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Guess Who Has the Highest Medical Claim Rejection Rate?

Agent Ferris said:
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?
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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.
 
apdst said:
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.
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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?
 
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Kandahar said:
(Also)What does "denied for reasons other than a claim edit" mean?
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Agent Ferris said:
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.
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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?
 
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LaMidRighter said:
Your side would be the first to report private insurers denying a claim,
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"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.

LaMidRighter said:
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,
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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.

LaMidRighter said:
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?
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Then don't get the public option.

LaMidRighter said:
Could it be that rationing will increase? :yes:
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Then don't get the public option.

LaMidRighter said:
Do you think that taxes will go up, because that will have to be an option, etc.
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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.
 
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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)," 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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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.
 
Kandahar said:
"My side"? I love that phrase. Which side would that be?
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Which side? Really? How about big government side, or if you prefer, for this debate, taxpayer subsidized healthcare.

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.
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What makes you think this isn't the case? For instance, the insurance commissioner of my state just asked for agents to contribute anything they may have on double billing, and other less than ethical extra procedures charged to various companies and insurances, but these aren't the stories you hear on the news, you hear about companies "denying legitimate procedures", oh, and by the way, if a doctor proves medical necessity to satisfy requirements, your better companies DO in fact pay out.
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.
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And you have experienced this personally or had a client complain to you of this? Cause I've been in the business for a while and haven't seen it, but then again what do I know, I'm just an insurance professional, not a clueless journalist. :roll:


And unless you can show that Medicare's denials are for illegitimate reasons, this statistic is meaningless.
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But you would assign a different standard to private health insurers? Nice, so government can deny no questions asked, but private is guilty until proven innocent, gotcha.
I've already identified several possible explanations for this, none of which involve a sinister government wanting to pull the plug on grandma:
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I'll take these one at a time.
1) Perhaps Medicare receives more fraudulent claims than private insurers.
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And why would that be? Could it be that government programs don't have a very good loss prevention mechanism, since the programs are not accountable to anyone outside of their own beauracracies, or maybe because losing money rewards bigger budgets in the upcoming fiscal year. How would this improve under a taxpayer subsidized plan?
2) Perhaps Medicare receives more claims that aren't covered because the law doesn't cover certain procedures.
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Uh, okay, medicare benefits are stated in writing, just like private plans, the denials are worded in a way in which scope of coverage is void because of a loophole.
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.
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You get a card with Medicare, same with any coverage, it's kind of hard to think you are covered when you are clearly NOT. This point is very weak.
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.
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It doesn't work that way under private, if it's in contract and meets the standard of necessity it gets paid.
5) Perhaps Medicare patients are more likely to fill out the claim form incorrectly than private insurance patients.
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????? You present a card to the doctor, he fills out the forms as necessary, the charge nurse takes care of her part, you sign.





Then don't get the public option.
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You really don't get it do you? The "public option" is designed to eventually be the only "option" read the laws, they are tailor made to drive insurers out of the market, the one's that do survive will be prohibitively expensive.







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.
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Read the CBO numbers, then get back to me.
 
Strucky said:
475,000 sick people rejected and your ok with this???!!!
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Upwards of 30,000,000 with NO medical coverage of any kind and you're ok with this???!!!

:doh
 
Glinda said:
Upwards of 30,000,000 with NO medical coverage of any kind and you're ok with this???!!!

:doh
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Wait a sec.! I thought the current arbitrary estimate was 40m, not 30. But actual breakdowns put the insurance poor(no access) at a little over 6m, a very small percentage of the population. The biggest demographic are voluntary non-participants(trade off insurance for more money), the second biggest......illegal aliens.
 
PeteEU said:
Oh they are? Maybe you should learn a bit about your own country first.
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Right, cause you've demonstrated SUCH a great understanding of that which is American over the years.:roll:

Papers Show Insurers Limited Coverage for Acne, Pregnancy - washingtonpost.com
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Oh where to start with an op-ed? 'Kay, let me 'splain something, first, most insurance contracts will NOT cover cosmetic necessity UNLESS it is a matter of immediate health concern, second, pregnancy riders are offered with initial contracting, IF you don't sign for it and it is specified that it is NOT IN INITIAL COVERAGE, then NO the insurer WON'T pay, this is why it is an insurance contract. This "whoa is me" reporting really needs to stop.


Domestic violence as pre-existing condition? 8 states still allow it | McClatchy
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And then you bring McClatchy, too rich. Okay, I'll bite.........the states allow it, what is the actual breakdown of companies that exclude as a pre-existing that operate IN THOSE STATES?

Insurer Calls Broken Wrist Pre-Existing Condition | Drudge Retort
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I have worked for companies that had tricky writing, this is something to watch out for, while a broken wrist may entail a pre-existing condition, most companies allow for a doctor's clearance for prior injuries, this becomes a non-pre-existing condition after a doctor clears it, not hard to do, and I have had prior injuries cleared for clients before. Next, what was the organizational model: There are traditional plans, fee-for-service plans, OPO's, PPO's, indemnity companies, HMO's, and there are HSA's, without the coverage model, the reporting is incomplete.

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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Yes I do, because you are using a blanket statement to make your case, there is good coverage and bad coverage, but with government there is one coverage, and it's bad more often than not.
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LaMidRighter said:
Wait a sec.! I thought the current arbitrary estimate was 40m, not 30. But actual breakdowns put the insurance poor(no access) at a little over 6m, a very small percentage of the population. The biggest demographic are voluntary non-participants(trade off insurance for more money), the second biggest......illegal aliens.
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The actual number is difficult to pin down. Regardless, I think we can all rest easy tonight knowing that certain people are more outraged that 475,000 were denied healthcare treatment than that tens of millions have no healthcare whatsoever. :roll:

Number of uninsured crucial in health debate
Obama frequently cites last year’s Census Bureau number of 46 million people with no health insurance. Some specialists, however, argue that figure is off by tens of millions.

The recession’s continuing toll on jobs, a tendency to undercount people on Medicaid, and other factors make it hard to come up with an exact number. And the most widely accepted range - 40 million to 50 million - includes some 10 million noncitizens, a detail that’s generally overlooked.

Even if there are fewer uninsured than now estimated, health analysts emphasize that it’s still a lot of people, and being uninsured has consequences. The Institute of Medicine has found that uninsured people are more likely to succumb to illness and suffer premature death.

The 45.7 million uninsured cited by Obama and others comes from the Census Bureau’s annual Current Population Survey for 2007. It’s the consensus figure, but some researchers believe the survey undercounted how many people are covered by Medicaid, the federal-state program for the poor.

Another government survey done by the Department of Health and Human Services says that about 40 million people were uninsured for all of 2007, and about 70 million were uninsured for part of the year.

But taking into account the effects of the recession, with more than 5 million jobs lost since last August cutting into employer-provided healthcare, researchers at the Urban Institute and elsewhere estimate that the present-day number of uninsured is closer to 50 million. That is the number used by the Congressional Budget Office.
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Glinda said:
The actual number is difficult to pin down. Regardless, I think we can all rest easy tonight knowing that certain people are more outraged that 475,000 were denied healthcare treatment than that tens of millions have no healthcare whatsoever. :roll:
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You have conveniently left out the qualifying data, I work in the insurance industry as an agent, so I see these numbers. 475k denied means absolutely zero to me without a numbers breakdown, I know non-industry people have a problem with grasping that sometimes doctors and insureds cheat, but it happens, which is why things are under such scrutiny by the companies who contract, denials don't happen because of greed for the most part.......are there bad companies, sure, but most denials happen for very legitimate reasons, and it all comes down to cost management.
 
LaMidRighter said:
it all comes down to cost management.
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You're right on this point. The fact is, insurance companies are profit driven, and are more interested in denying treatment than they are in providing it. They HAVE to be or they can't pay their greedy CEOs hundreds of millions, can't pay dividends to their shameless stockholders, who all get their compensation on the backs of the ill and dying.

CEO Compensation: Who Said Health Care is in a Financial Crisis?

Those of you who are struggling to pay for your generic medicines or wondering why the doctor is charging you a $5.00 co-pay, give some thought to these facts about how our health care dollars are allocated. At the end of this post, there is a list of 23 health companies I found on Forbes.com, what the CEO was paid in 2005, and the average paid to the CEO in the past five years.

Imagine adding vice presidents, Board of Directors, stock holders and the other 200-300 other companies all cashing in on your health to that total at the bottom.

Based on this, the next time you want to argue with your Primary Care doctor's front desk about a $5.00 co-pay, remember that he makes an average of $149,000.00 per year. On the other hand -- using United Healthcare as an example -- your insurance company paid their CEO -- one man -- $324,000,000 over a recent five year period.

BTW: 10% of 14.9 billion is 1.4 billion. If basic insurance costs $8,000/year for a family then taking 10% from just these CEO salaries would insure 35,000 Americans a year for five years. That is a lot of people that can be helped just by 23 men. Looking at the companies as a whole that profit from health care, we can probably pay for every uninsured person in this country for decades to come.

The numbers are numbing, which is why we should do something about this.

* United Health Group
CEO: William W McGuire
2005: 124.8 mil
5-year: 342 mil

* Forest Labs
CEO: Howard Solomon
2005: 92.1 mil
5-year: 295 mil

* Caremark Rx
CEO: Edwin M Crawford
2005: 77.9 mil
5-year: 93.6 mil

* Abbott Lab
CEO: Miles White
2005: 26.2 mil
5-year: 25.8 mil

* Aetna
CEO: John Rowe
2005: 22.1 mil
5-year:57.8 mil

* Amgen
CEO: Kevin Sharer
2005:5.7 mil
5-year:59.5 mil

* Bectin-Dickinson
CEO: Edwin Ludwig
2005: 10 mil
5-year:18 mil

* Boston Scientific
CEO:
2005:38.1 mil
5-year:45 mil

* Cardinal Health
CEO: James Tobin
2005:1.1 mil
5-year:33.5 mil

* Cigna
CEO: H. Edward Hanway
2005:13.3 mil
5-year:62.8 mil

* Genzyme
CEO: Henri Termeer
2005: 19 mil
5-year:60.7 mil

* Humana
CEO: Michael McAllister
2005:2.3 mil
5-year:12.9 mil

* Johnson & Johnson
CEO: William Weldon
2005:6.1 mil
5-year:19.7 mil

* Laboratory Corp America
CEO: Thomas MacMahon
2005:7.9 mil
5-year:41.8 mil

* Eli Lilly
CEO: Sidney Taurel
2005:7.2 mil
5-year:37.9 mil

* McKesson
CEO: John Hammergen
2005: 13.4 mil
5-year:31.2 mil

* Medtronic
CEO: Arthur Collins
2005: 4.7 mil
5-year:39 mil

* Merck Raymond Gilmartin
CEO:
2005: 37.8 mil
5-year:49.6 mil

* PacifiCare Health
CEO: Howard Phanstiel
2005: 3.4 mil
5-year: 8.5 mil

* Pfizer
CEO: Henry McKinnell
2005: 14 mil
5-year: 74 mil

* Well Choice
CEO: Michael Stocker
2005: 3.2 mil
5-year: 10.7 mil

* WellPoint
CEO: Larry Glasscock
2005: 23 mil
5-year: 46.8 mil

* Wyeth
CEO: Robert Essner
2005:6.5 mil
5-year: 28.9 mil


TOTAL 2005: 559.8 mil

TOTAL 5-Year: 14.9 billion
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If you can understand this, why would you be against a public option which is NOT profit driven? Because you might lose your job? :roll:
 
LaMidRighter said:
Oh where to start with an op-ed? 'Kay, let me 'splain something, first, most insurance contracts will NOT cover cosmetic necessity UNLESS it is a matter of immediate health concern,
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I see. So what is an immediate health concern.. blood pouring from the face? Looking like you have the plague, chicken pox and worse all at the same time? How about a deflated breast implant that is seeping into the body.. is that "immediate" enough or because it is part of a cosmetic surgery then it is a "pre-existing" condition.?

second, pregnancy riders are offered with initial contracting, IF you don't sign for it and it is specified that it is NOT IN INITIAL COVERAGE, then NO the insurer WON'T pay, this is why it is an insurance contract. This "whoa is me" reporting really needs to stop.
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So you are telling me that in a standard basic healthcare insurance coverage there is no pregnancy coverage for women? So insurance companies dont expect women to have babies... I see.

And then you bring McClatchy, too rich. Okay, I'll bite.........the states allow it, what is the actual breakdown of companies that exclude as a pre-existing that operate IN THOSE STATES?
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Read the article.

An informal survey by the House Judiciary Committee in 1994 found that half of the 16 largest insurers in the country considered domestic violence in deciding whether to approve health coverage. The Pennsylvania insurance Department reported a year or so later that nearly one out of four insurance companies factored in domestic violence when deciding whether to issue or renew policies.
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And you expect the companies to some how miraculous change their spots over a decade and especially when it is not illegal in those 8 states? If it was not a problem, then why the hell did the other 42 states put bans in place? Because they had nothing better to do?

I have worked for companies that had tricky writing, this is something to watch out for, while a broken wrist may entail a pre-existing condition, most companies allow for a doctor's clearance for prior injuries, this becomes a non-pre-existing condition after a doctor clears it, not hard to do, and I have had prior injuries cleared for clients before. Next, what was the organizational model: There are traditional plans, fee-for-service plans, OPO's, PPO's, indemnity companies, HMO's, and there are HSA's, without the coverage model, the reporting is incomplete.
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In other words you are defending the companies yet again for being able to screw over American's.. nice to know the conservative mindset rules again.

Yes I do, because you are using a blanket statement to make your case, there is good coverage and bad coverage, but with government there is one coverage, and it's bad more often than not.
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LOL you accuse me of using a blanket statement and then you throw out one of your own.
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Glinda said:
You're right on this point. The fact is, insurance companies are profit driven, and are more interested in denying treatment than they are in providing it. They HAVE to be or they can't pay their greedy CEOs hundreds of millions, can't pay dividends to their shameless stockholders, who all get their compensation on the backs of the ill and dying.



If you can understand this, why would you be against a public option which is NOT profit driven? Because you might lose your job? :roll:
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And government is burocracy-driven, and therefore artifically drives-up cost by adding levels of unneeded administration. Eventually it becomes the mission of this burocracy to sustain itself, instead of the public service.
 
Glinda said:
You're right on this point. The fact is, insurance companies are profit driven, and are more interested in denying treatment than they are in providing it. They HAVE to be or they can't pay their greedy CEOs hundreds of millions, can't pay dividends to their shameless stockholders, who all get their compensation on the backs of the ill and dying.



If you can understand this, why would you be against a public option which is NOT profit driven? Because you might lose your job? :roll:
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So how long have you been in the insurance business? I'd really like to know since you can undoubtedly say what a company's motivations are, or can assign which points I am right on, you know, since I actually DO work in the Life/Health insurance industry.
 
PeteEU said:
I see. So what is an immediate health concern.. blood pouring from the face? Looking like you have the plague, chicken pox and worse all at the same time?
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So when does acne or a facelift affect health? Since you brought it up?
How about a deflated breast implant that is seeping into the body.. is that "immediate" enough or because it is part of a cosmetic surgery then it is a "pre-existing" condition.?
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Look, your own article doesn't get it right, not my problem, a leaky breast implant that contains silicone IS covered, because that would be an immediate health risk, septic acne would be as well, now, what the story gets wrong is that the person would have coverage, just not for pre-existing conditions, EXCEPT for things that provably could cause death or disfigurement, they might even not cover something or reduce coverage, but then again NOT all insurance companies have the same policies, practices, or coverage models. See, it's easy to use a source that says blindly what you want it to, the problem is it doesn't stand up to scrutiny.


So you are telling me that in a standard basic healthcare insurance coverage there is no pregnancy coverage for women? So insurance companies dont expect women to have babies... I see.
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There is no "standard" coverage, there are state requirements, there are policy minimums, and there are in fact many companies that offer a low priced rider instead of just covering pregnancy as a blanket condition....you know.....cause not everyone will get pregnant like, men, infertile women, women who don't plan to have children, young children............



Read the article.
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I did, it was crap, first paragraph started out with bad info, it only got worse from there.



And you expect the companies to some how miraculous change their spots over a decade and especially when it is not illegal in those 8 states? If it was not a problem, then why the hell did the other 42 states put bans in place? Because they had nothing better to do?
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Companies that use that practice don't often retain customers, and chances are they will be answering to an insurance commissioner for something in the future anyway.



In other words you are defending the companies yet again for being able to screw over American's.. nice to know the conservative mindset rules again.
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I see, so you throw an insult because you are uninformed about the argument, and can't mind your own countries business. Gotcha, again, MYOB.



LOL you accuse me of using a blanket statement and then you throw out one of your own.
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You DO know what a blanket statement means right?
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lol @ the way this thread has turned into a slaughter fest.
 
Glinda said:
You're right on this point. The fact is, insurance companies are profit driven, and are more interested in denying treatment than they are in providing it. They HAVE to be or they can't pay their greedy CEOs hundreds of millions, can't pay dividends to their shameless stockholders, who all get their compensation on the backs of the ill and dying.



If you can understand this, why would you be against a public option which is NOT profit driven? Because you might lose your job? :roll:
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First off, the CBO is estimating based on current cost, major economists have already said that this is going to change, which I think the CBO has readily admitted, secondly, you do know that the B at the end of public healthcare is astronomically bigger than the M from the private sector right? If not, get a stopwatch and count to the two numbers. Next, I don't lose my job, I am independent, which means I can sell whatever I want and am basically my own boss, I'm not firing myself, but many agents will lose their jobs and everyone will suffer the consequences of public healthcare, if it gets passed and fails, I will expect an apology from all of the pro-subsidized healthcare people on this forum, I'll even make a thread to make it easier.
 
Objective Voice said:
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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And United Health Group insures 70 million people and has less of a % of claim denials.
 
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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"Believe it or don't" - There actually may a a corrrelation between acne and certain deseases such a thyroid cancer and /or typer thyroidism. "being in an abusive relationship" is not a pre-existing condition it is probably more of a life style.

Familiar to disclose is a though call since failure to disclose is important if that failure to disclose is material. Also there are conditionns that people have may not appear to be a long term impact upon health to them.

Who would have expected that having acne may impact a cancer ? Severe sunburn asa child or teen is also listed as a possible cause of Thyroid canacer in later years. I am not sure that we even thought it would casue skin cancer.
 
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Glinda said:
You're right on this point. The fact is, insurance companies are profit driven, and are more interested in denying treatment than they are in providing it. They HAVE to be or they can't pay their greedy CEOs hundreds of millions, can't pay dividends to their shameless stockholders, who all get their compensation on the backs of the ill and dying.



If you can understand this, why would you be against a public option which is NOT profit driven? Because you might lose your job? :roll:
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There is really nothing wrong with making a profit. All companies are profit driven.

I thought that he isue was insurance companies but most of the comp[anies you listed are DRUG companies and one I think is a hi-tech bio research commpany.

Is the compensation paid to these guys in line with other industries ?
 
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rivrrat said:
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
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Show me everything the state deems not medically necessary, because I seriously doubt that considering that more than 20% of their claim denials are from treatment which they deem not medically necessary that even half would fall into those above categories.
 
Agent Ferris said:
Show me everything the state deems not medically necessary, because I seriously doubt that considering that more than 20% of their claim denials are from treatment which they deem not medically necessary that even half would fall into those above categories.
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I gave you only a couple of examples. And what was "medically necessary" as far as the ambulance went was determined by US... the medical professionals operating the ambulance. We either said it was medically necessary, or we didn't. Ditto for the docs in the ER. Easily 90% of the medicare/medicaid recipients I picked up fell into the NOT medically necessary category. If not more. I'm being kind with that estimate. The only medically necessary medicare/medicaid folks I picked up in the ambulance were either heart attacks or car accidents. The rest of them were hypochondriac, attention seeking ****ers using the ambulance as a taxi service. I applaud Medicare for letting the medical professionals decide what was actually medically necessary and what wasn't (about the ONLY thing I will applaud them for) and I am glad they deny a ****load of claims because of it. However, it's too easy to get around... it was too easy for ambulance personnel to just simply lie and state that it WAS medically necessary.
 
rivrrat said:
I gave you only a couple of examples. And what was "medically necessary" as far as the ambulance went was determined by US... the medical professionals operating the ambulance. We either said it was medically necessary, or we didn't. Ditto for the docs in the ER. Easily 90% of the medicare/medicaid recipients I picked up fell into the NOT medically necessary category. If not more. I'm being kind with that estimate. The only medically necessary medicare/medicaid folks I picked up in the ambulance were either heart attacks or car accidents. The rest of them were hypochondriac, attention seeking ****ers using the ambulance as a taxi service. I applaud Medicare for letting the medical professionals decide what was actually medically necessary and what wasn't (about the ONLY thing I will applaud them for) and I am glad they deny a ****load of claims because of it. However, it's too easy to get around... it was too easy for ambulance personnel to just simply lie and state that it WAS medically necessary.
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From my understanding of Title 18 it's the Secretary of Health and Human Services and consultation boards which make the determination of benefits one will be entitled to:

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.

But are you seriously suggesting that elderly people who are far more likely to actually be sick are actually the ones coming in more often for treatment that is not medically necessary? I highly highly doubt it and in fact I'd be willing to bet my bottom dollar that they are being denied quality of life, and life extending treatment which will be exactly what happens to the rest of us once the fascist statist bastards in power take our healthcare out of hands of the private sector and into their own iron fists.

And furthermore; why in the hell would ambulance drivers be more willing to lie for people with medicare insurance than they would for people with private insurance? Your statements do nothing to diminish the point made in the OP and that is that all private insurance companies combined deny less claims than medicare when the Dem statists continually make opposite assertions about those evil private insurance companies.
 
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Agent Ferris said:
But are you seriously suggesting that elderly people who are far more likely to actually be sick are actually the ones coming in more often for treatment that is not medically necessary?
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In my experience, yes. Medicaid AND Medicare folks.


And furthermore; why in the hell would ambulance drivers be more willing to lie for people with medicare insurance than they would for people with private insurance?
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I wasn't willing to lie for any of them. Which is why I stopped working there. I was required by my employer to lie in order to keep my job, so I quit.

As for why they did it more for Medicaid/Medicare than private insurance... I'll give you a couple reasons. The main reason being that very, VERY few private insurance or self-pay folks ever abused emergency services. Those actions were almost exclusively Medicaid and Medicare ****tards. Because, well, you know... it was "free" for them.

Second reason is that it was easier to fool Medicaid and Medicare with simple terminology differences. Private insurance wasn't as gullible.

Last, Medicaid/Medicare denied more claims in general and were harder to get their money from in general. So anything the company could do to ensure that Medicaid/Medicare would actually pay, they would do.

Not to mention the fact that the vast majority of our passengers were Medicaid/Medicare recipients.


Your statements do nothing to diminish the point made in the OP and that is that all private insurance companies combined deny less claims than medicare when the Dem statists continually make opposite assertions about those evil private insurance companies.
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I wasn't trying to diminish that point. Someone asked what could be deemed medically unnecessary and I provided answers. I am NO advocate of Medicaid/Medicare.
 
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