If you suddenly found yourself working for an insurance company and received a claim that looks like this for MRI--

[Silent Type]

-- Medicare would pay somewhere between $800 and $1800 depending on type of MRI, whether it uses contrast, etc.

Do you think the insurance company should pay it, or deny it and ask for additional information?


-- Now, lets say you got 3 claims for this patient on the same day with slightly different amounts. Would you deny it and ask for additional information?

-- Now say, Medicare or private insurer has a coverage policy that says they will cover only one MRI per hospital stay, unless there are special circumstances. Typically private insurers copy Medicare coverage policies nowadays. Then you get a bill for 2 in 3 days. Would you deny and ask for additional information?


-- Say you got 2 bills from 2 different physicians/facilities. Would you deny and ask for additional information?

-- Finally, you get a bill that looks strange (like maybe a provider got hacked, and someone is billing multiple services to patients that weren't even seen), would you deny and ask for additional information?

Welcome to the world of insurance claim adjudication

Technical note: The claim the insurance company receives just has a date-of-service, CPT code for service, one or two diagnosis codes, patient and provider identification like a provider number. It doesn't include medical records just a few codes.

[stopdiggin]

1. Thanks. This post (and this point of view) is long overdue here.

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 .. "

[Iggo]

2. Why do they have to deny it just to ask for more information?

[Meowmee]

3. Exactly, lol

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

[Silent Type]

5. It's not denied in the sense they will never pay. It's denied because they ain't gonna cut a check until they get

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.

[Meowmee]

16. There are also denials regarding valid claims and treatment approvals with delay tactics

Are you denying that?

[Diraven]

58. But they leave the customer responsible

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.

[Silent Type]

59. In my opinion it's the doc's office responsibility. They have all the information, they under codes,

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.

[bucolic_frolic]

4. That's like a claims adjuster for houses. My 1999 MRI was $500.00.

Cash. 1/2 the going rate.

[dpibel]

6. Kudos for the diversion!!

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.

[Silent Type]

8. They've gotten care in most "claim" denials. Preauthorization is much the same. For example, Medicare's policy on MRIs

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.

[dpibel]

12. So some insurers are targeted by the scammers?

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.

[Silent Type]

19. You know who gets scammed the most -- MEDICARE.

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.

[dpibel]

22. Objection. Nonresponsive.

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.

[Silent Type]

24. You need to understand something. I have been for Medicare/caid-for-All since 1982. If I were to dig through my addict

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.

[dpibel]

34. Haven't missed 80% at all

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.

[Silent Type]

35. She has recieved threats from the Luigi cult.

[rog]

68. Are you sure about the Medicare policy?

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?

[Think. Again.]

7. Hospitals and insurance companies work hand-in-hand on thousands of claims a week....

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

[Silent Type]

9. Yeah sure. That's how Medicare or private insurers end up paying claims to providers who don't even exist.

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.

[Think. Again.]

11. I just don't believe mistakes or fraud could total 30% of claims.

[Silent Type]

13. One more time. Those are INITIAL denials -- similar to examples above -- that are overturned in over 80% of cases

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.

[Think. Again.]

15. Oh, okay, so this doesn't even address the 34% of final claims denied by UHC.

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

[Silent Type]

25. Because 80+% of initial claim denials are reversed exactly as outlined in the OP. Have a good night.

[questionseverything]

36. It happens with Medicaid because the government hires unscrupulous people to deny claims

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.

[Silent Type]

37. Good point, it ain't just private insurance. Medicaid and Medicare are government programs and likely model

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

[moniss]

42. Bullshit. I helped care for a lady

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.

[Silent Type]

43. I'd have to see the bills. He might have been submitting improper bills, that were changed

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

[moniss]

47. No changes I went through stacks of paperwork

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?

[Silent Type]

48. Like Wendell Potter, got rich supporting denying claims and felt guilty. Ask him if anyone died from his

denials .

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

[moniss]

51. Not talking about Potter.

[Eko]

10. Was that for just one MRI?

[Silent Type]

14. Yes. The actual claim form submitted electronically has a Units column. But, good example of claims not always making

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.

[Eko]

17. An MRI can cost up to $12,000.

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

[Silent Type]

20. Example in OP includes meds. The type sedation -- xanax or something -- is pretty cheap. Well, unless provider cheats.

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.

[Eko]

27. This is what I found.

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.

[Silent Type]

31. If you are uninsured, someone might charge you $50 K. Insurance will not approve $12K, including Medicare.

[Silent Type]

32. Let's say $12 K is going rate. Should insurer, including Medicare, pay $17K, or deny and ask for additional . . . . . .

[Eko]

28. Who was shot in the back for an insurance claim denial?

[Silent Type]

30. Give me a break. You know who Luigi shot and his rationale. Heard tonight Luigi was apparently never insured by UHC.

[Eko]

40. So if he was never insured by them he certianly wasnt denied a payment claim by them.

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.

[Silent Type]

41. I know enough to not join the Luigi cult.

[Eko]

45. Same here.

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.

[Silent Type]

46. OK, guess his manifesto said nothing about denials, claims, pre authorization. And UHC never insured him

apparently.

[Eko]

50. Here is his manifesto.

https://www.kenklippenstein.com/p/luigis-manifesto

“To the Feds, I'll keep this short, because I do respect what you do for our country. To save you a lengthy investigation, I state plainly that I wasn't working with anyone. This was fairly trivial: some elementary social engineering, basic CAD, a lot of patience. The spiral notebook, if present, has some straggling notes and To Do lists that illuminate the gist of it. My tech is pretty locked down because I work in engineering so probably not much info there. I do apologize for any strife of traumas but it had to be done. Frankly, these parasites simply had it coming. A reminder: the US has the #1 most expensive healthcare system in the world, yet we rank roughly #42 in life expectancy. United is the [indecipherable] largest company in the US by market cap, behind only Apple, Google, Walmart. It has grown and grown, but as our life expectancy? No the reality is, these [indecipherable] have simply gotten too powerful, and they continue to abuse our country for immense profit because the American public has allwed them to get away with it. Obviously the problem is more complex, but I do not have space, and frankly I do not pretend to be the most qualified person to lay out the full argument. But many have illuminated the corruption and greed (e.g.: Rosenthal, Moore), decades ago and the problems simply remain. It is not an issue of awareness at this point, but clearly power games at play. Evidently I am the first to face it with such brutal honesty.”

So,,,, I don't see where he talks about denials, claims, pre-authorization and anything about UHC in particular. If you have more information to share feel free to.

[vanessa_ca]

18. That is not a claim. n/t

[Silent Type]

21. Read the last paragraph. I explain that. But very few here are going to understand what an electronic claims looks like.

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.

[vanessa_ca]

39. "few here are going to understand what an electronic claims looks like"

I'll give you this, your attempts are entertaining.

[Silent Type]

44. I answered your question since you didn't read the note in OP. Have a good evening.

[vanessa_ca]

49. I didn't ask you any questions. Your notes in the OP are inadequate. Good night. eom.

[WhiskeyGrinder]

23. won't somebody please think of the claims???

[Silent Type]

26. Got a good laugh out of that, actually. I do care about shooting someone in the back while being misinformed.

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.

[FirefighterJo]

29. Funny

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

[Silent Type]

33. Get it and envious. But lot of the blame is on greedy providers for prices. I've never seen Medicare or private insurers

encourage providers to charge more.

[moniss]

38. That "form" looks sketchy.

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.

[Hellbound Hellhound]

52. Fun fact: UHC employees have been ordered to defend their murders. N/t

[Silent Type]

54. Considering the misinformation, Luigi cult, etc., don't blame them too. When people catch on government programs

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

[Hellbound Hellhound]

55. Try English next time Vlad. N/t

[Silent Type]

57. OK, Timothy McVeigh, or is it ghost of Unabomber?

[Ms. Toad]

53. First of all -

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.

[Silent Type]

56. So what do think a typical insurer might pay? Three times Medicare, 1.5, even less than Medicare by requiring

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

[Bettie]

60. So, is it your job to

defend insurance companies generally or is it specific to UHC?

[Silent Type]

61. Not "defending" anyone. Trying to point out not just insurance. It's also Congress, Medicare, Providers,

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.

[dpibel]

62. Will no one think of the insurance companies????

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

You heartless bastards.

[Silent Type]

63. Think we ought to put blame where it belongs, Congress primarily for failing us.

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

As listed, others are responsible too.

[dpibel]

64. They can't help themselves!

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!

[Silent Type]

65. Insurance companies exist because of Congress' inaction.

[dpibel]

66. Exist?

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?

[Scrivener7]

67. Insurance employees seem like they're as nervous as school children

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.