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

propublica.org

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

#311

Post by CaliforniaKarl »

hayst4ck wrote: post #262
nine_zeros wrote: post #249

Earlier quoted context omitted.

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…

That's why it's better to have everyone covered under insurance, so that the risk pool is larger, and the cost to the individual is lower.

That's why it's important to spend money on research; to develop new technologies and techniques, and improve existing technologies and techniques; that can make cost of care lower.

That's why it's important to have standards of care and treatment, for all medical providers to follow.

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

#312

Post by LBJsPNS »

hayst4ck wrote: post #262
nine_zeros wrote: post #249

Earlier quoted context omitted.

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…

Cry me a river when paying claims keeps insurers from turning a profit. They brought all the contempt heaped on them upon themselves.

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

#314

Post by danielschonfeld »

stouset wrote: post #69
blakesterz wrote: post #5

“We thought it might fall into a legal gray zone,” said the former Cigna official, who helped conceive the program. “We sent the idea to legal, and they sent it back saying it was OK.” Reading this article is just maddening. I've been dealing with different insurers for the past 7 years or so, and it's my experience they must all do something similar. Anyone with any kind of serious health condition is regularly driv…

Counterpoint. I have an Aetna PPO and experienced a stroke last year. $100,000+ hospital stay and insurance just… covered it. I paid $1,100 out of pocket. I had a $100,000+ surgery a few weeks ago to repair a heart issue that may have led to it. They just covered it. No fuss, no hassle. I paid $3,300, which was the remainder of my total annual out-of-pocket, and now I will pay $0 for healthcare for the rest of the ye…

And the cost of your Aetna PPO per year?

Also this is anecdotal. I too have an Aetna PPO and can tell you of horrid stories and countless hours on repeated phone calls with them.

Not saying you just did this (you obv did not) but as a whole in this country we need to start dropping the “it didn’t happen to me so something must be wrong with you” mentality. It is pervasive in the healthcare topic and unfortunately in many other facets of American life.

Germans in WWII that enjoyed the fruits of the regime have sang its praises - that didn’t mean the war machine on the whole wasn’t decimating the people and their country. We shouldn’t lose focus of how our country is being decimated by our collective ineptitude.

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

#315

Post by thallium205 »

darrin wrote: post #309
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…

If all insurance companies published all the code combinations covered for every procedure/diagnosis, I might buy this argument. But they don't. I've asked Blue Cross and they said they don't disclose those details. Many billing codes are open to some interpretation. So if insurance companies aren't transparent about what codes are or are not covered, why are the doctors' offices at fault when something is denied? Wh…

They aren’t allowed to publish them.

And they do use denial and remark codes to indicate the services don’t justify the diagnosis.

https://x12.org/codes/claim-adjustment-reason-codes

https://x12.org/codes/remittance-advice-remark-codes

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

#316

Post by throw737away »

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…

That is sick. I'm sorry.

I remember that town hall.

I know people at evicore. Some of them even seem to take pleasure in the fact that patients and doctors call them EvilCore.

They're very convinced that evicore delivers superior outcome at lower cost.

I quit Cigna late last year. Couldn't take the place anymore.

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

#317

Post by dennis_jeeves1 »

dilap wrote: post #310
davidw wrote: post #272

Earlier quoted context omitted.

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.

Gunna take something a lot more radical than that.

guillotine.

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

#318

Post by cscurmudgeon »

resoluteteeth wrote: post #181
cscurmudgeon wrote: post #174

Earlier quoted context omitted.

[flagged]

That just shows that the us has good medical treatment for people with essentially infinite money who don't have to worry about cost or insurance coverage so they can bypass the kind of issue the article is talking about entirely. For normal Americans who actually have to worry about these things, healthcare in the us is a nightmare. You can't just ignore insurance and judge the us healthcare system based on the best…

> That just shows that the us has good medical treatment for people with essentially infinite money who don't have to worry about cost or insurance coverage so they can bypass the kind of issue the article is talking about entirely.

No, that shows that even in places with public healthcare, there are issues.

Universal public health care is not the utopia that its proponents religiously advocate for.

> You can't just ignore insurance and judge the us healthcare system based on the best hospitals and doctors when most Americans aren't going to have access to that.

Most Americans have insurance. You can't ignore real data. Are you from the US?

https://sgp.fas.org/crs/misc/IF10830.pdf

Only roughly 8% are uninsured.

> , healthcare in the us is a nightmare

Compared to the rest of the world? It is not.

US is not the top, but within the top 20.

https://worldpopulationreview.com/country-rankings/best-heal...

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

#319

Post by dennis_jeeves1 »

camhart wrote: post #73

Why can't healthcare be fixed? I'm self employed, pay a crap ton of money for "good" insurance, and it's horrible. It's very difficult to find good doctors in network. Everything gets rejected from insurance and the Dr has to appeal it multiple times in order to sometimes get them to budge. It's absolutely broken, and even more so for those on individual and family plans (ie not through an employer). Last year I was…

A true free market is when anyone should be allowed to practice medicine including your barber. That would give your regular doctor a run for their money and have them perform better that the barber.

Similar goes for pharmaceuticals, a true free market does not exist.

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

#320

Post by Qem »

anonuser123456 wrote: post #215
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…

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.

How does one discover what is the insurance carrier's liability insurance provider. Is that public information?
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