Thread: Guess Who Has the Highest Medical Claim Rejection Rate?

Originally Posted by Kandahar

OK, let's take a look at the reasons why Medicare claims were denied. Most of them basically boil down to:

- The procedures simply are not covered under Medicare at all.
- The person is not actually enrolled in Medicare, or was not enrolled at the time of the procedure.

If you're arguing that more procedures need to be covered under Medicare and/or that coverage needs to be expanded so more people are enrolled (which would address both of those reasons for claim denial), I'm certainly willing to hear you out. But something tells me that is NOT what you arguing at all.

Those two deial reasons are true for Medicare and non Medicare claims.

They are good denial reasons-

The Medicare denial rate may be skewed because of the PART D coverage fiasco with the donut which is a black hole for claims.

Based upon my experiences I would say that the medicare denial rate has a good explanantion.

Originally Posted by Agent Ferris

That's right folks, medicare denies more sick people coverage then every single private insurance company combined. But hay by all means let's crush those evil insurance companies and vest our healthcare in the state. Obama, Reid, Pelosi you are sick ****ing jokes.

Very cute and intellectually dishonest post. Medicare also has more people on coverage than every private company combined. Bravo!

Originally Posted by EgoffTib

Very cute and intellectually dishonest post. Medicare also has more people on coverage than every private company combined. Bravo!

lmfao you don't have a clue what you're talking about. 35 million people are currently enrolled in medicare. 200 million people are currently enrolled in private health insurance firms. Not that this would matter anyways as the % of claim denials are provided in the chart. EPIC FAIL!!!

Healthcare Economist Medicare more likely to deny claims than commerical health insurers

Good article fom the Healthcare Economist

This is one paragraph example :
Another reason for the differential claims denial rates is the demographics of Medicare and commercial insurance enrollees. Almost all Medicare enrollees are over 65, while commercial insurers have enrollees who are of varying ages. Since older individuals are more likely to demand high cost medical procedures, if high cost medical procedures are the ones that are more likely to be denied then Medicare’s higher denial rate may simply be due to the composition of its enrollees.

Originally Posted by Kandahar

OK, let's take a look at the reasons why Medicare claims were denied. Most of them basically boil down to:

- The procedures simply are not covered under Medicare at all.
- The person is not actually enrolled in Medicare, or was not enrolled at the time of the procedure.

If you're arguing that more procedures need to be covered under Medicare and/or that coverage needs to be expanded so more people are enrolled (which would address both of those reasons for claim denial), I'm certainly willing to hear you out. But something tells me that is NOT what you arguing at all.

No actually for medicare stats say that most claims are rejected because: 1) "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)," and 2) the Procedures were deemed "not medically necessary," I would love to see the breakdown for that one as to what the state deems to not be medically necessary. I'm guessing quality of life procedures; such as, hip replacements and the like rather than elective procedures.

Originally Posted by Kandahar

I have no idea who Steven Israel is. At any rate, as soon as you show me some evidence that Medicare IS dropping people because they get sick, this might actually make sense.

Steven Israel (D) House of Representatives from the 2nd Congressional District of New York. And I think what they mean by dropping coverage is denying claims rather than actually completely cutting off their insurance.

Originally Posted by Agent Ferris

No actually for medicare stats say that most claims are rejected because: 1) "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),"

OK. Is that a problem with Medicare, or a reasonable claim denial?

Originally Posted by Agent Ferris

and 2) the Procedures were deemed "not medically necessary," I would love to see the breakdown for that one as to what the state deems to not be medically necessary. I'm guessing quality of life procedures; such as, hip replacements and the like.

Medicare covers hip replacements. But regardless, if it was deemed "not medically necessary" that's because Congress did not cover it when they wrote Medicare laws. Are you saying that more things need to be covered under Medicare? I'm certainly willing to entertain that argument.