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New Health Insurance Changes Take Effect | 87 comments (87 topical)

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That network vs. out-of-network (5.00 / 4) (#19)
by Chuck0 on Thu Sep 23, 2010 at 09:40:46 AM EST
is crap. It's a way for the insurance companies to deny claims. I had a health insurer in the past that denied EVERYTHING upon first submittal as "out-of-network." Now, I'm one of the anal people who researches, then double checks if a provider is in my network, so I knew the denials were BS. The insurer knew they were BS, but played the game hoping a certain percentage didn't call them on it. They paid every single claim I ever made, but every time, I had to call and make them do their job. A couple of items, I had to write two to three letters, threaten them with lawyers, but in the end, they paid. I don't fold too often. And never with POS insurance companies.

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What likely happened (none / 0) (#24)
by vicndabx on Thu Sep 23, 2010 at 09:53:52 AM EST
is your doctor was submitting claims using a provider number either not on file or not crosswalked to the in-network legacy provider number.  A few years back a law took effect that required every provider to obtain a unique identifier called an NPI (National Provider Identifier.)  These NPI's crosswalk or map to the old provider number used to process claims.  Problem is this mapping isn't always 1:1.  This has nothing to do with you or the insurer attempting to run a scam.  It's a system issue most if not all insurers have to deal with.  The gov't allowed providers to sign up for all kinds of NPI's instead of limiting them to one.  Ideally, there would be a single NPI only.

So contrary to the popular theme, it's not personal.  Where do y'all get this stuff from?  I understand it can be frustrating to deal w/bureacracy sometimes but "played the game hoping a certain percentage?"  C'mon.

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You should get off your knees (5.00 / 3) (#26)
by Chuck0 on Thu Sep 23, 2010 at 10:09:53 AM EST
and stop orally copulating insurance companies. You don't know what you're talking about. This wasn't the case with ONE doctor. What I said was, EVERY claim was denied. From EVERY provider I and MY WIFE dealt with. Don't tell me they ALL used some wrong number. The insurance company was gaming their insured because they know that Americans are sheep who taught not to question authority. And they win at it because I'm certain many people are not as tenacious as I in calling them on their crap. Like I just called you, on your crap.

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You should learn to have a discussion (none / 0) (#30)
by vicndabx on Thu Sep 23, 2010 at 10:43:51 AM EST
like an adult.  Thanks for talking.

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And you should (none / 0) (#60)
by gyrfalcon on Thu Sep 23, 2010 at 02:03:47 PM EST
read more carefully and/or address the points the person is actually making, not just make stuff up to suit your own narrative.

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You should know by now I don't make stuff up (none / 0) (#69)
by vicndabx on Thu Sep 23, 2010 at 02:52:45 PM EST
it detracts from the debate.  Nor do I wish to misinform people.

Info on the NPI: CMS Website

Google: "NPI Crosswalk Issues" or "NPI Claim Rejection"  you'll see a bunch of links w/info on how to deal w/this supposedly made up issue.  Here's some info from a Dermatology Provider website:

CMS recently announced that beginning Sept. 3, 2007 carriers will no longer correct billing or pay-to provider information submitted on Medicare claims submitted by dermatology group practices. This may lead to an increase in claims rejections when not using the correct National Provider Identifier (NPI) or NPI and legacy number combination. Group practices should be reporting the group NPI or group legacy number in combination with the group NPI in the billing or pay-to-provider identifier field.

This was three years ago, and this was Medicare.  Is it possible private insurers may be doing the same thing?  Also, I can't really speak to the commenter's particular situation other that to say what I believed may have happened.  Seems odd the all his/her claims would get denied.  I wonder who the insurer was (is it small or large?)  Were other subscribers claims denied?  Were the doctors truly on the network?  Maybe the directory was out of synch w/the claim system?  Point is, there's a bunch of reasons why this persons claims could've denied as out of network that may or may not have had anything to do w/him/her but also wasn't the result of some malfeasance on the part of the insurer.

Finally, please explain how a doctor will have any knowledge of the efficacy of doctors beyond the docs he already knows? (either in his group, or at partner locations)  The contention was the local doc knows best as to who may also be able to provide treatment.  How is it an insurer that has access to data at a macro level won't also have this info and make at worst, at least as good a recommendation, at best, an even better recommendation?

I don't have a problem being on the "wrong" side here.  I can state facts and be comfortable with that.

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Oh, come on now... (5.00 / 1) (#73)
by Anne on Thu Sep 23, 2010 at 03:23:53 PM EST
How does an internist know who the best specialists are?  How does a pediatrician know which are the best pediatric oncologists, pediatric cardiologists?  How does a gynecologist know which docs are the best for breast cancer, or ovarian cancer, or fertility?  

How?  Really?

They MAKE IT THEIR BUSINESS to know in order to make sure their patients are receiving the best care.  Doctors are quite capable at researching, of networking a problem, just the same as any other professional in a general practice who depends on other professionals to handle the more specialized matters.

Good docs know other good docs, and they don't send their patients to hacks - if they do, their patients don't come back - they find better care elsewhere.

Duh.

Little example:  last year, I needed a Virginia attorney to represent me in a guardianship/conservatorship proceeding for my elderly aunt.  I called someone in our DC office, and was referred to someone who did an excellent job for me.  When I needed an attorney to handle claims that needed to be filed against my aunt's husband's estate, the guardianship lawyer referred me to an estates and trusts lawyer who also did an excellent job for me.  

Can you think of a reason why someone I work with would refer me to a bad lawyer, or why the lawyer I was referred to and who represented me in one capacity would send me to someone incompetent or marginally proficient to assist me on another matter?

Their reputations are on the line; there is nothing good in it to make referrals based solely on the minimal qualifications you suggested.  "I know this guy" is probably not how it's done, just so you know.

As to your info about coding - no one said the coding issue wasn't real or that you were making it up; what the poster said was that "coding" was not the likely reason that every claim for every member of his family, for whatever reason, regardless of provider, was denied.

How was that not obvious?

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Who said it wasn't obvious? (none / 0) (#75)
by vicndabx on Thu Sep 23, 2010 at 03:53:56 PM EST
I did quite well in reading comprehension growing up.  I believe it's a trait I still have.

As I noted, it was a possible explanation.  Since it could affect every claim.  How?  Well, not knowing where the poster lives, let's assume he and his wife go to two different docs in a small geographic area.  Let's assume these doctors both use the same software vendor (as is not uncommon.)  My personal experience is these software vendors aren't usually quick w/fixes.  So a problem w/the provider number sent in on a claim might not be fixed right away.  Heck, for all I know the doc could be sending in the provider number in the wrong format.  Or, staff in the doc's office isn't using the software correctly.  Maybe this poster has a direct-pay contract, and payments weren't up to date or hadn't been posted to his account.  I don't know.  Point is there's all kind of reasons.  Again, I was speculating on a possible explanation. While these may not seem feasible to you or other laypersons, they would be quite reasonable to someone who's does what I do.  Not everything is a conspiracy.

Also, in your example, your first step was:

I called someone in our DC office

That seems in line w/what I stated about using friends and colleagues.  Nonetheless, that really wasn't what I was talking about.  The doc referring to friends and colleagues is not an issue.  There's nothing wrong w/that.  To go back, I was responding to this point:

What if the specialist your internist wants to send to because he or she thinks that doc is be best one for your problem, is not in the plan

My point was, that doc that's not in the plan is not your only recourse w/r/t care.  You should be able to stay in network and find a reputable, qualified, safe, effective doctor using the in network docs.   Your insurer does the same due diligence (if not more) you local doc does.  It's possible, that just maybe, the insurer also knows who's best to fix your problem.  Just because it's not who your doc knows doesn't mean he's not just as good or better.

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My insurer knows who's best? (5.00 / 0) (#77)
by Anne on Thu Sep 23, 2010 at 04:06:51 PM EST
Oh, sure they do - because they have my best interests at heart - even if they don't know me, don't have any relationship with me, and always have their eye on the bottom line, right?

Pardon me for not buying that one.

One should be able to take the recommendation of one's doctor, the person who knows him or her best, shouldn't they?  If the doc gives more than one name, then possibly, problem solved.  But if not, then what?

You're missing the point on how docs know who's best, but that doesn't surprise me.

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I'm not missing the point at all (1.00 / 0) (#82)
by vicndabx on Thu Sep 23, 2010 at 04:29:35 PM EST
You believe you should be able to go to an out of network doc if you so choose and allow that doc to choose who to refer you to.  You trust your own doc more.  I don't disagree with that.  

What I don't buy is an insurer will send you to some quack to save a few bucks which is what you are implying.

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Doctors pay to know others efficacy (none / 0) (#78)
by waldenpond on Thu Sep 23, 2010 at 04:16:32 PM EST
If a doctor has hospital privledges, efficacy is done by the hospital, but I don't think I have ever met a doc who doesn't pay to know efficacy rates.  Cost will depend on what/how often you feel like reporting and who and how often you want comparisons.  I am very surprised you are in the industry and are unaware their is a whole additional industry for outcome and productivity reporting.

Also, it is not malfeasance that drives the industry to automatically deny payment.  It's cash flow.  The longer they hang onto the cash, the more money they make investing (actually losing) the money.  Docs don't have an incentive to improve this either.

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Now we are talking something totally different (none / 0) (#86)
by vicndabx on Thu Sep 23, 2010 at 04:40:27 PM EST
I know hospitals have this info and share w/docs in their groups - hence the reason they usually refer to other docs associated w/the hospital.

I know there is all kinds of reporting that takes place, to state health agencies, to insurers, to the employer, etc.

Does every doc use this info?  Do some refer to someone they've used in the past w/o any addt'l follow-up on their current performance?  Of course.  Professional courtesies and all that.  Again, there's nothing wrong w/that either.  My point is something different as noted in my earlier post.

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When there are well-documented cases (5.00 / 4) (#31)
by Anne on Thu Sep 23, 2010 at 10:58:11 AM EST
of insurance companies tasking their employees to find ways to rescind policies, routinely just deny claims until the claimants just gave up, and offer monetary rewards to those employees for doing so, please do not insult our intelligence by chalking up the poster's experience to bureaucratic snafus.

Gaming the system is one way insurance companies make money for their investors; these are not charitable organizations, after all - they are stock-issuing, dividend-paying corporations for which the bottom line is the only line that really matters.

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Similar well-documented cases (5.00 / 0) (#54)
by Dr Molly on Thu Sep 23, 2010 at 01:32:58 PM EST
relative to the credit card companies and their 'mistaken fees', etc.

As if it's a surprise that they play these tricks by now. Most of us have spent hours on the phone battling these phony charges and dismissals, knowing full well what the game is.

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Right, OK (1.00 / 0) (#36)
by vicndabx on Thu Sep 23, 2010 at 11:46:25 AM EST
Us folks who actually do the work are blind know-nothings.    

You want to take isolated incidents and settled lawsuits as proof that things happen on a large scale throughout an industry that processes and pays millions of dollars in claims daily because it suits your agenda.  Go for it.  You want to repeat the same old talking points w/o any knowledge of the history of the health insurance industry.  Go for it.  You insult your own intelligence w/o any help from me.  I'm done.

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Isolated? (5.00 / 0) (#38)
by Anne on Thu Sep 23, 2010 at 12:16:08 PM EST
That it is going on at all, that it was not being done by rogue clerks, but on an institutional basis as part of a business plan makes scale irrelevant, don't you think?

It certainly was irrelevant to people who were denied coverage when they got sick because they forgot to disclose a visit to a dermatologist, for example.  And it certainly was irrelevant to people who all of a sudden couldn't get claims approved for no apparent reason.  I know someone who worked for a large insurance company a while back, and he was told to "lose" the claims the first time they were filed, ignore them the second time, and if the claimant was persistent enough to keep filing, to deny them.  If they still came back, they would pay.  Most people just gave up - no claim paid, more money for the company.

No one is accusing YOU of doing any of this.  And no one believes you to be an unethical person set on finding ways to keep people from having claims paid.  No one is even saying that claimants themselves don't try scamming the insurance companies, getting unethical providers to submit bogus claims and splitting the money.  It happens.

But we've all read about the companies that looked for ways to deny and rescind coverage for people who developed chronic and/or costly conditions - regardless of how little these companies had paid out on the claimants' behalf up to that point.

Look, I work in a law firm.  I constantly hear people ragging on "all the crooked lawyers."  I know that the majority of lawyers are ethical and honorable, but I don't deny that there are some bad ones out there taking advantage of people.  And I understand that if one lawyer screwed over one client, it is irrelevant to that client that the majority of clients are treated well.

You may consider examples of insurance companies actively working to pull the rug out from under people who have paid them thousands of dollars every year to be nothing more than "talking points," but the people who have been on the receiving end of overzealous insurance company greed would probably consider that to be more a matter of life and death, both physical and financial.

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New Health Insurance Changes Take Effect | 87 comments (87 topical)

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