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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?

    Quote Originally Posted by PeteEU View Post
    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?
    Only for you.
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    Re: Guess Who Has the Highest Medical Claim Rejection Rate?

    Quote Originally Posted by American View Post
    Only for you.
    So you are denying that private insurance companies deny coverage because of those examples?
    PeteEU

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

    Quote Originally Posted by Kandahar View Post
    Do you have any evidence at all to identify WHY they were denied care, and what the circumstances of their claims are? Or are you just jumping to whichever conclusion best fits with your preconceived notions of government health care?
    Your side would be the first to report private insurers denying a claim, so don't start that little spiel, cause I don't feel like going tit-for-tat in a pot/kettle matchup. Fact, you aren't an insurance agent and have been making some pretty "solid" claims as to the nature of coverage, fact, medicare denies the highest percentage of claimants even though it has a smaller portion of the population, fact, non-supplemental medicare coverage is weak at best, and I can't use clean language to fully explain how badly it sucks for someone with severe medical problems.
    This being said, what do you think will happen when the same system is extended to 75-100% of the population? Could it be that rationing will increase? Do you think that taxes will go up, because that will have to be an option, etc.
    Neither side in an argument can find the truth when both make an absolute claim on it.

    LMR

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

    Quote Originally Posted by PeteEU View Post
    So you are denying that private insurance companies deny coverage because of those examples?
    I am, but that is because I'm an agent and those examples would be illegal. Maybe you should learn a little bit about America before you mind it's business.
    Neither side in an argument can find the truth when both make an absolute claim on it.

    LMR

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

    Quote Originally Posted by LaMidRighter View Post
    I am, but that is because I'm an agent and those examples would be illegal. Maybe you should learn a little bit about America before you mind it's business.
    Oh they are? Maybe you should learn a bit about your own country first.

    Papers Show Insurers Limited Coverage for Acne, Pregnancy - washingtonpost.com

    Domestic violence as pre-existing condition? 8 states still allow it | McClatchy

    Insurer Calls Broken Wrist Pre-Existing Condition | Drudge Retort

    So again, do you deny that private insurance companies use any and all excuses to deny coverage? Things like.. wanting to adopt to being a police officer?
    PeteEU

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

    Quote Originally Posted by Agent Ferris View Post
    lol um no they deny more people than all of the private insurance companies combined. Are you suggesting that medicare insures more people then all of those private insurance companies combined?
    But Medicare also has over 6.3 million more clients than Aenta. Not a reasonable comparasion by any stretch considering that percentage wise, both have an equal amount of rejected claims (6.80% and 6.85%, Aenta to Medicare).

    It's really not a fair comparison. I could see if all insurance agencies listed had roughly the same amount of cases and Medicare had a higher reject rate, but when the agency you're trying to knock has well over 6 million more clients that the "competition", it's really not a fair comparison.

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

    Quote Originally Posted by apdst View Post
    They consist of more elderly people, because you can't draw medicare until you're 65. However, those people have been paying into medicare--matched by their employer--their entire working lives. There shouldn't be any reason they're denied treatment. I mean, an individual + his employer will pay literally hundreds of thousands of dollars into that system. Medicare payments are mandated by the government and Medicare is going to turn around and deny care? That's BS. I believe that if a person is denied care by medicare, that he should get a refund of every dollar that he ever paid into it and so should his employer(s).


    It just goes to show cocked up government run health care really is.
    To a large extent, I agree with you. But Medicare has to play by the exact same rules as established by the Dept. of Health and Humas Services as all other private insurance companies. To give them latitude just because Medicare is a government backed health care agency would really tic-off the private health care system and every special interest group that support private insurance. It's one of the reasons H.R. 3200 wanted to implement equal health care standards across the board and have health benefits reviewed on a regular basis to ensure standards remained fair throughout the health care system. But the opposition viewed such equality standards as "government getting between you and your health care provider". Kinda puts that argument in a different light now, doesn't it?
    Last edited by Objective Voice; 10-08-09 at 12:28 PM.

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

    Quote Originally Posted by Kandahar View Post
    (Also)What does "denied for reasons other than a claim edit" mean?
    Quote Originally Posted by Agent Ferris View Post
    I believe that means if you file the paperwork for the claim incorrectly it is automatically denied and you have to re-file the claim properly.
    Okay, so you would agree then that most of these rejected Medicare claims aren't for the purpose of outright denying people coverage for medical reasons but rather they are rejections do to administrative errors, i.e., the claimant didn't check a certain box or forgot to include this supplimental document or didn't sign a form, or maybe something was coded incorrectly, etc, etc?
    Last edited by Objective Voice; 10-08-09 at 12:33 PM.

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

    Quote Originally Posted by LaMidRighter View Post
    Your side would be the first to report private insurers denying a claim,
    "My side"? I love that phrase. Which side would that be?

    I would not bitch about it if insurers denied a claim for some of the reasons listed here, such as the patient is not actually a policy holder with the insurance company or they filled the form out wrong. My problem is when insurers look for a pretext to deny a high cost procedure, such as combing through the patient's medical files for an unrelated preexisting condition from 10 years prior.

    Quote Originally Posted by LaMidRighter
    Fact, you aren't an insurance agent and have been making some pretty "solid" claims as to the nature of coverage, fact, medicare denies the highest percentage of claimants even though it has a smaller portion of the population,
    And unless you can show that Medicare's denials are for illegitimate reasons, this statistic is meaningless. I've already identified several possible explanations for this, none of which involve a sinister government wanting to pull the plug on grandma: 1) Perhaps Medicare receives more fraudulent claims than private insurers. 2) Perhaps Medicare receives more claims that aren't covered because the law doesn't cover certain procedures. 3) Perhaps people are more likely to think they're Medicare members when they aren't, than they are to think they're Cigna members when they aren't. 4) Perhaps high-cost procedures universally receive more scrutiny among ALL insurers, so the insurer with the highest proportion of high-cost procedures will inevitably deny more claims. 5) Perhaps Medicare patients are more likely to fill out the claim form incorrectly than private insurance patients.

    These are just a few of the possible explanations I can think of. I'm sure there are others.

    Quote Originally Posted by LaMidRighter
    fact, non-supplemental medicare coverage is weak at best, and I can't use clean language to fully explain how badly it sucks for someone with severe medical problems.
    This being said, what do you think will happen when the same system is extended to 75-100% of the population?
    Then don't get the public option.

    Quote Originally Posted by LaMidRighter
    Could it be that rationing will increase?
    Then don't get the public option.

    Quote Originally Posted by LaMidRighter
    Do you think that taxes will go up, because that will have to be an option, etc.
    I think taxes will go up to subsidize health insurance for those who can't afford it...but that's true whether or not there is actually a government-run insurance plan. As for the public option itself, I see no reason why taxes would need to go up (except maybe for the first year the plan is operational), since it would be covered by premiums just like private insurance plans are.
    Last edited by Kandahar; 10-08-09 at 12:51 PM.
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    Re: Guess Who Has the Highest Medical Claim Rejection Rate?

    Quote Originally Posted by Agent Ferris View Post
    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.
    I can give you examples of "not medically necessary" from my own experience in the healthcare field as an EMT.

    Taking an ambulance to the hospital for a sprained thumb = not medically necessary.

    Taking an ambulance to the hospital because you don't "feel well" = not medically necessary.

    ER treatment for a headache = not medically necessary

    When Medicaid/Medicare enacted these rules and required that all ambulance rides be "medically necessary" before they would pay for them, the private sector's response was to lie on the trip sheets and state that the rides WERE medically necessary when 90% of the time they were NOT. (ditto for ER visits) It's one of the reasons I quit driving an ambulance - I refused to take part in Medicaid/Medicare fraud.

    But, just from my experience working in the industry as a medical professional, I'd say that 90% of the 'emergency treatments' given to medicaid/medicare recipients were completely medically UNnecessary in the region in which I worked.

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