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Cigna saves millions by having its doctors reject claims without reading them

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Re: Cigna saves millions by having its doctors reject claims without reading them

#261

Post by Scoundreller »

wahnfrieden wrote: post #245
Scoundreller wrote: post #216

Earlier quoted context omitted.

Both public and private systems have "death panels". Though cited article suggests even death panels run by doctors are no guarantee of effectiveness.

The article is not about death panels run by doctors, they are run by insurance companies. The doctors in this scenario are workers given bounded instructions on how to operate by the ones running it, without autonomy on how to organize the death panel decisionmaking. It's in the title - the "having" shows who is in control. These are not worker owned cooperatives. Nor are most state owned death panels.

> doctors

> without autonomy

This is an incredibly poor way to act given that doctors usually have unlimited personal liability, even if they are employees

Re: Cigna saves millions by having its doctors reject claims without reading them

#262

Post by hayst4ck »

nine_zeros wrote: post #249
Centigonal wrote: post #98

Earlier quoted context omitted.

Situations like this are infuriating to me. Our healthcare system needs to have some kind of provision for "this patient needs to be on treatment X probably for life. They are authorized for this treatment and subsequent claims will be approved unless there is a qualifying event (e.g. a recall, condition changes, patient and their doctor switch treatment, etc)." I have UC that's well-controlled with mesalamine, and I…

Here's a simple solution. Insurance HAS to pay if a doctor recommends it. This is what premiums are for. If insurance cannot pay, they can go out of business.

I don't love insurance companies and I don't love the profit incentive they have.

If a patient breaks a leg and a doctor recommends not experiencing gravity for a while, do we fly them to space?

I am using hyperbole to demonstrate a point: there are meaningful economic limits that must be created by some entity and enforced.

What is the value of a human life? The GDP of a nation is a hard upper limit. The total money a particular person in question has access to is the lower limit.

If you run an insurance company (or you run government run healthcare) you can't avoid answering that question with an actual real dollar amount.

At some point spending money on a person with a particular condition does mean that someone else with a different condition can't have money spent on them.

Re: Cigna saves millions by having its doctors reject claims without reading them

#263

Post by borissk »

nine_zeros wrote: post #254
throwawayce wrote: post #96

I work for Cigna, and recently went through cancer treatment. They rejected every scan and treatment until my doctor challenged. My first doctor couldn't figure out how to challenge and it set back my initial treatment. Then last year the CEO did a town hall with a tear jerker clip show about how evicore is helping cancer patients. But evicore is the part of Cigna that kept rejecting my treatment. It was incredibly i…

Brutal. Once you get the treatment and feel better, please share it with your local news stations. This is the kind of story that should take the company out of business.

The local news station probably receives a big part of it's budget and profits from medical ads. It won't run any material that can threaten it's main income.

Re: Cigna saves millions by having its doctors reject claims without reading them

#264

Post by Eric_WVGG »

ClumsyPilot wrote: post #201
kurthr wrote: post #13

Earlier quoted context omitted.

Wife is a nurse. Required surgery for lifesaving/severe disability (inherited congenital, killed her father). Insurance was Aetna and Hospital Self Insured. Surgery recommended by world class surgeon she worked with. Finally pre-approved on 3rd appeal after 8 months and 150pages of documentation of every piece of every single communication (who, when, response, expected next contact) only weeks before surgery schedul…

> Standard answer is we can't tell you why you were rejected (code only) because the criteria are from a third party and their review document is proprietary So you paid for a service, and you don't get the service you paid for, and you will not be told why? If I did this in my line of work, I would be in prison for fraud.

Here’s an example of something that happened to my sister that isn’t exactly the same, but is the same sort of philosophy in action.

My sister was the manager of a coffee franchise named after a certain character from classic literature. Her location was doing extremely well, she was a competent type-A who commanded a great deal of respect in her entire district, and was generally assumed to on the fast-track for promotion.

One day, $200 was missing from her daily cash. She was fired the next day. Not for the missing money; they came showed her a list of very minor issue (clerical errors, an unwashed countertop on a random inspection, a couple unhappy customer feedbacks) that had come up in her eight-year career, and said she was fired for general incompetence.

Two weeks later, one of her ex-employees called up, crying; she was doing her laundry, and found $200 in one of her pockets. She had gone to the safe to make change for the register and screwed up.

The point here is: corporations understand that you can't fire someone or deny coverage based on reasons that can be contested. It's not fraud if you fire them for some other reason. It's not fraud if you don't even know why you denied coverage. You're only in trouble if you play fair.

We’re Americans and we love this sht and it's no wonder the CEO of that coffee company thought he deserved to be President.

Re: Cigna saves millions by having its doctors reject claims without reading them

#265

Post by AnthonyMouse »

stathibus wrote: post #2

This reminds me of the US patent approval system. There are too many claims to properly vet them all, so just "click and submit" and only put effort into the ones that come back to complain. (Except the PTO is biased toward approval and not rejection, of course.)

Not exactly. The US PTO rejects a large proportion of patent claims. It can be quite expensive / time consuming to get a US patent as an individual inventor. But you can appeal the rejections, and large corporations and patent trolls have staff attorneys who do that all day long, so then tons of garbage patents get approved too.

Re: Cigna saves millions by having its doctors reject claims without reading them

#266

Post by jc_811 »

Wow. This is almost the exact plot of The Rainmaker by John Grisham[1] that came out in 1995:

“Rudy uncovers a scheme by Great Benefit to deny every insurance claim submitted, regardless of validity. Great Benefit was playing the odds that the insured would not consult an attorney. A former employee of Great Benefit testifies that the scheme generated an extra $40 million in revenue for the company.”

[1] https://en.m.wikipedia.org/wiki/The_Rainmaker_(novel)

Re: Cigna saves millions by having its doctors reject claims without reading them

#267

Post by thallium205 »

borissk wrote: post #260
thallium205 wrote: post #253

Insurance companies deny medical necessity claims because the procedure and diagnosis code combinations don't align with what is pre-determined to be medically necessary. One of the big reasons why this happens that nobody ever talks about is because the doctors office does not code the claim correctly and it gets denied. The patient is pissed and blames the insurance company, the doctor is pissed and blames the insu…

All right, US insurance companies deny millions of valid claims not because of greed, but because "the doctors office does not code the claim correctly". It's just an unforeseen side effect that said insurance companies end up with billions of annual profits and patients sometime die... Your post remains me of how Russians often react on their forums to posts regarding the corruption in Russia. There are undeniable p…

I’ve worked in healthcare revenue cycle management for over a decade. If you don’t accurately tell the insurance company what you’re doing and why you’re getting denied. Doesn’t matter if it’s health, auto, home, etc. There are thousands of codes, millions of combinations, and all being mostly hand coded by minimum wage workers. There are constant fuck ups most of which don’t require anyone but a computer to review to know it’s wrong. But okay cool conspiracy.

Re: Cigna saves millions by having its doctors reject claims without reading them

#268

Post by alphanullmeric »

nobodyandproud wrote: post #218
alphanullmeric wrote: post #136

Earlier quoted context omitted.

Nothing to do with patriotism, I just question why supporters of collectivism constantly flee to capitalist countries.

Sounds like misplaced patriotism to me. Not everyone came to this nation due to capitalism. My parents partially came here to be free to say whatever they wanted and not disappear, for instance. It doesn’t mean healthcare is done right; just as using TP to wipe one’s ass is 100 years backward. I sometimes wish they stayed back, because my own life and theirs would’ve probably been much better in the long run.

You’re always free to go back. Unlike many collectivist countries, we won’t stop you from leaving, or try to force you to do things in general. So it’s not unsurprising that your attempts at forcing others to pay for your things is met with hostility when you and others that share your views don’t even want to face those policies themselves.

Re: Cigna saves millions by having its doctors reject claims without reading them

#269

Post by lotsofpulp »

menage wrote: post #184
lotsofpulp wrote: post #150

Earlier quoted context omitted.

Technically, you just need money to pay for it. However, buying the employer’s choice lets you pay for premiums with pre tax funds, and the employer usually subsidizes 70% of the premiums. So for an individual, it is roughly a $10k per year benefit to get it via employer and for a family of 4, $40k per year benefit.

That's not true. As I discovered when my COBRA ran out recently, finding individual plans that match the coverage of employer plans is very hard or impossible, regardless of how much you're willing to pay.

I’ve always been able to find the same or similar BCBS plan my employers offer on healthcare.gov. If it has the same metal level (platinum/gold/silver/bronze), it should be the same actuarial value.

Only thing that Carrie’s

Re: Cigna saves millions by having its doctors reject claims without reading them

#270

Post by stochastastic »

TedDoesntTalk wrote: post #258
anonuser123456 wrote: post #215

Earlier quoted context omitted.

The sneaky thing to do is have your attorney send a letter to the insurance carrier's liability insurance provider, detailing everything you uncover and that they will be on the hook for the malpractice claim. That will get you an highly aggressive advocate with teeth.

What is a liability insurance provider? Are you saying Cigna and other medical insurance companies have insurance themselves?

Yes, they typically will buy insurance to deal with risks outside their core business (like the health insurer having liability coverage).
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