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Guess Who Has the Highest Medical Claim Rejection Rate?

DenialsByInsurer2008.jpg

This image makes me highly suspicious of the claim that 21% of private health claims in California are denied.
 
Really? So if I'm an elderly man who goes to a witch doctor who uses a voodoo doll to try to cure me, there's no excuse for Medicare denying my claim?

Is that really the best argument you can come up with? I mean, no ****, really?



Irrelevant to the subject at hand.

It's very, very, very relevant to the subject at hand. All we've heard, to date, from the Libbos is how government insurance won't deny claims. Obviously that's not true.
 
If you have more sick people, of course it's more likely that more claims will be denied. :roll:

But this is based on claims made and claims rejected and they still have a higher % of rejection. Obviously if you make a medical insurance claim you are sick or injured and if you're elderly you're probably more likely to be really sick and/or injured thus one should come to the conclusion that they should have less of a claim rejection % and yet they have a higher rejection %.
 
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Why would denial of coverage by medicare be based on a different criteria than the denial of coverage for private insurance companies?

Because Medicare bureaucrats, unlike private insurance bureaucrats, don't have to worry about maximizing profits.

Agent Ferris said:
And yet they still deny as a % they still deny claims .5% higher than the worst provider Aetna.

I can think of several explanations, none of which have anything to do with the big evil government wanting to pull the plug on grandma:

1. More fraudulent claims are filed with Medicare then private insurers.
2. Certain claims are specifically excluded from Medicare, but not from private insurers. (In which case it's silly to argue against the effectiveness of Medicare based on these denials, as the easy fix would be to end the exclusion.)
3. If high cost medical claims are uniformly more likely to be denied, then it makes sense that the insurer with the most old and sick people would have the most denials.

Unless you have some evidence that the circumstances of these claims and denials are all identical, you can't draw any meaningful conclusion from the data.
 
Is that really the best argument you can come up with? I mean, no ****, really?

Are you or are you not claiming that there are no circumstances where the government should deny claims? If so, I just provided you with one.

apdst said:
It's very, very, very relevant to the subject at hand. All we've heard, to date, from the Libbos is how government insurance won't deny claims. Obviously that's not true.

You have heard no such thing, and you know it. However, a government plan would be less likely to deny you claims for silly pretexts like an unrelated preexisting condition from ten years prior.
 
If you have more sick people, of course it's more likely that more claims will be denied. :roll:

475,000 sick people rejected and your ok with this???!!!
 
Obviously if you make a medical insurance claim you are sick or injured

That's obvious? I file a claim with my insurance company every time I have a routine checkup. I would imagine that such claims are a larger proportion of a private insurer's total claims than the government's, since private insurers try to avoid covering the old and sick whereas the government specializes in it.

And if insurers are not likely to deny a claim for a routine checkup...well, you do the math. ;)

Agent Ferris said:
and if you're elderly you're probably more likely to be really sick and/or injured thus one should come to the conclusion that they should have less of a claim rejection %

Why? If high cost procedures are most likely to be denied, then the insurer with the highest proportion of high cost claims is the one most likely to deny claims.
 
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Are you or are you not claiming that there are no circumstances where the government should deny claims? If so, I just provided you with one.

You provided a rediculous example. The point is, all we've heard from the Libbos is how claim denials won't happen under government health care. That's an obvious lie.



You have heard no such thing, and you know it. However, a government plan would be less likely to deny you claims for silly pretexts like an unrelated preexisting condition from ten years prior.


You're full of **** and your middle name is doo-doo and you know it. That's exactly what your boy has been saying for months now.
 
Because Medicare bureaucrats, unlike private insurance bureaucrats, don't have to worry about maximizing profits.

Um I would think that maximizing profits would entail denying MORE claims.

I can think of several explanations, none of which have anything to do with the big evil government wanting to pull the plug on grandma:

1. More fraudulent claims are filed with Medicare then private insurers.

I'm guessing that people 65 and older are more likely to be in need of medical treatment.

2. Certain claims are specifically excluded from Medicare, but not from private insurers. (In which case it's silly to argue against the effectiveness of Medicare based on these denials, as the easy fix would be to end the exclusion.)

Which such claims? And even if that's true that would be a check in the negative box arguing for medicare versus private insurance.

3. If high cost medical claims are uniformly more likely to be denied, then it makes sense that the insurer with the most old and sick people would have the most denials.

I'm not aware that you are allowed to deny treatment based on cost. I mean if you have cancer and it's treatable by kemo, should an insurance provider be allowed to deny treatment because it would be cost prohibitive?

Unless you have some evidence that the circumstances of these claims and denials are all identical, you can't draw any meaningful conclusion from the data.

Starting on pg. 11 it gives the reasons why the claim was rejected for medicare and the % of times that reason was given. Cost for the treatment is not listed.

http://www.ama-assn.org/ama1/pub/upload/mm/368/reportcard.pdf
 
That's obvious? I file a claim with my insurance company every time I have a routine checkup. I would imagine that such claims are a larger proportion of a private insurer's total claims than the government's, since private insurers try to avoid covering the old and sick whereas the government specializes in it.

Actually according to pages 10 and 11 on this PDF claim rejections based on routine examination is higher for medicare than for United HealthCare 3.9% versus 2.5% respectively.

http://www.ama-assn.org/ama1/pub/upload/mm/368/reportcard.pdf

And if insurers are not likely to deny a claim for a routine checkup...well, you do the math. ;)

Routine checkup claims are rejected.

Why? If high cost procedures are most likely to be denied, then the insurer with the highest proportion of high cost claims is the one most likely to deny claims.

Again I'm not aware of cost of treatment being a disqualifier in and of itself rather experimental treatment can be rejected and would fall under "type of treatment not covered" category of the list of disqualifiers provided on the PDF.
 
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.

None of what you posted means much unless we know the reason for rejection. For example we ( we as when I was in the corporate world of insurance) would reject a claim becasue the provider sent us the claim but we may not be the primary for that coverage. It very well could be that Medicare is the primary.

There is also dupliucate and double billing which "we" are very good at detecting so that is not a vaild factor to show as a reject.

Your stats show lines of rejection not sure if the comparisons between the companies and Medicare are based on comparibale "lines".
 
You have heard no such thing, and you know it. However, a government plan would be less likely to deny you claims for silly pretexts like an unrelated preexisting condition from ten years prior.

Steven Israel just made that very claim and I quote:

"the days of insurance companies dropping your coverage because you get sick will be over."
 
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.

When I worked for the Aetna we administered one of the major regions of Medicare coverage so are the MEDICARE reject stats included inthe Aetna's totals ?
 
When I worked for the Aetna we administered one of the major regions of Medicare coverage so are the MEDICARE reject stats included inthe Aetna's totals ?

Not sure but even if they were that would make Aetna's actual totals even lower wouldn't it?
 
Hold your horse ferris : NHXS is a company that has an axe to grind. They work and are paid by providers to try and squuees more payment out of "us" the insurance companies. This is from their own website " healthcare providers the advantages they need to recover more revenue and appeal denials more successfully "

See all these people are after "us" insurance companies and want "us" to pay out more.

Therefore they will go and post so called reject rates that are not based on sound principles or most likely skewed against "us" insurance companies.

I was supicious when I saw your initial post now I see that you are quoting a company that is not playing fair since they are playing the game for the provider gainst the insurance companies.
 
Hold your horse ferris : NHXS is a company that has an axe to grind. They work and are paid by providers to try and squuees more payment out of "us" the insurance companies. This is from their own website " healthcare providers the advantages they need to recover more revenue and appeal denials more successfully "

See all these people are after "us" insurance companies and want "us" to pay out more.

Therefore they will go and post so called reject rates that are not based on sound principles or most likely skewed against "us" insurance companies.

I was supicious when I saw your initial post now I see that you are quoting a company that is not playing fair since they are playing the game for the provider gainst the insurance companies.

Um the statistics are based on the AMA's National Health Insurance Report Card which is based on datapulled from the nationally mandated Health Insurance Portability and Accountability Act of 1996. Do you have contradictory statistics or just an ad-hominem logical fallacy?
 
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.

You people out here also need to understand that "we" insurance companies have valid reasons to deny claims and that "we" may deny a claim when first submitted but pay it later when it is sumitted coreectly.

Why do we deny claims?

1- submitted with invalid place of service address such as a PO box for service address. Do people think that "we" the insurance companies are stupid and beleive that a doctor can see patients and perform opeartions in a Post Office Box. - that is a fraud alert
2- wrong tax id of provider submitted
3- claim submitted for DOS date of service not within the policy period
4- submitted with wrong or miss-matched member name
5- submitted with invalid, nonexistent or missing memeber ID number
6- services or drugs are not covered by the members plan
7- provider not in our network
8- provider lost his lisence
9- duplicate claim
10- overlapping billing for claim
11- duplicate line item
12- duplicate procedure billed
13- procedure was billed within another procedure
14- mememer not insured by us
15- claim is for an accident but submitted as a health claim
16- claim is a Workers Comp claim but memeber submitted as health claim
17- claim submitted as a Hospital Claim but procedure is not a hospital procedure
18- clam submitted on wrong form
19- claim is for a nom covered procedure
20- claim submitted for wrong memeber
21- claim submitted for wrong gender e.g hitorectomy charges for a male, or prostate scan for a female
22- claim submitted for an ugly person but we do not process ugly claims on Tuesdays - just joking but who reads such a long list anyways

I was a corporate auditor and now perform auditing as a private consultant so I can keep writing and writing there are almost coountless legitimate reasons to reject a claim.
 
Steven Israel just made that very claim and I quote:

"the days of insurance companies dropping your coverage because you get sick will be over."

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:
 

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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Um the statistics are based on the AMA's National Health Insurance Report Card which is based on datapulled from the nationally mandated Health Insurance Portability and Accountability Act of 1996. Do you have contradictory statistics or just an ad-hominem logical fallacy?

There is no ad hominen or falacy on my part. If your stats are from the AMA you need to understand that they represent the provider and the provider is tring to get us to pay for all that they submitt. If we reject a claim they are not happy. I have not seen the the details of what the stats you posted are from. Are legitimate denials included ?

Just need to vett the accuracy.
 
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:

FROM STICKI WIKI
Congressman NY 2ND DISTRICT :

DEMOCRATIC PARTY
After Rick Lazio left his House seat to run for the United States Senate in 2000, Israel was elected to the House of Representatives as a Democrat. Israel received 48% of the vote, defeating Republican Joan Jonhson, who received 34%, and three independent candidates who received 6% of the vote each
 
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