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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

#361

Post by geerlingguy »

magila wrote: post #42
geerlingguy wrote: post #22

Earlier quoted context omitted.

I have Crohn's disease, and I'm fairly certain dealing with health insurance's ineptitude directly led to multiple hospitalizations and a major surgery last year. Had it not been for their constant denials of a drug I had been on for over two years prior, I might still be taking that medication instead of having developed antibodies for the 6 months they denied. My doctors office gave me free samples as long as they…

I also have Crohn's and am going through this right now. Months of delays and denials for a new drug lead to two hospitalizations. I'm currently on TPN (IV nutrition) while I taper my Prednisone dose as low as possible prior to surgery. The funny/sad thing is: between my hospitalizations, TPN and related home health care, and surgery, this is all going to cost my insurance far more than the drug they were denying wou…

Exactly my thoughts. I can't believe the calculus here.

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

#362

Post by IG_Semmelweiss »

kube-system wrote: post #206
ncallaway wrote: post #31

I genuinely think every health insurance denial should have to come from a named doctor at the health insurance company who is personally and professionally liable for the health outcomes from a denial. Deny someone life-saving care without a sound medical reason? That’s a malpractice lawsuit and a potential loss of their medical license.

That doesn’t make any sense. Insurance claims are submitted to insurers after providers have already performed the care.

A claim denial will result in patient responsibility, which ends up with a service but costing patients a lot of $$.

OR in this case, the pa was denied for the cpts requested. In which case care may be denies by the provider or facility

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

#363

Post by fzeroracer »

dennis_jeeves1 wrote: post #319
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.

This already exists and we know what the outcome of it is. It's alternative medicine. Insurers will gladly and gleefully let you do holistic woo bullshit because it saves them money.

A 'free market' as you state just results in people falling for bullshit care.

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

#364

Post by tim333 »

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…

Dunno exactly but pretty much every country on earth seems to get by without these sort of stories. American politics?

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

#365

Post by knodi123 »

snozolli wrote: post #77

“Put yourself in the shoes of the insurer,” Howrigon said. “Why not just deny them all and see which ones come back on appeal? From a cost perspective, it makes sense.” Something about "do no harm" comes to mind.

was it the hypocritic oath, "second, do no harm"?

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

#366

Post by camhart »

ratg13 wrote: post #165
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…

Once you get rich or in politics, healthcare is no longer a problem, so you don’t see it. Even this thread is full of Americans trying to tell other Americans that the US system is “better” than Europe

Europe's healthcare isn't perfect like many Americans make it out to be. It has its own list of cons. Although it is very nice when you go to a Dr there and talking about money isn't even a thing.

My wife is German. There are Dr's that refuse to work with insurance altogether. There are procedures not covered at all. The employer pays for half the insurance, the state (aka taxes... so you) pay for the other half. Self employed people who failed to pay their "half" can still end up with life crushing bills (personal experience in the family). Not sure what happens if unemployed (I assume the State does step in there to cover it 100%?).

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

#367

Post by ncallaway »

kube-system wrote: post #206
ncallaway wrote: post #31

I genuinely think every health insurance denial should have to come from a named doctor at the health insurance company who is personally and professionally liable for the health outcomes from a denial. Deny someone life-saving care without a sound medical reason? That’s a malpractice lawsuit and a potential loss of their medical license.

That doesn’t make any sense. Insurance claims are submitted to insurers after providers have already performed the care.

More and more often care is gated by prior authorizations by insurance. This is because insurance companies have more and more often required many procedures to have a prior authorization before hand and will refuse to pay bills if a prior auth wasn’t obtained.

My proposed policy would apply both to prior authorizations and post care claims.

Post care claim denials can be serious too. If you need repeated treatments a denial to a claim can have an impact on your ability to receive subsequent treatments.

I have a dear friend that was suddenly paralyzed, and now needs ongoing PT from specialists to work to regain use of their limbs. Their insurance has tried to get out of paying the bills several times (they’ve gotten it done so far, but each of the claims has been… a near thing). If one of those bills doesn’t go through, their ability to continue PT at this facility would almost certainly be impacted.

So, yes, a claim denial may impact ongoing care in similar manner to a prior authorization denial.

———

Finally, I’d actually want to add criminal liability for what was described in this particular article.

> “We literally click and submit,” one former Cigna doctor said. “It takes all of 10 seconds to do 50 at a time.”

A doctor working for an insurance company issuing medical denials in this kind of a scheme should be facing jail time, not just personal liability or professional discipline.

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

#368

Post by nobodyandproud »

alphanullmeric wrote: post #359
nobodyandproud wrote: post #343

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 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.

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

So you’d pay for law enforcement and a military, but without roads and highways they would be ineffective.

What is your proposal? Do police and soldiers have to pay money for its use?

> You have no idea how much I make, which your claim entirely depends on

And you have no idea whether I’m overpaying for healthcare to subsidize your care.

Those services you’re enjoying now and the professionals you’re relying on? Those are costs far beyond just the single treatment and whatever private insurance you’re paying for.

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

#369

Post by ncallaway »

IG_Semmelweiss wrote: post #362
kube-system wrote: post #206

Earlier quoted context omitted.

That doesn’t make any sense. Insurance claims are submitted to insurers after providers have already performed the care.

A claim denial will result in patient responsibility, which ends up with a service but costing patients a lot of $$. OR in this case, the pa was denied for the cpts requested. In which case care may be denies by the provider or facility

Critically, many patients also require ongoing services, where a claim denial wouldn’t prevent you from receiving the first service, but it may absolutely impact the second, third, etc.

So, I don’t think I’d exempt claim denials from my proposed regulation. Named doctor, personally and professionally liable from the consequences of their denial.

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

#370

Post by ncallaway »

theGnuMe wrote: post #124
ncallaway wrote: post #31

I genuinely think every health insurance denial should have to come from a named doctor at the health insurance company who is personally and professionally liable for the health outcomes from a denial. Deny someone life-saving care without a sound medical reason? That’s a malpractice lawsuit and a potential loss of their medical license.

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.

Yep, basically we should make it much easier to identify the specific doctor that is responsible for the denial (to make them easier to sue personally, and discipline professionally), and we should make the liability for such a denial extremely explicit.
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