Guess Who Denied the Most Health Care Claims in ’07 and ‘08

In case anyone cares:

The AMA’s National Health Care Report Cards rates 6 private payers against Medicare on several criteria. The measure of “Denials” may give us a clue about how well “government-run healthcare” takes care of your medical bills.

www.ama-assn.org...
www.ama-assn.org...

Highest Total Denials (A.M.A. "Metric 12") 2007, 2008: Medicare (10.85%)
Highest Average Denials 2007 and 2008: Medicare (5.435%)
Private Payer Average Denials: 3.86%

Sorry.

jw

Woot!!! thats revealing - I am on Medicare - got accepted this year and the only reason they didn't turn me down I think [besides having a life threatening condition] is because end stage renal patients have their own lobby in Washington D.C. - seriously....makes a difference...sad though that one is necessary to have any clout...but congress has its hand out and the palms must be greased to get anything done...Gads what a mess...thanks for this info starred and flagged..

reply to post by realshanti
Good luck to you.

I've worked for and against insurance companies. I've worked for and against government.

Against is better. I have successfully helped countless people negotiate various "systems" to success. Insurance, school, law, benefits, car repairs, health care, you-name-it. It is not always easy. Sometimes you win, then lose, little victories before you succeed. Sometimes you win all the way through.

But, you can ALWAYS win! It is a SYSTEM, after all. It is made to perform some function for YOU.

It is not always easy to "beat the system." It is ALWAYS deeply rewarding.

When dealing with any program that is supposed to provide you "benefits," there are certain rules that almost always guarantee success. And certain rules to guarantee failure.

Insurance, disability, unemployment, Medicare, V.A., you name it; if someine else has control over what you need, you have to kow the rules to win. Knowing the rules enables you to win more often than you lose, or to always win.

First, you must understand that there are "magic words."
Second, the first "entitlement" or "benefit" decision is never the last.
Third, you MUST know how the system works - that is, who the people are, how they're motivated and evaluated, and who has the REAL power.

Every "entitlement" system is subject to control by "gatekeepers." They are the first line of defense for precious, maybe scarce, resources - theirs.

If you learn the magic words, you will get past the gatekeeper to the real decision makers. It is imperative to do this as soon as possible.

Learn for yourself how your benefits are intended to flow.
Learn the process to initiate the flow and, most importantly, MAINTAIN the flow. Many times, you can tap the spigot, but it gets shut off when you're not paying attention.

Above all, NEVER take "No" for an answer. Ever.

I could write a book on this, now that I think of it. Or a blog.

Again, good luck.

Keep up your fight and deny ignorance.

jw

I tore the meniscus in BOTH knees severely while on a temp job working for a friend. I didn't want to get him in trouble (since someone else had gotten hurt when he wasn't around and they were blaming him for it) so I kept quiet.

I wasn't sure what was wrong. I thought I would be okay in a couple of months. Six months later my knees were buckling out from under me when I tried to walk.

I used my insurance to get an MRI on one knee. Doc said he'd operate on one knee, let it heal, then work on the other. Did the operation. Then GOT A SURPRISE -

Since I'd not worked in six months (while trying to heal my knees on my own) I was told by the State of California (this is at the start of the financial meltdown) that I was no longer eligible for unemployment. They said it was because I'd not worked in six months. (Not being able to walk might have had something to do with that)

Next, while going back for follow ups at my doctor's I was told that my insurance was CANCELED. Once again, the excuse was I'd not worked in six months and was no longer eligible. So I was stuck with no income, trying to heal from a bad operation on one knee and a torn meniscus on the other.

Today, it's been a year since the operation. Both knees are still painful, but I've been doing all the nutrition and exercise tricks I can to come back from the injuries. Zero help from any insurance company or government.

Cartilage is the most difficult thing to heal, but I think in another year it should be better.

However, had I simply put the money I'd given the government and my insurance company over the past 20 years into an account I could have paid out of pocket for both operations ten times over.

Does the "system" suck? Yes it does. It's designed to squeeze the maximum dollars from individuals for as long as it can. Use it and you may become 'risky' and lose it.

I'd much rather have what my Canadian friends have. It makes much more sense (it just doesn't pad the pockets of insurance companies and the medical establishment).

My insurance company told me they would happily take me back for $1200 per month. How else will anyone be able to charge $15 for a single aspirin? I told them to forget it.

When looking at these figures, you have to take two things into account:

1) They are coming from the AMA, a group who heavily favored eliminating Medicare until about 3 months ago,

and 2) Doctors file many, many, many more Medicare reimbursement claims than they do private health claims. Most physicians who accept Medicare do so with the understanding that there is a larger pool of money in Medicare than in private insurers. If I'm working with a patient who uses Medicare, I would file reimbursement for every bit and piece of equipment and medical care given, as I know that most likely, the cost will average out when you take accepted claims and rejected claims into account. I wouldn't file as many with private insurers, as they are most likely to reject all but the most barebones claims.

These two points could explain rejection rate inflation on Medicare's part.

reply to post by Whatthehell?
In most states, you must be "able to" and "looking for" work to receive UE benefits.

Workers' compensation insurance policies are "no fault" policies. If you are working and you get hurt, they pay 100% of medical and up to 70% lost wages.

If your employer didn't have WC insurance, you can sue him if his negligence caused your accident.

Most medical insurance policies are incident-based, rather than claim-based. If an "incident" happens during the policy period, even if you don't make a "claim" until after the policy expires or is replaced, your injury from the incident is covered.

ALL policies require "timely notice" of claims. You have to tell them about it within a reasonable time after the date of the first manifestation of your injuries.

Somebody may owe you some bucks.

jw

Originally posted by VneZonyDostupa
When looking at these figures, you have to take two things into account:

1) They are coming from the AMA, a group who heavily favored eliminating Medicare until about 3 months ago,

and 2) Doctors file many, many, many more Medicare reimbursement claims than they do private health claims. Most physicians who accept Medicare do so with the understanding that there is a larger pool of money in Medicare than in private insurers. If I'm working with a patient who uses Medicare, I would file reimbursement for every bit and piece of equipment and medical care given, as I know that most likely, the cost will average out when you take accepted claims and rejected claims into account. I wouldn't file as many with private insurers, as they are most likely to reject all but the most barebones claims.

These two points could explain rejection rate inflation on Medicare's part.

YES!!!

Plus, the way that Medicare is structured and the demographic in which it covers sets the stage for denials...the same denials that private insurance would distribute if these patients were not on the "public option".

[edit on 6-10-2009 by Aggie Man]

reply to post by VneZonyDostupa

You've missed the fact that these are percentage of claims per individual insurer denied. Not percentage of total claims or just total claims denied.

When looking at these figures, you have to take two things into account:
1) They are coming from the AMA, a group who heavily favored eliminating Medicare until about 3 months ago,

First, these aren't just "figures."

The "Report Cards" are 16 pages (2008) and 24 pages(2009) and include in-depth analysis of dozens of criteria. These reports cover SEVEN payers: Aetna, Anthem/BCBS, Cigna, Coventry, Health Net, Humana, United Health Care, AND Medicare.

It wasn't "targeted" at anybody other than people who pay them for their work.

2) Doctors file many, many, many more Medicare reimbursement claims than they do private health claims.

Nope. These aren't total numbers, they are percentages of claims PER payer.

And, not all AMA members participate in Medicare!

Unfortunately, even if you lump all the private payers together, Medicare's RATE of denial is much higher.

Uh, oh.

jw

[edit on 6-10-2009 by jdub297]

Just recently found out that my father was denied coverage due to Sleep Apnea. Problem is, he was never diagnosed. In fact, he was never even tested for it.

First, these aren't just "figures."

The "Report Cards" are 16 pages (2008) and 24 pages(2009) and include in-depth analysis of dozens of criteria. These reports cover SEVEN payers: Aetna, Anthem/BCBS, Cigna, Coventry, Health Net, Humana, United Health Care, AND Medicare.

It wasn't "targeted" at anybody other than people who pay them for their work.

Every group massages the statistics to make it slant the way they want. Did these figures compare denial of secondary claims versus primary? Did they take into account claims which were denied due to a cancelled scrip? Did they take into account those which were denied because the treatment was contraindicated by a senior physician?

These are the sorts of things the AMA doesn't disclose because then the balance would shift the other direction.

Nope. These aren't total numbers, they are percentages of claims PER payer.

No one said they were total numbers. If you reread my post, you'll see that I explained that a larger percentage of Medicare claims are filed simply as overkill. If I -think- my patient could benefit from an MRI, and he has a fairly comprehensive Medicare package, you better believe I'm filing a claim and shipping him off to imaging. though that claim to Medicare may be denied later, and it may not. If, however, the patient has a private insurer who doesn't like to cover things they don't pre-approve, and I don't think an MRI is absolutely necessary, I'm more likely to go a different route.

Basically, it boils down to knowing that Medicare will often cover things private insurers won't on specific patients. Granted, sometimes the reverse is true, but in my experience, I've had less trouble having claims approved through Medicare, even for relatively pricey and new procedures.

And, not all AMA members participate in Medicare!

Only about 30% of American physicians join the AMA. It's essentially a fraternity with a lobbying arm. When I was in medical school, they tried to get all of us students to sign up with the promise of a free Netter's Anatomy Atlas, but we had to sign up for a credit card first. Lovely organization

Unfortunately, even if you lump all the private payers together, Medicare's RATE of denial is much higher.

Source?



[edit on 10/6/2009 by VneZonyDostupa]

[edit on 10/6/2009 by VneZonyDostupa]

Medicare fraud takes a lot of money every year from the Medicare program.

To stop the fraud the medicare system treats all claims as suspicious till proven wrong.

This accounts for many of the denied claims that are later payed when the doctors provide more evidence to back the claim.
www.google.com...
www.washingtonpost.com...
www.washingtonpost.com...
en.wikipedia.org...

there is the massive medicare fraud and then there are doctors and hospitals that just slightly pad there bills to make up for the illegals they
have to treat. and these may be denied too.

reply to post by DevolutionEvolvd

Just recently found out that my father was denied coverage due to Sleep Apnea. Problem is, he was never diagnosed. In fact, he was never even tested for it.

I cetainly hope you appealed that. You have every right to contest wrongful denial of benefits.

I am helping a friend who has been denied, accepted on appeal, denied again, and re-accepted, ONLY after we spent hours marshalling facts to prove Cigna's and Social Security's bad faith denial.

Make them pay.

good luck

jw

reply to post by VneZonyDostupa
If you use the links provided, you could see the Report Cards in their entirety, including supporting documentation from the payers them selves and independent third parties.

Source?

If you use the links provided, you could see the Report Cards in their entirety, including supporting documentation from the payers them selves and independent third parties.

That's why they're in the OP.

jw

reply to post by ANNED

Medicare fraud takes a lot of money every year from the Medicare program.

To stop the fraud the medicare system treats all claims as suspicious till proven wrong.

Every claim, public and private, is subject to specific coding and billing requirements to minimize fraud.

This is true regardless of the nature of the source of the money. EVERYONE is subject to fraud, and ALL claims must be substantiated.

Nevertheless, many criminals realize that the Government will not do as good a job of screening, and will pay claims that are blatantly fraudulent.

Government incompetence is the single largest source of medicare and medicaid fraud.

(Want a free electric scooter, hearing aid, or glucose meter? No doctor required. No tests, no 'messy paperwork.' Just provide your Government program info., and it's yours. Guaranteed. (sound familiar?) Try THAT with private insurance.)

Private payers do not just accept any claim at face value.

Would you?
jw

Originally posted by jdub297
reply to post by VneZonyDostupa

 

If you use the links provided, you could see the Report Cards in their entirety, including supporting documentation from the payers them selves and independent third parties.

Source?

If you use the links provided, you could see the Report Cards in their entirety, including supporting documentation from the payers them selves and independent third parties.

That's why they're in the OP.

jw

Neither of your links provide the information I asked for, which would clear up any transparency issues that are raised between the time the data was collect and the time the AMA "analysed" it.

So, I'll ask again...source? I don't see how you can realistically say Medicare denies more claims than "all other private insurers combines". Even your links don't support that.

Every claim, public and private, is subject to specific coding and billing requirements to minimize fraud.

This is true regardless of the nature of the source of the money. EVERYONE is subject to fraud, and ALL claims must be substantiated.

Nevertheless, many criminals realize that the Government will not do as good a job of screening, and will pay claims that are blatantly fraudulent.

Government incompetence is the single largest source of medicare and medicaid fraud.

(Want a free electric scooter, hearing aid, or glucose meter? No doctor required. No tests, no 'messy paperwork.' Just provide your Government program info., and it's yours. Guaranteed. (sound familiar?) Try THAT with private insurance.)

Private payers do not just accept any claim at face value.

Would you?
jw

The government doesn't screen as tightly because it is not a for-profit business. I would rather receive smaller reimbursements from my claims if it meant I could provide any treatment I felt applicable without having to argue with minimum-wage phone-monkeys about why I don't want my patient on beta-blockers and am instead opting for a newer medication that has been shown to be more effective in that specific patient population.

Take today, for example. I had one of those lovely phone-monkeys, who didn't sound like they had even gotten a high school degree, tell me that my patient couldn't have the new anti-retroviral for their HIV because it was 'shown' to be 'barely any better', nevermind the fact that my patient had already developed a resistance to current HAART therapies, and thus this was the only option.

reply to post by VneZonyDostupa

Neither of your links provide the information I asked for, which would clear up any transparency issues that are raised between the time the data was collect and the time the AMA "analysed" it.

I do not know what you asked for. The links include the complete "Report Cards " for 2008 and 2009. There are links within the reports to the AMA and payers own records used in their compilations.

I don't see how you can realistically say Medicare denies more claims than "all other private insurers combines". Even your links don't support that.

Yes, they do: Combine the private payers' denial rates for 2008 and 2009, combined. Take the average.

Take the Medicare rate of denial for 2008. Combine with 2009 rate. Take the average.

Subtract the private payers' combined average denial rate form the Medicare combined average denial rate.

If the result is a postive number, Medicare has a higher combined rate.
If the result is a negative number, Medicare has a lower combined rate.

I learned how to do this from Mrs. Skloss in the 4th grade.
I got an "A."

jw

I do not know what you asked for. The links include the complete "Report Cards " for 2008 and 2009. There are links within the reports to the AMA and payers own records used in their compilations

The information I asked for is very clearly stated in the tenth post of this thread (see: 10/6/2009 at 05:31 PM). Until you can show me that this information was controlled for in the AMA study, I still call shenanigans on the denial rates as a sign of poor treatment.

Yes, they do: Combine the private payers' denial rates for 2008 and 2009, combined. Take the average.

Take the Medicare rate of denial for 2008. Combine with 2009 rate. Take the average.

Subtract the private payers' combined average denial rate form the Medicare combined average denial rate.

If the result is a postive number, Medicare has a higher combined rate.
If the result is a negative number, Medicare has a lower combined rate.

I learned how to do this from Mrs. Skloss in the 4th grade.
I got an "A."

jw

You should also have learned that saying they have a combined lower number means you add them values, not average them. Saying that all the private insurers combined have a lower denial rate means adding the denial rate of Aetna to the value of BlueCross, etc, giving you a double-digit value. If you meant that the AVERAGE private insurer has a lower denial rate than medicare, than your above schematic is correct.

You may want to get your mathematical terminology correct before spouting off like that. It makes you seem less foolish.

reply to post by VneZonyDostupa
Even if you added the 6 private payers for 2008 and9, THEY ARE STILL LOWER!

Call the study what you want. The fact that you can't find what you want to see doesn't change the facts:

For 2007 and 2008, Medicare had the highest claim denial rate.

If you don't like the Reports, take it up with the publishers, the American Medical Association.

jw

Originally posted by jdub297
reply to post by VneZonyDostupa

 

Even if you added the 6 private payers for 2008 and9, THEY ARE STILL LOWER!

Call the study what you want. The fact that you can't find what you want to see doesn't change the facts:

For 2007 and 2008, Medicare had the highest claim denial rate.

If you don't like the Reports, take it up with the publishers, the American Medical Association.

jw

Now that I have a little time, let's take a deeper look at the study you posted. The main point of interest is Metric 13, the CARCs for the denials, broken down by percent. It explains why the denials occured, and helps us understand why, exactly, so many were turned back.

Now, the two most interesting CARCs for our debate, as you are claiming MediCare reduces the treatment a patient receives due to thse denials, would be 96 (care isn't covered by the insurance plan) and 197 (pre-certification not submitted, so claim is denied). Using these two as our measuring stick, let's examine each plan.

Aetna - Code 96: 15.5%, Code 197: 8.4%, TOTAL: 23.9% of denials.
Anthem - Code 96: 14.9%, Code 197: 3.6%, TOTAL: 18.5% of denials
CIGNA - Code 96: 10.8%, Code 197: 0% (no pre-cert requried), TOTAL: 10.8% of denials
Humana - Code 96: 15.3%, Code 197: 6.7%, TOTAL: 22% of denials
UHC - Code 96: 3.4%, Code 97: 0% (no pre-cert required): TOTAL 3.4% of denials
Medicare - Code 96: 0%, Code 197: 0% (pre-cert not required), TOTAL: 0%

So, using YOUR link, you can see that Medicare denials are dwarfed by those denials doled out by private insurers for either pre-certification BS or the treatment was simply "not covered".

If you look at the CARC for MediCare, you'll see that the large majority of denied claims were for fraud. 10.1% were due to the patient ID not matching the ID on the claim, 6.4% were claims by patients not enrolled in MediCare, 28.% were denied because the patient had supplementary insurance which takes a higher priority in elective care, and 5.2% were denied because the patients were in hospice care, meaning they had been deemed medically terminal.

Again, I'm using YOUR numbers from YOUR link. I still think the private insurance numbers have been fudged a bit, but even so, they support my argument that MediCare provides more care than private insurers by not denying legitimate claims.