same way...the provider of services or materials fills out the paper work.

As far as elaboration I did provide a link to where that table came from, click it.

 

[Zeb_Carter]

One thing you may want to consider: insurance companies make money by denying claims...as I'm finding out right now as the victim in an auto accident.

Insurance companies make money by collecting premiums and paying less for the services than the total premiums they collect. Denial of claims is just one small part of it and most are paid for on the second go round. But you have to file an objection withing a certain period of time. I have had to do that several times, each time they paid the claim.

So the question is now...is the data only of that first denial or after all appeals have been exhausted?

 

[Dragonlipz]

I'm curious. Was it Aetna? Humana?

A chart showing the major carriers and how Medicare compared to them in the study follows: Get the info here.

http://i739.photobucket.com/albums/xx40/mmatters/DenialsByInsurer2008.jpg

Well, well.

The Medicare denial rate found in the study was, on a weighted average basis, roughly 1.7 times that of all of the private carriers combined (99,025 divided by 2,447,216 is 4.05%; 6.85% divided by 4.05% =1.69).

You would think Medicare's sheer size might enable it to have smoother procedures with its providers that would enable it to turn down a lower percentage of claims. But no, this is the government we're talking about.

So who's the most "heartless" now? And why should Americans accept the idea of gradually being forced into a government-run system when, based on documented government experience, they will be more likely to see their claims denied?

And I didn't even get to the idea of refusals to treat in the first place, something that is present to some degree in virtually every state-run system, but is currently against the law in hospital emergency rooms in the U.S.

mmmm...

Mark Twain said: "There's lies, damned lies, and then there's statistics...."
Zeb, you need to change the channel.....better yet turn off FAUX NEWS......think for yourself.....I know you can do it.....hard at first....
I know that looking at them blonde titties is fun but those collagen lips ain't tellin' ya anything worth knowing.....
You're better than that....prove it to yourself.....rise up....

 

[Guest]

Blue Cross does not pay for flu shots.

Blue Cross has denied many of my husband's claims, only to approve them after we sent them through again and again. Assholes.

Blue Cross refused to pay for the stitches above my eye for the injury I received after the car door closed on me while unloading flowers after a show closing night.

They said - they will never pay for any injury caused by a vehicle. HOkay. Allstate car insurance did pay.

Blue Cross promised to pay for infant coverage for the first 30 days after they were born. Unwritten law, kids are covered until they are able to be officially added by the parents.

It's a lie. They didn't cover it, they seemed so surprised when we asked, even though right before our daughter was born more than one person SWORE she'd be covered.

Blue Cross tries to not pay for a damned thing. We pay, as a family, more than a thousand each month for basic insurance premium coverage and copays and prescription drug costs.

And yet we have to fight to get them to them to cover what they've said they'll cover.

 

[3113]

Blue Cross tries to not pay for a damned thing.

I believe you, and top your story with this one:

Like a lot of self-employed people, Valerie Scaglione and her husband, Michael, who run two businesses from their home outside Auburn, find themselves in a significant health insurance crunch. Monthly premiums for Blue Cross coverage for them and their three daughters have soared over the years to almost $2,000, Scaglione says. She estimates that in the past six years, the family has spent more than $140,000 on premiums and co-payments. Yet when she tried to switch from the family's expensive individual insurance to a Blue Shield group plan that's more affordable, she said, she and her oldest daughter were denied coverage. She said neither of them has the medical conditions that were listed as reasons for being denied - bronchitis and a skin ailment. "I have three children," said Scaglione, 47. "We have to have insurance. Stitches may be required. A broken bone may have to be set. We have no chronic diseases. We're a normal family. This is crazy."

Consumer advocates consider their story emblematic in many ways of complaints that plague the entire health insurance industry. "We've seen people denied for things as minor as heartburn," said Anthony Wright, executive director of Health Access California, a statewide health advocacy coalition. "It gets to the point where living is a pre-existing condition. The system is fundamentally broken if insurance can be denied to anyone who actually needs coverage."

...Shopping for better coverage, she [Scaglione] joined the Japanese American Citizens League for the group's member benefits, including a Blue Shield family plan that would cost $1,200 a month. The Scagliones were shocked when Blue Shield approved Michael and the twins for coverage, but not Valerie and Samantha. Letters from the insurer pointed to Samantha's bronchitis last year and a suggestion that Valerie had been treated for rosacea as reasons for disqualification.

"I've never had that a day in my life," Scaglione said of the blotchy skin condition. "They say Sam has a cherry-colored birthmark. It's not there. They're listing things that aren't even correct." When Scaglione tried to see that their medical records with UC Davis Medical Group reflected accurate information, Blue Shield refused her requests to appeal its decision. "There are no rules," said Wright, the health advocate. "Insurers can deny coverage for any reason. The industry isn't standardized."

Full Story here.

 

[amicus]

One can post a personal experience, an, anecdote, knowing it cannot be challenged or even questioned and may be true, false, made up, or parts of all three.

There should be no doubt, however, that there have been miscarriages of justice in the health insurance field and every other area of endeavor as well. That is why we have laws and courts and, ulp, lawyers.

But take this little fact into consideration: those greedy avarious health insurance companies, proft making bastards that they all are, make 3 to 4% profit on the dollar.

That's right folks, three to four cents on the dollar profit; about the same as those awful, terrible, greedy energy sucking bastards like Exxon-Mobil, three cents on the dollar.

This administration says they will cut five billion plus dollars from 'waste and fraud' in the Medicare system. Oh, yeah? Now they discover waste and fraud?

The waste and fraud inherent in any government run bureaucratic system is far, far greater than the profit margin for any of those greedy capitalists bastards, who, because they operate on a profit basis, will not tolerate waste and fraud.

Government revels in it.

Amicus

 

[JamesSD]

Most of the people on Medicare are old people right?

So, I imagine there's a pretty high rate of them filling out the forms wrong, along with fraud.

It's certainly one interesting piece of data, but I'm not confident it is an apples-to-apples comparison.

 

[amicus]

I have not searched this, but watching advertisements on television from lawyers advising those under 62 and not eligible for medicare or social security, that anyone, 'disabled', is qualified for benefits and 'call right now' kind of ad, might offer a clue as to the attempted fraudulent claims and such and the rate to refusal?

Amicus

 

[Huckleman2000]

Christ almighty, Zeb, you're a complete dick posting this as an example of Medicare denying legitimate coverage. The report includes the "reason codes": (apologies for lost formatting)

Medicare
Code: 16
No. of Denials: 132,020
Percentage of Total: 27.8%
Reason Code Description: Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code).
Medicare
50
99,546
20.9%
These are non-covered services because this is not deemed a ‘medical necessity’ by the payer.
Medicare
109
65,588
13.8%
Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
Medicare
96
40,591
8.5%
Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code).
Medicare
31
27,481
5.8%
Claim denied as patient cannot be identified as our insured.
Medicare
49
18,626
3.9%
These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
Medicare
26
14,751
3.1%
Expenses incurred prior to coverage.
Medicare
B9
14,232
3.0%
Services not covered because the patient is enrolled in a Hospice.
Medicare
All other
62,731
13.8%
Medicare Total
475,566

It appears to me that Medicare has many procedures in place to prevent fraud and such - the very things Amicus decries above. Would you prefer that Medicare simply hand out reimbursement without any procedural checks? The program's administrative overhead is still a fraction of the private insurers'.

 

[ishtat]

On the other hand.

My observation is that any business which pays out between 93%(worst case) and 97%(best case) of the demands made upon it can hardly be accused of the kind of bastardry claimed by a number of posters.

In fact a number of posters indicated that whilst their first claim was denied the subsequent (fully completed??) claim was paid. So who was responsible for the initial denial?

Maybe Insurance company shareholders should express their concerns about the number of claims paid without sufficient checks.

 

[Huckleman2000]

Let's look at some (not all) of the codes from the private insurers, shall we?
Aetna
55
753
7.7%
Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.
Aetna
197
552
1.3%
Payment adjusted for absence of precertification/ authorization.
Aetna
27
535
1.2%
Expenses incurred after coverage terminated.
Aetna
119
427
1.0%
Benefit maximum for this time period or occurrence has been reached.
Anthem BCBS
119
198
1.7%
Benefit maximum for this time period or occurrence has been reached.
Anthem BCBS
51
155
1.3%
These are non-covered services because this is a pre-existing condition
CIGNA
38
502
5.5%
Services not provided or authorized by designated (network/primary care) providers.
Coventry
160
18
3.1%
Payment denied/reduced because injury/illness was the result of an activity that is a benefit exclusion. This change to be effective 4/1/2008: Injury/illness was the result of an activity that is a benefit exclusion.
UnitedHealthcare
51
912
3.0%
These are non-covered services because this is a pre-existing condition.

 

[JAMESBJOHNSON]

Right, when your Medicaid runs out, you're magically cured.

Truth is, Medicaid is a bureaucracy, and like most bureaucracies, saying no is matter of policy; they almost always turn you down the first time. You often have to apply more than once, and the same goes for payment, if there is any hitch in the paperwork at all it can take years and repeated appeals to get them to pick up a bill.

No. Medicare and Medicaid assign you specific life-time benefits for different treatments. If you exhaust the benefit they stop paying.

Another reason for rejection is: Hospitals file the wrong claims for the wrong patients. If you go to the emergency room for a kidney stone and the ER makes a claim for a work related injury another patient had, your insurance wont pay for the workman's comp problem.

Psychiatric patients exhaust their life-time benefits more than any other group. People literally check-in and stay for years.

 

[Guest]

My observation is that any business which pays out between 93%(worst case) and 97%(best case) of the demands made upon it can hardly be accused of the kind of bastardry claimed by a number of posters.

In fact a number of posters indicated that whilst their first claim was denied the subsequent (fully completed??) claim was paid. So who was responsible for the initial denial?

Maybe Insurance company shareholders should express their concerns about the number of claims paid without sufficient checks.

Quite often the reasons given for denial are ridiculous.

They'll pay two out of three claims for parts of the same procedure (my husband's latest CT scan is a good example - different fees, different departments) then claim they didn't receive paperwork. Or that the claim numbers are wrong. Or that they need more information about the procedure. Or that we sent the wrong form (we didn't.)

At times, they'll do anything possible to delay payment, it seems. Quite frustrating.

 

[Boota]

I would wonder about the percentage of claims that are approved after the initial denial. As said above, misfiled paperwork and general human error are to be blamed for quite a bit of denied coverage. I don't know about Medicaid, but I've been turned down by my private insurance company on every single claim I've ever made until I personally followed up and got them to pay it. My former companies strategy is to deny every claim the first time and just see who takes the bill on as their own. Probably works more often than not. Fucking scumbags.

 

[JAMESBJOHNSON]

I would wonder about the percentage of claims that are approved after the initial denial. As said above, misfiled paperwork and general human error are to be blamed for quite a bit of denied coverage. I don't know about Medicaid, but I've been turned down by my private insurance company on every single claim I've ever made until I personally followed up and got them to pay it. My former companies strategy is to deny every claim the first time and just see who takes the bill on as their own. Probably works more often than not. Fucking scumbags.

It can get bizarre at times. Here's an example.

I had a teenage client. Mom tossed him out and he was in fostercare. He had insurance with mom AND Medicaid. But neither of them would pay, because of the dual enrollment. So my hospital turned the bill over to an Indian collection agency. Well! Who do you suppose the Indians harassed? Mom? No. The state? No. Me? Yes.

I could not make the rude, shrieking assholes understand that I worked for the hospital they were trying to collect for. They finally stopped calling me after our lawyer called them.

 

[JAMESBJOHNSON]

Insurance companies also reject tons of fraudulent claims. People access your hospital records and bill for services they never performed. It used to be a big problem. The hospital clerk makes a few bucks from the scammer if you or the insurance company pay.