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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

#351

Post by magicalist »

roenxi wrote: post #339
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.

Is "not perfect" strong enough criticism if people are being covered by services that do nothing? Today's article is saying that that large insurers might just be rejecting claims without reading them. Without the ACA, presumably money wouldn't be being spent on companies that literally just take the money for compliance reasons then don't provide a service. This is one of the more annoying failure modes of socialise…

> Is "not perfect" strong enough criticism...

Absolutely pick a different phrase, but it'll still have applied before the ACA and it'll apply after except for people with preexisting conditions, eliminating lifetime caps, and maximum out of pocket limits.

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

#352

Post by 1123581321 »

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…

I get your example is hyperbole, but just for fun: the space flight would be recognized as an experimental treatment since it’s known not to be a routine/established procedure. Expenses would be covered if a legitimate clinical trial of space flights were being conducted. Otherwise, costs would be out of pocket unless a special approval were granted. If space flight were being seriously studied for an extremely rare disease, it would likely be paid for by the research institution.

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

#353

Post by magicalist »

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…

> Now that's an issue I don't see in the article. How many claims were wrongfully denied?

Well gee, to actually estimate that you'd need a medical expert to review the claims.

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

#354

Post by [deleted] »

karmelapple wrote: post #162
rqtwteye wrote: post #123

Earlier quoted context omitted.

I am from Germany and agree that US healthcare is very shiny. But once you get sick it’s very easy to get stuck in an extremely expensive bureaucratic nightmare between hospitals and insurances. I prefer the German system where I can go to a doctor or ride an ambulance without the fear of having to pay tons of money.

The German healthcare system was surprising to me. It was affordable, it was fairly honest, and our anecdotal experience was not as good as most experienced we’ve had in the USA. A few examples for those wondering: * the total cost for over a week stay was a couple hundred dollars - very affordable! * certain painkillers banned in the USA were the first line of defense there * getting very strong pain killers was nex…

[deleted]

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

#355

Post by IG_Semmelweiss »

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…

Not only the automation is a problem. Cigna is the only one that knows the rule set.

This forces the patient or biller to try out multiple combination of codes until he strikes told. This is why healthcare is so expensive. Remove cpts and icds and the admin overhead syatem goes away

But that requires insurances to be there for catastrophic care only (I.e. reverse lottery) , and this is not palatable with the govt crowd

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

#356

Post by xwdv »

mdorazio wrote: post #238
xwdv wrote: post #153

Earlier quoted context omitted.

Post COVID hospital in Ohio, limped in with severe ankle sprain, got doctor in less than 15 minutes and out within an hour with splint and crutches. Even got X-Ray.

What city? Most of us in this thread live in larger cities. When I lived in LA and had to go to the ER, the wait was 5 hours and they literally rolled a cart over and made me prepay my insurance deductible (several hundred dollars) before a doctor even saw me. Helped a friend get to the ER in Phoenix and it was about 3 hours.

Cleveland

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

#357

Post by dragonwriter »

01100011 wrote: post #273
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!

They are already being autodenied, the human is in the loop only for superficial compliance with rules requiring a qualified medical professional “reviewing” before denying.

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

#358

Post by adrr »

pyrelight wrote: post #350
adrr wrote: post #293

Earlier quoted context omitted.

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…

Why isn't Kaiser significantly cheaper? They are non-profit. Whats the difference between PPO and HMO? Maybe 10%?

https://www.kff.org/report-section/ehbs-2022-section-1-cost-...

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

#359

Post by alphanullmeric »

nobodyandproud wrote: post #343
alphanullmeric wrote: post #304

Earlier quoted context omitted.

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 enf…

Highways are no different from healthcare. I don't care if the government does them. You use it you pay for it.

You have no idea how much I make, which your claim entirely depends on. You also don't seem to be reading very carefully, I'm stating what I believe should happen. I would like people to be forced to pay for less things. You would like people to be forced to pay for more things. Simple as that.

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

#360

Post by IG_Semmelweiss »

d1str0 wrote: post #170
theGnuMe wrote: post #124

Earlier quoted context omitted.

There's some doc on twitter who was denied by insurance and he filed a board complaint against the insurance doc claiming malpractice. I think he won.

Know any more details? This seems rather promising.

the claim denier worked for insurance. he had a complaint on file for entering a hip replacement backwards

the tweeter thread shows devastating images . the point is that a provider like that, has no business denying coverage. plus apparently he was not board cert and other issues from lapses in licensing

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