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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

#341

Post by olliej »

throw737away wrote: post #316
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.

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

A superior outcome by what measure? Non-treatment with a cheaper life insurance payout than cost of treatment is "superior". Treatment with a worse long term outcome that is cheaper overall is "superior".

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

#343

Post by nobodyandproud »

alphanullmeric wrote: post #304
nobodyandproud wrote: post #292

Earlier quoted context omitted.

> 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. No, I won’t be forced. I’ll just get shouted down by anonymous accounts just like the cancel culture of the left. You think complacency is patriotism. I actually would prefer to improve my country. > So it’s not unsurprising that your attempts at forcing others to pay for y…

Law enforcement and military exist to prevent you from using force on others, and others from using force against you. You're absolutely correct, I'm in favour of forcing you to not use force on others. The only positive right I believe in is the enforcement of negative rights. Alternatively, I simply state that we both agree on law enforcement and military but not healthcare, so at a baseline you want to force other…

> Law enforcement and military exist to prevent you from using force on others, and others from using force against you. You're absolutely correct, I'm in favour of forcing you to not use force on others. The only positive right I believe in is the enforcement of negative rights

I specifically also mentioned highways. How does that fit into this narrative?

> Alternatively, I simply state that we both agree on law enforcement and military but not healthcare, so at a baseline you want to force others to pay for more things than I do.

I’m already paying for your care, so I’m paying for more than my fair share.

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

#344

Post by flangola7 »

ridgeguy wrote: post #256
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.

"For every complex problem there is an answer that is clear, simple, and wrong." - H. L. Mencken Even a moment's thought about the power disparity between an insurer and an individual facing medical problems leads me to conclude your "simple solution" has little to recommend it.

I have no idea what you're trying to say.

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

#345

Post by cameronh90 »

kwhitefoot wrote: post #246
speedgoose wrote: post #227

Earlier quoted context omitted.

The Norwegian public healthcare is great. The default recommendation to most health issue is to do more sport. Being very physically active usually helps, so it’s not a bad recommendation. You may experience more pain compared to some other healthcare systems. Like France from my experience and probably USA from what I read. I had some unforgettable experiences in Norway, such as a colonoscopy without sedation or ana…

> I had some unforgettable experiences in Norway, such as a colonoscopy without sedation or anaesthesia in case I can tolerate the pain. What pain? I have had a colonoscopy without any sedation, also in Norway. It was uncomfortable, occasionally very, but I wouldn't have called it painful. I think you must have encountered an incompetent doctor. Can't imagine why you would want general anaesthesia unless it was stric…

Arguing over whether something is painful or merely very uncomfortable seems like splitting hairs.

That said, I had a colonoscopy with alprazolam and fentanyl, and it was, if anything, a moderately enjoyable experience. There was the odd slightly painful moment as they went round corners, but the drugs made me feel great throughout and I walked home afterwards with a mild afterglow.

However, while I personally certainly wouldn't have requested general anaesthesia, I think it should be down to patient choice. I'm from the UK, and we often take a clench your teeth and bear it attitude to patient suffering, which I think can often be borderline inhumane. Ultimately if a patient wants to accept a 0.001% chance of dying to avoid experiencing pain or discomfort, mental or physical, that is up to them. You also have to consider the second order effects of people avoiding treatment due to fear of pain, as well as people who may have been raped or otherwise have very valid reasons to not want to experience having something inserted into their rectum.

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

#346

Post by throwawaylinux »

conductr wrote: post #323
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.

This alone should be grounds for a class action lawsuit. It’s ridiculous they do this in an obviously automated way. If they want to raise the bar on requirements of “submitting a claim “ that’s fine, our healthcare admins can figure it out. But patients should be allowed to be dragged through the mud like this.

It's funny when it comes to the law including civil disputes, us commoners are always told "oh no the judges look at the intent behind the deal, and consider what a reasonable person would expect" when it comes to explaining why bank errors and such don't work in our favor.

No reasonable person would ever enter into a contract for health insurance with a company that would reject their claim after a doctor looks at it for literally 10 seconds, but apparently when it comes to the big end of town, the exact letters of the law become much more important.

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

#347

Post by olliej »

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…

It can be. You make it a public service. Much like roads, public health a "loss making" industry, so the options are "a public service that treats everyone" or "a for profit industry that works to avoid treating people while charging as much as possible".

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

#348

Post by olliej »

javajosh wrote: post #156
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…

>Why can't healthcare be fixed? Because doctors and patients won't fix it. Doctors can charge whatever they want. They could see more patients, charge less, and charge cash. They could do their own diagnostics during the visit. People from other countries will be shocked to know that US doctors never do their own diagnostics, and instead refer patients to other providers, which require their own payment and paperwork…

No doctors cannot charge whatever they want. They can charge what insurance companies specify.

Doctors in other countries don't do their own diagnostics: a GP isn't a radiologist, isn't a microbiologist, isn't a lab technician, etc.

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

#349

Post by sveiss »

theGnuMe wrote: post #251
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…

>Insurance was Aetna and Hospital Self Insured Does this mean that the hospital self-insured and provided the surgery? As in why have Aetna involved at all then?

This is common for medium or larger companies.

Instead of paying monthly insurance premiums, the company directly funds the claim payments as they come in. They outsource the work of adjudicating claims, negotiating with providers/facilities, cutting checks, setting approval criteria and first level appeals to another company, called a Third Party Administrator.

Now, who happens to have all the skills and expertise to do the job of a TPA? The big health insurers. These are giant companies with many lines of business. One of those lines is selling insurance to individuals and small businesses, another is selling administrative services to larger ones.

Note that even with a self-insured plan, there’s often insurance involved too: the company will buy a separate “stop-loss” policy that kicks in and starts paying after the employer has paid out a certain amount in total over a year. This protects them from the risk of covering a plan member with a particularly expensive condition.

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

#350

Post by pyrelight »

adrr wrote: post #293
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…

What do you mean by fixed? Affordable? That means we would have to lower medical professional income and we have a shortage of them. Insurance have tried to push down their rates but they just stop taking insurance so we have to pay more to see a decent doctor. We could be more punitive to insurance companies for denying claims but the cost of insurance would become even higher. There is no easy fix.

I doubt you'll find many other industries that have as many unnecessary employees as you would in healthcare.

Given that they're for-profit, they have every incentive to hire as many people as possible to answer phones and create a bureaucratic nest of people who go to work to literally make it hard to use the insurance you're paying for.

Compare to car insurance, where many companies tout how "easy" it is to file a claim, and in most cases it is pretty easy to get your car fixed, get a rental car in the meantime, and get back on the road in a few days. Everybody in the process gets paid, you can shop around every 6 months for cheaper rates, etc. By all accounts, car insurance is profitable.

If healthcare was made simpler, with standard prices for procedures across all hospital systems and insurance carriers, and actual doctors who aren't of the same caliber of the ones prescribing Viagra from some random site in Albania, we could start to fix the system.

As it stands now, and I'm sorry for the people involved who work these jobs, but if health insurance reduced it's bloat of unnecessary workers, many of whom go to work to specifically answer calls from people whose claims are denied, we could lower costs, cover more people's procedures, and keep physician pay the same.

As it stands now, nurses do most of the work in the healthcare system, whether it's in the doctor's office or in the hospital, and unless you're in a niche field of nursing, they get paid less than an entry level PHP developer.

A nurse can lose their license if they make a horrible mistake at work. Hospitals see nurses are replaceable and that's why many of them burnt out during COVID when staffing ratios were thrown to the wayside, raises and department transfers were halted, and techs and other low-skilled nursing positions were eliminated, increasing the burden on RN's.

It's not correct that in order to lower healthcare costs, we have to lower physician pay. Healthcare is just not a business that can be left to the free market.

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