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

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

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

    The HEALTHCARE ECONOMIST - Sme link has two other paragraphs and they support what some of us have alreadt posted

    "If you look at the AMA report cards, youll see that most claims denied by Medicare were due to billing errors (inadequate data on billing forms, wrong carrier, not enrolled in program, etc.). Also, some denials are for non-covered services such as routine physical exams. Medicare has been more effective in requiring compliance with the program, which is entirely appropriate considering that these are our taxpayer dollars that they are spending.

    In contrast, the relaxation of compliance standards by the private health plans has wasted funds that we have paid in as premiums. Charging us higher premiums so that they can pay dubious claims does not represent private sector efficiency. We are paying the private plans far more in administrative costs than we do for Medicare, yet they are not providing the claims processing efficiency that we deserve. As an example, Medicare pays the contracted rate 98% of the time, whereas the private insurers do so only 66% to 84% of the time. The fact that they cant get right the rates that they contracted for demonstrates the profound incompetence of the private insurance industry."
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    Re: Guess Who Has the Highest Medical Claim Rejection Rate?

    Quote Originally Posted by Agent Ferris View Post
    Is it even legal to deny coverage based on it being cost prohibitive?
    They aren't necessarily denying them BECAUSE they are more cost prohibitive. But insurers are more likely to carefully scrutinize high-cost procedures than routine procedures, which will mean more denials for plans with a lot of patients demanding high-cost procedures.
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    Re: Guess Who Has the Highest Medical Claim Rejection Rate?

    Quote Originally Posted by Kandahar View Post
    OK. Is that a problem with Medicare, or a reasonable denial?


    This is the NCPDP Rejection Code:

    Powered by Google Docs

    The chart that I provided clearly states that it doesn't include "reasons other than a claim edit," which I'm pretty sure would be a claim filing error which are covered by the NCPDP Reject Code.

    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.
    Are you sure it is Congress which determines what is covered and what isn't covered, because from my understanding of Title 18 it's the Secretary of Health and Human Services and consultation boards which make that determination:

    Sec. 1804. [42 U.S.C. 1395b-2] of the Social Security Act of 1965: (a) The Secretary shall prepare (in consultation with groups representing the elderly and with health insurers) and provide for distribution of a notice containing—

    (1) a clear, simple explanation of the benefits available under this title and the major categories of health care for which benefits are not available under this title,

    (2) the limitations on payment (including deductibles and coinsurance amounts) that are imposed under this title, and

    (3) a description of the limited benefits for long-term care services available under this title and generally available under State plans approved under title XIX.
    Last edited by Agent Ferris; 10-08-09 at 01:03 AM.

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

    Quote Originally Posted by F107HyperSabr View Post
    Healthcare Economist Medicare more likely to deny claims than commerical health insurers

    The HEALTHCARE ECONOMIST - Sme link has two other paragraphs and they support what some of us have alreadt posted

    "If you look at the AMA report cards, you’ll see that most claims denied by Medicare were due to billing errors (inadequate data on billing forms, wrong carrier, not enrolled in program, etc.). Also, some denials are for non-covered services such as routine physical exams. Medicare has been more effective in requiring compliance with the program, which is entirely appropriate considering that these are our taxpayer dollars that they are spending.

    In contrast, the relaxation of compliance standards by the private health plans has wasted funds that we have paid in as premiums. Charging us higher premiums so that they can pay dubious claims does not represent private sector efficiency. We are paying the private plans far more in administrative costs than we do for Medicare, yet they are not providing the claims processing efficiency that we deserve. As an example, Medicare pays the contracted rate 98% of the time, whereas the private insurers do so only 66% to 84% of the time. The fact that they can’t get right the rates that they contracted for demonstrates the profound incompetence of the private insurance industry."
    Ya but again the original chart from the OP left out claim edits, isn't that what a claim edit means IE a claim filing error?

    Furthermore; only 3.9% of claims are denied based on filing for routine checkups. The majority of claim denials from the original chart are based on the procedures being deemed "not medically necessary", I'm guessing quality of life procedures.
    Last edited by Agent Ferris; 10-08-09 at 01:06 AM.

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



    Is it just me or are people really that stupid? Anybody who claims that Medicare covers less people than private insurers needs to use a different table as their evidence of any BS claim they make. The chart at hand only takes into account a small subset of private insurers, it seems. Look at the number of claims. ~7 million for medicare and less than 3 million for private insurers combined. Get all of the private insurance companies on the list, then we can compare statistics.

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

    Quote Originally Posted by Smoke[MaxX] View Post


    Is it just me or are people really that stupid? Anybody who claims that Medicare covers less people than private insurers needs to use a different table as their evidence of any BS claim they make. The chart at hand only takes into account a small subset of private insurers, it seems. Look at the number of claims. ~7 million for medicare and less than 3 million for private insurers combined. Get all of the private insurance companies on the list, then we can compare statistics.
    A) Those are number of claims not number of those insured.

    B) Those are the seven major insurers.

    C) Do you know what a % is? Even as a % of claims denied medicare still rejects more people.

    D) 200 million people are covered by private insurance, only 35 million are covered by medicare.

    E) Aetna provides insurance to 21 million people.

    [ame=http://en.wikipedia.org/wiki/Aetna]Aetna - Wikipedia, the free encyclopedia[/ame]


    F) Anthem provides insurance to 11.6 million people.

    Business Partners

    G) CIGNA provides insurance to 46 million people.

    CIGNA Newsroom: As Employee Benefit Enrollment Season Begins, CIGNA Suggests a ?Spring-Cleaning? Approach to Putting the Family Financial House in Order

    H) Coventry provides insurance for 4.6 million people.

    Coventry Health Insurance

    I) Healthnet provides insurance to 7.3 million people.

    [ame=http://en.wikipedia.org/wiki/Health_Net]Health Net - Wikipedia, the free encyclopedia[/ame]

    J) Humana provides insurance to 11.5 million people.

    [ame=http://en.wikipedia.org/wiki/Humana]Humana - Wikipedia, the free encyclopedia[/ame]


    K) UnitedHealth group provides insurance to 70 million people.

    [ame=http://en.wikipedia.org/wiki/UnitedHealth_Group]UnitedHealth Group - Wikipedia, the free encyclopedia[/ame]


    L) That's a grand total of 172 million people.

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

    Quote Originally Posted by Kandahar View Post
    They aren't necessarily denying them BECAUSE they are more cost prohibitive. But insurers are more likely to carefully scrutinize high-cost procedures than routine procedures, which will mean more denials for plans with a lot of patients demanding high-cost procedures.
    Actually we scrutinize all "routine" and "high cost". It's the frequency / severity issue. "Routine" claims are invariably high volume hence the numbers multiply. The high cost cases are economically severe. Like a hard smack at our bottom line. In the practical sense yes a claims processor will most likely hit the pay "button" quicker for codes that she is familiar with.

    The industry has also moved to automated claims adjudication with character recognition software therefore at lot of the "routine" stuff is pushed through on a "if the code is a fit pay it rule. "
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    Re: Guess Who Has the Highest Medical Claim Rejection Rate?

    Quote Originally Posted by Agent Ferris View Post
    Ya but again the original chart from the OP left out claim edits, isn't that what a claim edit means IE a claim filing error?

    Furthermore; only 3.9% of claims are denied based on filing for routine checkups. The majority of claim denials from the original chart are based on the procedures being deemed "not medically necessary", I'm guessing quality of life procedures.
    "edits" are used in the processing routines and some edits are checking that the data submitted is valid but also that it matches coverage and elligibilibility data bases.
    I do not recall the Viet Cong asking me if I was a natural born or Naturalized American before they shot at me, they just shot at all of us f107HyperSabr

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

    Quote Originally Posted by TacticalEvilDan View Post
    Their denial percentage is comparable to each of those other insurance companies, especially Aetna.

    Misrepresentation FTW!
    Well then a state run healthcare system is just as good as private. Well I think I'll call my senator and tell him to vote for Obamacare. I want free healthcare like the Brits.
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    Re: Guess Who Has the Highest Medical Claim Rejection Rate?

    Does Medicare deny coverage due to pre-existing conditions like being in an abusive relationship, having had a broken bone once long ago and not reporting it, or having acne?
    PeteEU

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