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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

#271

Post by anonuser123456 »

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?

Every business has insurance, including insurance companies. This is because they specialize in their own business and outsource non-core business.

An insurance provider for a specific industry has teams of skilled attorneys that are expert in that specific domain. Cigna might self insure if they consider medical malpractice a core part of their business. In that case, your attorney sends the letter to their corporate counsel.

Often times, day to day business people just ignore liability risks because it's not in their core mandate. But the corporate counsel is in charge of managing legal risk, and they will see such a situation as unacceptable. Corporate counsels also hold a lot of sway within a businesses structure.

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

#272

Post by davidw »

djbusby wrote: post #241
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.

Lawyers, the best way to get reasonable healthcare in USA. What can be done?

Elect people, starting at the local level, who want to change the system?

That change doesn't have to be 100% or perfect. The ACA ensured that a lot more people got covered, even if it was not perfect.

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

#273

Post by 01100011 »

loeg wrote: post #29

> His claim was just one of roughly 60,000 that Dopke denied in a single month last year 60,000 / 20 workdays in a month / 8 hours in a workday => this guy rejected about 375 claims per hour, on average. Over six claims a minute. He spent less than 10 seconds on each claim, for a full month of work time.

Soon, a GPT/LLM will auto-deny an order of magnitude more than that!

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

#274

Post by hayst4ck »

duxup wrote: post #239
kwhitefoot wrote: post #235

Earlier quoted context omitted.

> there should be some consequences for someone acting as a "doctor" testifying in a court case and having very little clue what was going on, but choosing to testify. It will make no difference. It is the people higher up and the investors in the company who are responsible. The doctors in question don't behave as they do just because they want to, they do it because that is what the company that employs them demand…

I'd like to see the doctor be at least at risk of losing his license. It's a serious profession and should be held to standards.

If you reach out to the medical licensing board and communicated that situation it's not implausible that there would be consequences.

Here is what it is for California:

https://www.mbc.ca.gov/Consumers/File-a-Complaint/complaint-...

https://www.mbc.ca.gov/FAQs/?cat=Complaint&topic=Complaint:%...

  What kinds of complaints warrant a formal investigation?

   In general, any complaint that would warrant disciplinary action if 
   substantiated (e.g., sexual misconduct, gross negligence and/or 
   incompetence, etc.) is referred for investigation. Other kinds of 
   complaints may also require a formal investigation. These include physician 
   impairment, unprofessional conduct and unlicensed practice issues.

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

#275

Post by AnthonyMouse »

dcow wrote: post #126

What would be the problem with requiring all healthcare to be non-for-profit? You can still have it privatized, but you can’t ever be in a situation where you’re trying to maximize profits. Someone poke holes in the idea…

The incentive to maximize profits (i.e. minimize costs and maximize number of customers) is the benefit of a privatized market. The profit-minimizing mechanism is supposed to be competition, because then people switch away from plans that have a poor balance between price and rejecting claims. But because most plans are tied to employers, that part doesn't work.

If you had a non-profit with no competition it would be little different than the government, i.e. susceptible to regulatory capture and with poor incentives to constrain bureaucratic inefficiency.

Non-profits in a competitive market would be better, but so would for-profit insurers in a competitive market. The problem isn't that somebody is making money -- a service is being provided and somebody is getting paid one way or another -- the problem is it's too hard to switch so bad providers proliferate.

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

#276

Post by ClumsyPilot »

Eric_WVGG wrote: post #264
ClumsyPilot wrote: post #201

Earlier quoted context omitted.

> 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 pro…

I understand that, but how is it legal to refuse to fullfil your insurance obligations without revealing the reasons?

Like in US insurance is at will, okay, fine.

But insurance is surely under a legal obligation to fullfill their end if the bargain?

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

#277

Post by css »

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, it's called reinsurance: https://en.wikipedia.org/wiki/Reinsurance

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

#278

Post by dahfizz »

davidw wrote: post #272
djbusby wrote: post #241

Earlier quoted context omitted.

Lawyers, the best way to get reasonable healthcare in USA. What can be done?

Elect people, starting at the local level, who want to change the system? That change doesn't have to be 100% or perfect. The ACA ensured that a lot more people got covered, even if it was not perfect.

The ACA just gave more power and money to these same scummy insurance companies.

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

#279

Post by borissk »

thallium205 wrote: post #267
borissk wrote: post #260

Earlier quoted context omitted.

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 t…

Even if we assume you're right, the way that the system is setup and the fact that there are constant fuck ups, but no effort to fix them are not accidents. Yes, there are conspiracies out there (surprise, most people are not angels) and the US health system is definitely one.

Check out the insurance companies profits. Those are directly linked to denied customer claims. Claims are not denied en-mass, by accident obviously - unless you're a complete fool.

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

#280

Post by ahi »

SapporoChris wrote: post #56
loeg wrote: post #29

> His claim was just one of roughly 60,000 that Dopke denied in a single month last year 60,000 / 20 workdays in a month / 8 hours in a workday => this guy rejected about 375 claims per hour, on average. Over six claims a minute. He spent less than 10 seconds on each claim, for a full month of work time.

"A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments." "Cigna said its review system was created to “accelerate payment of claims for certain routine screenings,” This sounds like simple automation with an error rate that is acceptable by Cigna. Of course it's not acceptable to anyone wrongfully denied a claim. Now that's an issue I do…

They are not legally allowed to automate this. These cases MUST be reviewed by qualified medical personnel.
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