[oramar]

http://www.post-gazette.com/pg/07334/837893-28.stm

[azhiker96]

insurers have systematically denied and delayed payments and claims that are rightly owed to the doctors, or under-reimbursed the physicians.

I don't blame the docs and am glad they won. If employers delayed paychecks to nurses or payed us less than our agreed upon wages I bet we'd be talking to lawyers too!

[oramar]

I am positive they do that. Hold back on payments, deny payments when they know claim is legit.

[ingelein]

If these health insurance companies are so bold as to deny payments to docs, than how much bolder are they when denying benefits to their clientele? All the more reason to get the private health insurance racketeers out of our healthcare.Makes me think of that cartoon Viking has posted showing a huge room full of insurance company workers denying thousnands of people.

[morte]

had a dental insurer drag their feet on paying a bill, have a nurse friend who works in ins...she told me they commonly delay, even a month puts a lot of "interest" in THEIR pockets.....soooo i called them, explained that the bill had been repeatedly submitted with the required documentation (this office was very money oriented) and i KNEW exactly what they were doing, and it had best stop....the bill was paid....also had a provider BILL me for a CT scan 15 days after it was done....at first i thought my insurer had declined to pay....not the case it hadnt been processed thru yet...same friend told me a thirty day turn around was very good, 15 wasnt ever going to happen....called the provider and read them the riot act....told them i viewed that as attempting to get paid twice (how many older folk do you know that would pay a bill on receipt, providing they had the money) even commented i had thought of reporting them, they werent too happy with me, either.....and generally i am very easy to get along with, but cant stand liars and cheats

[Dental Hygienist]

I'm 99% sure that dental insurance companies systematically deny claims. If they don't flat out deny it, they will stall stall stall so as to sit on the captial and make interest. Dental insurance is a HUGE joke and waste of money. First of all, most plans have a yearly maximum of $1,000-$1,500 and yet the yearly premiums are almost that much! Then they'll fight tooth and nail to not have to pay it out in legitimate claims!

One of their favorite tricks is to "request more information"...because legally that buys them time. there are laws in place that regulate how quickly they must pay a legitimate claim; but they can get around that by "requesting more information" repeatedly and buying them another 30-90 days each time they make such a request. (depends on state laws)

It is getting to the point that nearly all claims other than routine cleanings and diagnostics they are "requesting more information" such as an x-ray or periocharting or narrative...it's not because they actually CARE about this info...infact sometimes it has nothing to do with the procedure being claimed...it's just a ploy to buy time and discourage the provider and subscriber from pursuing the claim. We've caught on and start automatically sending an x-ray with each claim. Half the time they'll still send back a written request for the x-ray we already sent them!

I guess they figure that a certain amount of people will just give up on getting the claim paid, and for those that they indeed have to pay, well at least they got to earn interest on that money for a little while longer.

I attended a seminar by a dentist who was so frustrated with ins. that she closed her practice and went to work for a dental ins. co as a clinical expert. She said that she actually got financial incentives for DENYING claims and that she made more money denying claims than she did from performing dentistry! her conscience eventually got the better of her and she took her knowledge of the ins. industry and went and opened another practice and was much more successful the second time around because she had learned "how to play the game"

The whole thing is just sickening. I think ins. cos should be sued more, not less. They raise premiums while systematically withholding payment? I smell a rat!

[ingelein]

And to think that some still cling to the idea that private health insurance corporationss are more trustworthy than our own government, not the present government, I dont trust them either.

[sheluke]

I hesitate to do this...but every story deserves to have both sides told. And I have no doubt there are some ins co who push the limits or even bend & break the rules in the name of making $.

HOWEVEr-believe it or not, there are some private companies who are in it trying to do the right thing, trying to look out for the best interests of the 'members' (patients) and believe they can balance fiscal responsibility with good health care, or at least have nurses & doctors on staff working very hard to accomplish this goal.

Nurse for over twenty years, and spending a few years on the ins side of a managed care company, I learned a whole new vocabulary, philosophy, you name it! But also fortunately, was working in a company that believed in challenging it's staff to be more productive, set goals for both accuracy and speed of processing, and supported an all nurse staff within the pre-certification and med management segments. Very challenging, tough to actually follow all the FBPA while not infringing on the separate set of rules in place by the State Bureau of Insurance, who often differed from the Office of Personnel Management (for anyone who has Federal coverage), or the state medicaid or the Medicare rules!
But the typical reasons for denial were 1. not a benefit (that's usually cut & dried, you either have it or you don't and if you don't, it's not the ins co fault, it is your employer who chose which benefits to purchase; 2. medical necessity (usually these are the ones requiring more info, and hopefully justified as well-for example a hysteroscopy may be for infertility or for other medical reasons; if requested by the areas leading infertility specialist and the patient has no fertility coverage, additional info may be needed to show a 'medical condition')
or 3. billing/coding issues-if a doctor sends in a claim with a diagnosis of abdominal pain but the procedure code is for an ankle x-ray, yeah, gonna question that! Or a physician gets the authorization to nasal septal perf repairs or septo for deviated septum then lo and behod bills for the rhinoplasty gonna want to see if that extra code was justified or just because "while we're in there, we can fix that bump and tip".

A lot of people don't realize if all of things were "just paid for" it would drive up premiums even more and just add to the decline of our health care system. As a consumer, who pays premiums too, I want to know that someone is doing some sort of audit to determine that everyone else who pays premiums into my 'pot' (my employer group) is getting services we actually are paying for and not cosmetic or not covered benefits, as well as watch out for those very few providers who have been known to milk the system a bit for their own $.


Just another perspective-it was truly fascinating learning the insides of insurance! Multi faceted, with as many goods and bads as anything else.