The Company Helping America's Health Insurers Deny Coverage for Care
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Re: The Company Helping America's Health Insurers Deny Coverage for Care
#2Evicore is a highly suspicious company, and the story of the patient who passed away in this article is sad. But I have noticed insurers do this (false claim denials) all on their own too. I and many friends have experienced Aetna routinely denying things that are explicitly covered by their plans and mentioned in the plan documents. They force you into an exhaustive cat and mouse game of chasing their team to reprocess denied claims. But after the initial denial, every conversation goes to some other part of their support team with hour long waiting times (meaning you may have to try multiple times across multiple weeks due to other obligations in your schedule), incompetent staff that barely speak English (making it hard to get the info or action you want), and very loose commitments from Aetna (they’ll promise getting back in 45 business days but even with that they won’t have done anything when you check in weeks later). I think these are purposeful games meant to deter people from successfully filing claims, by exhausting them, or simply shifting their payments into the future. I feel it is criminal. Not just in terms of fraudulent denial but in affecting people’s health by creating stress for them over big medical bills that should be covered.
Re: The Company Helping America's Health Insurers Deny Coverage for Care
#3Evicore is a highly suspicious company, and the story of the patient who passed away in this article is sad. But I have noticed insurers do this (false claim denials) all on their own too. I and many friends have experienced Aetna routinely denying things that are explicitly covered by their plans and mentioned in the plan documents. They force you into an exhaustive cat and mouse game of chasing their team to reproc…
When it appears a legitimate claim is going to be denied, I recommend immediately opening a case with your state’s insurance regulator. If it’s an employer sponsored plan, the Dept of Labor. Success is not assured, but it creates a paper trail for regulators and other interested parties, including attorneys you might eventually involve.
(volunteer patient advocate)
Re: The Company Helping America's Health Insurers Deny Coverage for Care
#4Evicore is a highly suspicious company, and the story of the patient who passed away in this article is sad. But I have noticed insurers do this (false claim denials) all on their own too. I and many friends have experienced Aetna routinely denying things that are explicitly covered by their plans and mentioned in the plan documents. They force you into an exhaustive cat and mouse game of chasing their team to reproc…
When it appears a legitimate claim is going to be denied, I recommend immediately opening a case with your state’s insurance regulator. If it’s an employer sponsored plan, the Dept of Labor. Success is not assured, but it creates a paper trail for regulators and other interested parties, including attorneys you might eventually involve. (volunteer patient advocate)
That’s a great tip. I remember wanting to report this to some authority then but just didn’t have the time to deal with it. I wonder if I can still do it now after this has been settled (the claim was eventually paid, months late, after many many hours spent on phone calls).
Re: The Company Helping America's Health Insurers Deny Coverage for Care
#5Evicore is a highly suspicious company, and the story of the patient who passed away in this article is sad. But I have noticed insurers do this (false claim denials) all on their own too. I and many friends have experienced Aetna routinely denying things that are explicitly covered by their plans and mentioned in the plan documents. They force you into an exhaustive cat and mouse game of chasing their team to reproc…
It's not even just insurance companies. My wife and I had a child earlier this year, uncomplicated natural birth, fully covered under insurance. However the hospital initially filed the claim incorrectly, causing the claim to be denied and us to receive a bill in the thousands well in excess of our deductible/coinsurance.
Hours of phone calls to insurance and hospital later, we think we have it resolved but are informed it may take up to 6 weeks to process. Fine, we wait six weeks. Hospital starts threatening to send us to collections for non-payment. Hours of phone calls later it turns out they were waiting on information from insurance that they never received. So six phone calls later we think we've gotten it all sorted out. This time people actually follow through, hospital switches our payment to pending and that's the last we heard of it. Got confirmation that insurance paid out several months later.
Again, the hospital messed up the paperwork, but the burden of solving the problem falls on us, with serious financial consequences if we don't. While we're dealing with a newborn no less. There should really be a law that makes institutions liable for such errors.
Also insurance was a little shady as well. The amount of the outstanding bill should have pushed us over our out-of-pocket-max for the year, but when they finally paid out they marked it as an "adjustment". Which means we're still in the coinsurance part of plan. So we're getting deeply discounted healthcare for the rest of the year, but not free. It's not worth the time for us to run down, and maybe they're doing everything in line with the fine print, but it definitely smells rotten.
Re: The Company Helping America's Health Insurers Deny Coverage for Care
#6Earlier quoted context omitted.
When it appears a legitimate claim is going to be denied, I recommend immediately opening a case with your state’s insurance regulator. If it’s an employer sponsored plan, the Dept of Labor. Success is not assured, but it creates a paper trail for regulators and other interested parties, including attorneys you might eventually involve. (volunteer patient advocate)
That’s a great tip. I remember wanting to report this to some authority then but just didn’t have the time to deal with it. I wonder if I can still do it now after this has been settled (the claim was eventually paid, months late, after many many hours spent on phone calls).
You can still file a complaint even if the issue has been resolved. It will be logged.
Re: The Company Helping America's Health Insurers Deny Coverage for Care
#7Evicore is a highly suspicious company, and the story of the patient who passed away in this article is sad. But I have noticed insurers do this (false claim denials) all on their own too. I and many friends have experienced Aetna routinely denying things that are explicitly covered by their plans and mentioned in the plan documents. They force you into an exhaustive cat and mouse game of chasing their team to reproc…
It's not even just insurance companies. My wife and I had a child earlier this year, uncomplicated natural birth, fully covered under insurance. However the hospital initially filed the claim incorrectly, causing the claim to be denied and us to receive a bill in the thousands well in excess of our deductible/coinsurance. Hours of phone calls to insurance and hospital later, we think we have it resolved but are infor…
I'm in a similar situation now. I don't understand why the insurance company and the hospital billing staff can't talk to each other, and require me to act as a mediator. At this point it feels malicious.
Re: The Company Helping America's Health Insurers Deny Coverage for Care
#8Evicore is a highly suspicious company, and the story of the patient who passed away in this article is sad. But I have noticed insurers do this (false claim denials) all on their own too. I and many friends have experienced Aetna routinely denying things that are explicitly covered by their plans and mentioned in the plan documents. They force you into an exhaustive cat and mouse game of chasing their team to reproc…
It's not even just insurance companies. My wife and I had a child earlier this year, uncomplicated natural birth, fully covered under insurance. However the hospital initially filed the claim incorrectly, causing the claim to be denied and us to receive a bill in the thousands well in excess of our deductible/coinsurance. Hours of phone calls to insurance and hospital later, we think we have it resolved but are infor…
> There should really be a law that makes institutions liable for such errors.
Does there need to be an explicit law?
Could one sue in small-claims court for the time and expense damages?
Re: The Company Helping America's Health Insurers Deny Coverage for Care
#9Earlier quoted context omitted.
It's not even just insurance companies. My wife and I had a child earlier this year, uncomplicated natural birth, fully covered under insurance. However the hospital initially filed the claim incorrectly, causing the claim to be denied and us to receive a bill in the thousands well in excess of our deductible/coinsurance. Hours of phone calls to insurance and hospital later, we think we have it resolved but are infor…
I'm in a similar situation now. I don't understand why the insurance company and the hospital billing staff can't talk to each other, and require me to act as a mediator. At this point it feels malicious.
In all practical ways, it is malicious. The system is intentionally designed to pay out as few claims as legally possible and use every legal means to obstruct and draw out the claims process. The U.S. healthcare system as a whole is a bastion of inefficiency and corruption.
Re: The Company Helping America's Health Insurers Deny Coverage for Care
#10Earlier quoted context omitted.
I'm in a similar situation now. I don't understand why the insurance company and the hospital billing staff can't talk to each other, and require me to act as a mediator. At this point it feels malicious.
In all practical ways, it is malicious. The system is intentionally designed to pay out as few claims as legally possible and use every legal means to obstruct and draw out the claims process. The U.S. healthcare system as a whole is a bastion of inefficiency and corruption.
This is the answer.