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Health insurance claim denial rates range from 13% to 35% by insurer

randalolson.com

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Re: Health insurance claim denial rates range from 13% to 35% by insurer

#51

Post by bonsai_spool »

FireBeyond wrote: post #41
bonsai_spool wrote: post #32

Earlier quoted context omitted.

> Doctors are incentivized to prescribe treatments, because that's how they make money for themselves and their practice. This is literally illegal! Physicians cannot refer patients to entities they own or have an interest in. What is perverse is that, while we have the Stark Law to constrain physician behavior, we've decided that it's okay if a diffuse group like a non-physician-owned hospital chain enforces rules t…

Diagnostic imaging companies - each of the big ones (Siemens, GE, Philips) all offer in-house financing on very favorable terms for MRI, CT, etc., that they specifically advertise to physicians. They also all offer specialist consulting help to facilitate you getting a CoN (Certificate of Need) for your facility. Hell, they also will help you find other physicians in your area who'd like to go in with you on setting…

Everything above is fair, if true. I don't see a reference in your answer so I can't assess the quality of evidence.

The point is that they cannot refer you to one of their companies. Of course, there may not be a meaningfully-competitive local market, so patients may end up needing to go to the physician-owned imaging facility. I do not thing this is a large issue for most of the US population though it's probably an issue on a spatial basis.

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#52

Post by claw-el »

FireBeyond wrote: post #49
eightysixfour wrote: post #36

Earlier quoted context omitted.

Again, this is already happening. Hospital side care providers use systems which optimize for expected payout value. That increases payout totals and insurance costs for everyone. The ACA tried to make health outcomes a part of the calculation for everyone involved but it is hard to compete with the all mighty dollar.

"Repricers" work on both sides of the equation - providers and provider networks use them to maximize the procedure codes around an ICD-10 diagnosis code. And insurers use them to minimize the list of procedures they'll accept and pay for around a given ICD-10 code.

Honestly, if this means a more certain payment confirmation up front and not a surprise bill, I see this as a good thing for patients.

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#53

Post by amanaplanacanal »

s0ibeanz wrote: post #14

What we have today isn't insurance in any meaningful sense. Traditional insurance is about pricing risk: healthier people pay less, higher-risk people pay more, and the pool works because premiums reflect actuarial reality. The Affordable Care Act largely banned that. Insurers can no longer use health status or pre-existing conditions to set rates (via "community rating" and guaranteed issue rules). The result is tha…

It makes sense. People don't want insurance, they want health care.

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#54

Post by recursivecaveat »

It seems kind of silly to tout the 5% "not medically necessary" line when 7 times as many were denied for "a reason the insurer never specified". I wouldn't really describe claim denials for reasons like administrative or missing referrals as value neutral either. These are roadblocks controlled by insurers that waste patient and provider time, and reduce access to care.

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#55

Post by dghlsakjg »

mullingitover wrote: post #47
dghlsakjg wrote: post #30

Earlier quoted context omitted.

Obama proposed and pushed for single payer and it was voted down in the senate. Specifically, if you want to blame someone, it was Joe Lieberman who would have been the deciding vote, and he killed it. Joe Lieberman realized that he was from a state with massive moneymaking insurance operations. Had nothing to do with Obama streamlining bureaucracy.

> Specifically, if you want to blame someone, it was Joe Lieberman who would have been the deciding vote, and he killed it. I too believed that Joe Lieberman sucked, and sure, he did. However: there's a pattern of parties creating convenient designated villains within the party (usually someone not up for re-election) who can take the blame for doing the thing the party insiders planned to do all along. It's been esp…

Maybe it’s a massive insider conspiracy to have the party ruin its own landmark legislation of the era and all of the coconspirators have kept their mouth shut on a major scandal for more than a decade.

Maybe it was the 1.1 million dollars in donations from the healthcare industry to Joe Lieberman.

We may never know.

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#56

Post by beej71 »

naturalmovement wrote: post #45
beej71 wrote: post #17

When I went to an in-network ENT (that I found on my insurer's website) they were billed $850 for my 10-minute exam. The insurance said they'd pay $550. So I got to pay the rest. And this is gold coverage with an already-met deductible. You just never know what the roulette wheel is going to hand out. Makes me think of that study a few years ago that found most Americans couldn't afford an unexpected $400 medical bil…

You may have had 10 minutes face-time with your doctor, but he spent time before your exam reviewing your case, and time afterwards dictating the notes. So likely 30-40 minutes was spent on you and this does not include the nurses and front desk support staff, the janitor cleaning the toilets, all who need a living wage, rent and/or property tax for the facility, facilities maintenance and upkeep. Not to mention the…

I didn't assert the doctor was pocketing it all out that there weren't other expenses. But if it costs $850, I'd like insurance to pay $850.

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#57

Post by beej71 »

EtienneDeLyon wrote: post #24
beej71 wrote: post #17

When I went to an in-network ENT (that I found on my insurer's website) they were billed $850 for my 10-minute exam. The insurance said they'd pay $550. So I got to pay the rest. And this is gold coverage with an already-met deductible. You just never know what the roulette wheel is going to hand out. Makes me think of that study a few years ago that found most Americans couldn't afford an unexpected $400 medical bil…

Did you try looking for a less-expensive ENT?

I did not, but in my experience it's difficult to pry prices out of medical providers in advance.

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#58

Post by beej71 »

memcg wrote: post #39
beej71 wrote: post #17

When I went to an in-network ENT (that I found on my insurer's website) they were billed $850 for my 10-minute exam. The insurance said they'd pay $550. So I got to pay the rest. And this is gold coverage with an already-met deductible. You just never know what the roulette wheel is going to hand out. Makes me think of that study a few years ago that found most Americans couldn't afford an unexpected $400 medical bil…

What insurance company do you use? I thought that in-network means the provider has agreed to accept the insurers usual and customary rate and that you are not liable for the difference.

This was Providence in Oregon. I thought that's what it meant, too. But in this case there's a contracted "allowed amount" that is all the insurance will pay the doctor. If the doctor chooses to charge more, you get to pay that.

Which really freaks me out. If you're insured at a contract rate of $5000 and they bill $30,000...?

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#59

Post by mullingitover »

dghlsakjg wrote: post #55
mullingitover wrote: post #47

Earlier quoted context omitted.

> Specifically, if you want to blame someone, it was Joe Lieberman who would have been the deciding vote, and he killed it. I too believed that Joe Lieberman sucked, and sure, he did. However: there's a pattern of parties creating convenient designated villains within the party (usually someone not up for re-election) who can take the blame for doing the thing the party insiders planned to do all along. It's been esp…

Maybe it’s a massive insider conspiracy to have the party ruin its own landmark legislation of the era and all of the coconspirators have kept their mouth shut on a major scandal for more than a decade. Maybe it was the 1.1 million dollars in donations from the healthcare industry to Joe Lieberman. We may never know.

> Maybe it was the 1.1 million dollars in donations from the healthcare industry to Joe Lieberman.

Frankly Joe should've been furious about how little he received, then:

> Campaign finance: The key players in the crafting of Obamacare were largely dependent upon health industry corporations for election and re-election. Barack Obama received $22.4 million in 2008, and the health sector was his third-most-important source of corporate donors (health industry donations alone were thirty-two times greater than all labor union contributions to Obama). The twenty-three members of the Senate Finance Committee (SFC) received nearly $16 million in 2008 and $20 million in 2010. Since 2003, the Committee’s Chair, Max Baucus, had received $3.4 million, or 23 percent of his total campaign donations; the minority leader, Republican Charles Grassley, had received $2 million. Committee members’ opposition to a “public option” that would compete with private insurers tended to correlate with donations from the health industry over the previous two decades.27 The structure of the electoral process thus guaranteed the presence of health industry loyalists in key Congressional offices.

Source: https://newlaborforum.cuny.edu/2014/10/01/healthy-wealthy-an...

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#60

Post by FireBeyond »

bonsai_spool wrote: post #51
FireBeyond wrote: post #41

Earlier quoted context omitted.

Diagnostic imaging companies - each of the big ones (Siemens, GE, Philips) all offer in-house financing on very favorable terms for MRI, CT, etc., that they specifically advertise to physicians. They also all offer specialist consulting help to facilitate you getting a CoN (Certificate of Need) for your facility. Hell, they also will help you find other physicians in your area who'd like to go in with you on setting…

Everything above is fair, if true. I don't see a reference in your answer so I can't assess the quality of evidence. The point is that they cannot refer you to one of their companies. Of course, there may not be a meaningfully-competitive local market, so patients may end up needing to go to the physician-owned imaging facility. I do not thing this is a large issue for most of the US population though it's probably a…

> Of course, there may not be a meaningfully-competitive local market, so patients may end up needing to go to the physician-owned imaging facility.

Certificates of Need. A legal requirement in most states for creating a new healthcare facility. Ostensibly to make sure that the population in that area has adequate healthcare options. But lobbied for by healthcare facility and hospital owners, it actually surveys other providers (your competitors) in the area and asks if their revenue would be adversely affected by you opening up. Too much of this, and no CoN for you.

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