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California Health Insurance Claim Rejections Come Under Investigation – Surf’s Up

Posted Sep 05 2009 10:21pm

This is big and the red tape that goes along with it.  In another article a representative from the insurance industry stated many of these are clerical or paperwork errors, and there is some substance to that as I am sitting here right now looking at 10 that were denied, but paid on the same patient image a month ago, nothing changed except the fact that the carrier needs to update their data integration to either put out a policy to not put dashes in the social security number or put that option in their processing software.  Let’s not over look the fact that that it took time for me me to re-submit to the clearinghouse too. 

Sure there are duplicates too, but I don’t think this is what we are talking about here with this focus, although it does make a point of how complicated and inefficient medical billing is, on some issues there’s no rhyme or reason and administrative time spent by medical practices to deal with this type of stuff too is maddening.  The big denials of course are the ones that make the news, as for each one of those, there are plenty more.  Again, they use scoring to keep fraud down and when scoring for fraud and greed cross the line for risk management, we have a problem, patients and doctors have problems.  What is also amazing to me is that on these highly publicized cases we hear the very cold hearted reasons for not covering the claim too.  Again, it’s down to business intelligence software that grades and makes those decisions, until a human steps in to make adjustments.  It’s all about those algorithms that run 24/7, humans need sleep and can’t function at that level.  Once more, this is what we need, paper doesn’t cut it.

Are We Ever Going to Get Some Algorithm Centric Laws Passed for Healthcare!

Again I wish our lawmakers could come to terms with this and read up.  They still don’t get it.  I’ll reference this once more as I have several times, but watch the video from the Senate in January with the healthcare IT stimulus initiative and see how much is not known.  It speaks for itself with none of the Senate committee having a clue on what electronic medical records look like and how they work, much less personal health records that are for everyone, they don’t read up on technology it appears. 

Health Fraud Scores Could Be a Contributing Factor to Medical Claims Being Denied

Just being better in touch would really help and again I hope they understand the magnitude of this investigation too.  I wrote about the “dud” Town Hall meeting I accidentally attended last week.  I say that as there was no announcement, but just the phone ringing that connected you to the meeting, all by phone. 

With the technology and resources we have today there’s a better way to communicate, notify constituents, and I felt it was somewhat like “Surf’s Up, Let’s Have a Town Hall” agenda.  image

Nothing will be accomplished here until we have laws that spell out the rules and how to protect citizens and get away from the “Surf’s Up” spontaneous constituent meetings.  It’s also somewhat amazing too that with all the unrest we are seeing, that with the story of Goldman’s code being stolen that nobody has infiltrated on this code, so they must have their security locked up as it should be.  BD 

OAKLAND, Calif., Sept. 2 /PRNewswire/ -- More than one of every five requests for medical claims for insured patients, even when recommended by a patient's physician, are rejected by California's largest private insurers, amounting to very real death panels in practice daily in the nation's biggest state, according to data released today by the California Nurses Association/National Nurses Organizing Committee. CNA/NNOC researchers analyzed data reported by the insurers to the California Department of Managed Care. From 2002 through June 30, 2009, the six largest insurers operating in California rejected 31.2 million claims for care - 21 percent of all claims.

PacifiCare denied 40 percent of all California claims in the first six monthsof 2009. Cigna, which gained notoriety two years ago for denying a livertransplant to 17-year-old Nataline Sarkisyan of Northridge, Calif. and thenreversing itself, tragically too late to save her life, was still rejectingone-third of all claims for the first half of 2009.

Rejection of care is a very lucrative business for the insurance giants. Thetop 18 insurance giants racked up $15.9 billion in profits last year.

California's Real Death Panels: Insurers Deny 21% of Claims | U.S. | Reuters

Related Reading;

If You Think The “So Called Death Panels” are Something To Worry About – Read This and Get Educated

Goldman Stolen Code – Has Algorithmic Fraud Become A Business Model in HealthCare Too?

Health Insurance Premiums To Rise 29 Percent Letter Sent by Insurer – What Does Your Score Say?

Ingenix Data Base Has Some Long Reaching Legal Tentacles with Aetna, Blue Cross, Blue Shield, Humana
Are We Ever Going to Get Some Algorithm Centric Laws Passed for Healthcare!
Goldman Stolen Code – Has Algorithmic Fraud Become A Business Model in HealthCare Too?
Health Care Insurers Suggest Algorithms and Business Intelligence solutions to provide health insurance solution
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