Medical billing is a nightmare. Even the people that work within - will tell you without hesitation that it is consistently a cluster ___ . And then you have 'providers' - whose most consistent response will be .. "Don't know. Not my problem .. "

deal with the provider first and correct the issue(s)

answers. When they get an answer -- the same day, next day, whatever -- they'll either process it or ask for more info. That's why over 80% of "denials" are eventually overturned.


It's still a denial and if the doctors/hospital doesn't reply it will never be processed.

Are you denying that?

For figuring this conflict out with the denial, when the issue is really between them and the provider. When their literal reason for existing as a company is to handle stuff like this for the customer. They make this the customer's problem because the customer doesn't know anything about medicine or medical billing, so then there's a better chance they'll screw it up so the insurance company won't have to pay the claim.

they can understand if a change on codes is needed, have the medical records and diagnoses info, etc. Most of time the office does it electronically, few phone calls.

On any denial the patient should call the provider.

Calling insurer is a waste, unless your doctor isn’t responding to you. In most cases docs have incentive to appeal because they know most patients can’t afford the whole bill.

Cash. 1/2 the going rate.

In the situations you posit, the insured has already gotten the care, no?

So you--the hypothetical claims adjudicator--are about to be in a fight with the provider.

Especially in the aggravated situation you posit where there are multiple bills for same service, same patient, same day. That, obviously, has nothing to do with the patient at all.

You seem to have missed the fact that the real outrage, which may be misplaced, is not about issues of billing after the treatment.

It's denial of treatment.

And, even if it's ultimately about billing and payment, as you've established, UHC, about which you seem to have tender feelings, is ahead of all the other companies, whether initial denials or final dispositions.

is that except in emergency cases -- patient is on op table for severe brain injury -- is usually to do an ordinary cheap xray first say for shoulder pain that ain't gonna kill you. They might even require trying inexpensive pain meds, physical therapy, etc.

Once again the preauthorization come in and it basically says, "We would like approval for a shoulder MRI." The claim form doesn't include the other information, so what do you do. Just say sure do an MRI for shoulder pain, heck MRI everything and do whatever surgery you want, or ask for additional information?[/b

Thanks for asking an obvious question.

Since all the denials are legitimate, the fact that one company denies claims at double the rate of the next closest entrant in the race must mean that that company simply receives more bogus claims.

Would that about get it?

Or is it just that all the claims adjudicators at the other companies are just too stupid to catch all the bogus bills?

I hope you can agree that there must be some clear explanation for the difference in claim denial rates.

Here's an example--

Twenty-Three Individuals Charged in $61.5 Million Medicare Fraud Schemes

Tuesday, February 7, 2023

Office of Public Affairs

Court documents were unsealed this week charging 23 Michigan residents for their alleged involvement in two illegal schemes to defraud Medicare of more than $61.5 million by paying kickbacks and bribes and billing Medicare for unnecessary medical services that were never provided.

“As alleged, the defendants and their co-conspirators repeatedly paid illegal bribes and kickbacks so they could submit claims for medically unnecessary home health services throughout the Detroit metropolitan area, exposing patients to needless physician services and drug testing and costing Medicare tens of millions of dollars,” said Assistant Attorney General Kenneth A. Polite, Jr. of the Justice Department’s Criminal Division. “As these actions demonstrate, we will work tirelessly to tackle complex, illegal schemes that take advantage of vulnerable populations and defraud federal programs of taxpayer dollars meant to provide health care to millions of Americans.”


https://www.justice.gov/opa/pr/twenty-three-individuals-charged-615-million-medicare-fraud-schemes

I could provide many more. But if someone gives a darn, they can go to the site above and read about thousands examples of improper billing and fraud.

How does this happen? Medicare is often passive often pursing improper claims by "pay and chase," thus not denying as many claims up front as private insurers do. If we are lucky Medicare catches these a few years down the road.

Private insurers are more aggressive up front, preferring not to pay before making sure it's legit. Yeah, sure, sometimes they are just trying to keep doctors from billing Botox as treatment for headaches, when it's really to smooth your forehead.

This isn't even bothsiding. It's just "there's somebody worser."

See, talking about how much Medicare gets scammed (and it's surely true that some great political fortunes...ahem...Rick Scott...have been built on Medicare fraud).

But that's not why people are peeved, is it?

Real human beings love Medicare because they get the care they need. Fraud is regrettable, but it's not consumer fraud. It's business fraud.

And you can criticize Medicare all you like for what you call "pay and chase," but that at least makes sure people get the care they need pretty expeditiously.

If you cannot understand why people are angry because the totally careful, entirely justified claims denials by private insurers cause real people pain, I'm pretty sure I can't explain it to you.

You bet. The position of this totally hypothetical claims adjudicator is hard. But that does not change one whit the fact that those tough decisions may be even harder on the person being denied treatment or being threatened with collections.

And, one more time, a point you have not addressed: Why is it that one company stands well above all the others in denying claims? Because they're extra extra careful? Well, they're being extra careful with their profits. Not with government money.

I could probably find a paper I submitted to a rube state legislature in 1982 and was all but called a commie.

Fact is, until our Congress gets off its rear, we are stuck with private insurers.

As to UHC being higher, maybe scammers and providers think they are easier to cheat, just like Medicare. One trick providers use if a claim or preop doesn't get paid/approved within a few weeks is to keep submitting it. That might yield 40 denials for one claim. Point is, the 30% might not be reflective of what is happening. And of course, you have missed that over 80% are overturned, most with a resubmission of codes or an explanation.

I think people need to hear this so they don't go shooting some poor insurance clerk, McDonald's employee who turned Luigi M in, etc., in the back.

But 80% of the most is still the most. It's just math.

As we've established in one of the many other threads on this subject.

And, TBH, I'm thinking that the number of people who are as crazy, or antisocial, or amoral, or whatever it is that Mangione turns out to be is vanishingly small.

Pretty sure the McD worker is safe.

And I'm even more sure that no one on this board is going to shoot an anonymous, good-hearted insurance claims worker. But you go get 'em, just in case.

what is your background? I ask because your posts constantly and consistently criticize Medicare providers and claim that many of them commit fraud. Yet do your best to defend insurance companies.
.

, medical equipment manufacturers, etc.

Most of all it's Congress. The whole damn system is corrupt and people just blame insurers, who wouldn't be in this position if Congress did it's job.

I have only Medicare A & B, no supplemental, and no Advantage. I have had much imaging done in the last couple of years; MRI, CT scans, echocardiograms, X-rays, etc ... none of them were emergency situations. I was never asked to take a less expensive test, and Medicare paid their share of everything, no questions asked. Maybe you're thinking of coverage by Medicare Advantage, rather than 'real' Medicare?

or if they turn out to be high utilizers Medicare might audit them years later to see ig guidelines met.

... as I said, there has NEVER been a problem with my Medicare coverage. Since I don't have a supplemental, I pay 20% of the Medicare approved amount, which is a remarkably good deal, considering. Even though I'm using Medicare more as I get older (just turned 80), I feel I'm still ahead of the game 'paying as I go', vs paying some insurance company a monthly premium and risking denial and/or more red tape. In regard to another part of this discussion, my MRI and CT imaging costs me somewhere between $35-50, depending on the test.

My sister, on the other hand, is a Canadian citizen. She has raised two children to adulthood, is being treated for CLL, and has never seen a medical bill. She does not know what a copay is! Her husband just had a successful major surgery for which there was also no charge and no copay. They are of modest means (retired public school teacher / retired government employee) and do NOT pay exorbitant taxes. They are extremely happy with the health care they have.

I won't see it, but 'maybe' the US can catch up to that some time in the future. Right now I don't think we are as civilized as they are in Canada.

like doctors, nurses, medical assistants, CEOs, medical device makers, drug companies, etc., that they will now be paid like their counterparts in countries with better health systems.

They should, but they won't.

... docs in Canada make plenty of cash, and they don't need malpractice insurance, either. Also, their offices don't have to spend huge amounts of money dealing with various insurance companies. Hospitals don't need a huge billing department.

I should also mention that I'm on a pretty expensive drug. No Part D, so my cost is $650/month here in the US. I started importing a generic from a Canadian pharmacy a few months ago. Cost: $62 for a 3-month supply (free shipping), and I guarantee everyone along the supply chain is making plenty of money, otherwise they wouldn't do it. This is a generic that 'has' been approved for use in the US as of 2019, but the drug companies litigated and blocked availability until 2028.

My doc was skeptical, so he ordered a blood test (paid for by Medicare, no problem), and the efficacy is exactly the same as the brand-name drug.

...the office people know each other, oddball claims are very rare.

Besides, almost all of this stuff nowadays is handled electronically. It's not like 20 years ago when you had to call and stay on hold, etc.

because the provider sends in the requisite info. And it happens with government programs like Medicare and Medicaid too.

Oh, before you ask what happens to the other 20%, I'll answer.

In many cases the provider reads the coverage policies -- which, again, are usually just like Medicare's coverage policy -- and says, "Oh they are right, we'll try that other stuff and if patient is still having an issue order an MRI." Or they go, "Oh, chit, we put the wrong codes on the form, not wonder they denied our Preauthorization.

There is some portion of claims and preauthorizations that are never approved. Maybe by error, maybe intentionally, maybe the provider is a quack trying to do Chelation therapy or something, etc. In the latter case, they'll never respond and go look for another insurer who they can sneak the claim through.

Why are you even bringing up initial claim denials? No one is discussing that and it certainly isn't what mangione was concerned about.

Uh handles some Medicaid policies in Illinois, deny, deny, hurry up and die is the motto.

Most people are in so much pain they can’t wait.

for Medicare-for-All, a Public Option, etc.

whose doctor gave up even billing for her because his people kept having to submit over and over and over and over while the insurance company was playing the cash flow game. So after you spend 8 months sending them the same info they requested initially and doing it 8 months in a row they finally pay the claim. He had treated her and her then deceased husband their whole lives and he said to me he wasn't going to bill for his services since he had long ago made whatever income he cared about and he was sick of arguing and having the insurance company say a form with service codes hadn't been sent when it had been. Over and over again. It was nice that he was independent and had the luxury to control his billing.

Don't try to hand me this crap that companies don't play that game of stalling payments either. I've seen it and lived it. Also don't try and preach to me about the integrity of insurance adjusters. I've seen weasel behavior over the years that would curl anybodies hair.

and paid. Happens frequently, especially if it was many years ago.

a mile high in order to try and calm this lady and reassure her that things were OK as far as payments and she wasn't going to lose the little house her and her husband had built and lived in and that as he died she cared for him in that house.
I'm a college educated person who has worked for companies major and small at all levels from low to high and I know very well how things go at a corporate level as well as how things down lower go. Is there fraud in medical billing? Absolutely as we all know of Medicare fraud. But is it at the level that should carry huge rejection rates for all initial claims? No f**king way. Or do we not believe those who come forward from the insurance industry and become whistleblowers?

denials .

Besides, you would have have gotten details on what went on between office staff and insurers. What year was this?

sense.

I guess the insurer should just pay all those to avoid denials and getting shot in the back. Of course, our premiums will go through the sky.

Needing to be sedated for one can increase the cost quite a bit.

There are very few MRI's -- if any -- that anyone pays that much for. I think Medicare tops out around $3 K for the most complex MRI.

If you'll give me an example of the MRI that cost $12K, I'll tell you what Medicare thinks it's worth.

An MRI can cost anywhere from $400 to $12,000, depending on the provider, health insurance, location, extra medications, and body part scanned.
https://www.goodrx.com/health-topic/diagnostics/how-much-does-an-mri-cost
It was just from a google search.

That could indeed be one of his reasons but it might not even be one or one that would not make him shoot someone without a lot more reasons that are way more important than that. You claimed something specific when you don't really know the specifics. None of us do at this point.

I'm not going to join any cult. That doesn't make your argument nor mine correct though. He didn't kill someone who denied claims. He killed the CEO of a company that denies claims and treatment. The person setting policy on denying claims and treatment. Not the person denying the claims. So, no one was killed for denying a claim.

apparently.

The numbers in the OP end up on the electronic form.

Would you pay as I outlined in OP? If so, your insurance company would not be very competitive.

You do realize any government program -- like Medicare -- uses the same process.

One final thing, I see tonight's news says Luigi M apparently was never insured by UHC. The hero just shot someone for the hell of it.

In Trumps shithole country Belgium I pay 25 Euro for an MRI..m

encourage providers to charge more.

Normally there are procedure codes etc. all over the place and I see nothing here except a those generic descriptions and dollar amounts. At this point I'm not buying the document as legit. Furthermore the medical billing I've seen done between providers and insurance companies isn't done on the basis of a whole slug of "individual" paper billings coming in. Depending on the billing cycle for the facility, from what I remembered, if it was let's say weekly then all of the billing to say Aetna for example would be in one billing computer to computer. People at the insurance company review that more so than an individual bill submission from an insured.

It is indicated in the OP technical note about the insurance company receiving codes etc. but as a patient I've received plenty of medical bills from medical care providers and they are never anything so limited as this picture. The service codes etc. are there also along with dates of service etc. and usually along with a reference to the name of a doctor. Especially in these days of managed care it is dubious to me that any facility would do an expensive procedure without submitting for pre-authorization first. That would carry codes also and none of that appears here. You would have a more detailed invoice for a car repair than what this is and all of my medical billings that I receive as a patient are way more extensive than this. That picture looks like something somebody hammered out on a color laser printer.

aren’t any better in these, they better do the same. Same for docs and hospitals who gamed the system from inception of Medicare.

Insurance companies don't pay the billed amount. They pay an amount closer to the Medicare amount, based on their negotiated prices with providers. The providers write down the rest. So showing the billed amount and comparing it to the Medicare rates as if that is what the insurance company would pay is misleading.

elective/non-urgent MRIs be referred out to keep doc from profiting off their referrals and over-utilizing their profit machines, etc.?

defend insurance companies generally or is it specific to UHC?

poor policy, even Democrats abandoning the push for significant reform, CMS’s failure to property regulate private insurers in ACA and Med Advantage, etc.

Those who support shooting people in protest , better buy a lot of bullets.

I mean, that's who the real victim is here!!

You heartless bastards.

Until we do that, over half country is insured by private insurers.

As listed, others are responsible too.

Unless Congress acts, insurance companies are helpless in their drive to fuck people over!

It's Congress, man. Insurance companies, I'm telling you, are the victim!

You might want to look that word up.

Wait!

You're in the insurance industry, right?

You, therefore, know that insurance regulations are state level.

If you're trying to say that it's the fault of Congress that we don't have universal single-payer health insurance, I'd say you're partly right.

But I'm thinking there may be another part of that.

What could it be?

Oh!

Billions of dollars of insurance lobby money!

That couldn't possibly have anything to do with it, right?

the same agency that oversees Medicare regulates ACA and Medicare Advantage plans. They have not done their job.

Based on comparison between my insurance EOBs and me Medicare EOBs.

and staff have been for decades.

As a person who worked in schools, let me say, "Buckle up and good luck with that. Because gunners have made any relief from your situation impossible."

And if you're a gunner, a lot of this is on you and maybe you and your gun buddies should do something about that.

The provider writes the rest off.
Happens all the time.

I don't know why it's that way. I used to freak out. Then I found put the provider writes the whole thing off. It's very strange.

providers are paid for performing an MRI, which impacts the overall cost for patients.

Insurance companies do the same thing if you stay in network.

I once was taken by Ambulance to a hospital in a rural area. The ambulance company billed for $4k (no life support or ekg involved.) Medicare said No, you only get $200. I only had to pay $40.

Medicare is great!

and I'll include that Medicare should pay what the hospital charges. If they don't like paying that amount perhaps they should make sure the hospital doesn't charge that much.

get more money and rip off tax payers.

So Congress stepped in and changed the reimbursement system to stop that scam.

Time they step in again.