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Guess Who Has the Highest Medical Claim Rejection Rate?

Kandahar said:
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. :roll:
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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.
 
Agent Ferris said:
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.
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Very cute and intellectually dishonest post. Medicare also has more people on coverage than every private company combined. Bravo! :sarcasticclap
 
F107HyperSabr said:
I already questioned the veracity of your source regarding denial rates of medical claims. There is also another factor to consider and the so called stats that you provided do not show why "we" deny a cliam.
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I already provided that list from the secondary source material IE the AMA's National Health Insurance Report Card:

the The AMA NHIRC results are based on
 
EgoffTib said:
Very cute and intellectually dishonest post. Medicare also has more people on coverage than every private company combined. Bravo! :sarcasticclap
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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!!!
 
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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.
 
Kandahar said:
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. :roll:
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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.
 
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Kandahar said:
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. :2wave:
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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.
 
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Agent Ferris said:
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),"
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OK. Is that a problem with Medicare, or a reasonable claim denial?

Agent Ferris said:
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.
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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.
 
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F107HyperSabr said:
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.
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Is it even legal to deny coverage based on it being cost prohibitive?
 
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."
 
Agent Ferris said:
Is it even legal to deny coverage based on it being cost prohibitive?
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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.
 
Kandahar said:
OK. Is that a problem with Medicare, or a reasonable denial?
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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.
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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.
 
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F107HyperSabr said:
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."
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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.
 
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DenialsByInsurer2008.jpg


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.
 
Smoke[MaxX] said:
DenialsByInsurer2008.jpg


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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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.
 
Kandahar said:
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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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. "
 
Agent Ferris said:
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.
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"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.
 
TacticalEvilDan said:
Their denial percentage is comparable to each of those other insurance companies, especially Aetna.

Misrepresentation FTW!
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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.
 
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 said:
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?
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Only for you.
 
Kandahar said:
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?
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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? :yes: Do you think that taxes will go up, because that will have to be an option, etc.
 
PeteEU said:
So you are denying that private insurance companies deny coverage because of those examples?
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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.
 
LaMidRighter said:
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.
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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?
 
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