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Please begin with an informative title:

I just came across this article on Big Government that will probably be the top story on Fixed News tomorrow.

The article using data from the American Medical Association suggests that between March 07 - March 08 Medicare denied a higher percentage of people than many of the countries largest private health insurance companies.

Intro

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AMA Report Card (Metric 12)

AMA Denial Statistics

Update:

Reasons

1) Private Health Insurers (PHI) deny people that want to buy health insurance, but have a pre-existing condition, in other words they cherry pick the healthy while medicare covers you no matter what. These people aren't accounted for in the statistics.

2)The numbers are simply bullshit!

Researchers from the California Nurses Association/National Nurses Organizing Committee analyzed data reported by the insurers to the California Department of Managed Care. From 2002 through June 30, 2009, the six insurers rejected 45.7 million claims -- 22 percent of all claims.

For the first half of 2009, as the national debate over healthcare reform was escalating, the rejection rates are even more striking.

    Claims denial rates by leading California insurers, first six months of 2009:

    • PacifiCare -- 39.6 percent
    • Cigna -- 32.7 percent
    • HealthNet -- 30 percent
    • Kaiser Permanente -- 28.3 percent
    • Blue Cross -- 27.9 percent
    • Aetna -- 6.4 percent


 AMA's statistics don't account for the fact that
PHI's often drop people when they get sick and if they drop you, you are no longer one of their customers that can be denied.

Let me put it this way.

Let's say a PHI starts with a million customers in January and ten thousand claims are filed over the course of the year. Five thousand of those customers who filed a claim promptly have their coverage dropped.

The statistics don't include these people so in reality PHI's deny a far larger percentage of customers.

They just do much of it by dropping coverage entirely.

In conclusion California Department's numbers >>>>> AMA's

3)The American Medical Association  is the same organization that said medicare would make the USA a socialist country (hardly trustworthy)

Yes AMA has voiced support for a public option, but they've also recently voiced support for the Baucus plan that mandates Americans to buy from the PHI's and offers no public option.

Mandates the families (who have seen their loved ones murdered for money) to give PHI's more of their money again!

The fact of the matter is if AMA can support both a public option and the regressive Baucus plan then they will probably support anything labeled reform.

4) The health industry often tries to take advantage of Medicares generosity

MichiganGirl wrote:

I know just three weeks ago my Grandmother had to contact Medicare because she had been hospitalized for a minor stroke the month before, and among the list on the itemized bill were both a testicular exam, and pregnancy test appeared...

Needless to say, my grandmother did not need, nor receive either a pregnancy, or testicular exam; so she mailed a copy to Medicare to make sure they were aware of the fraudulent charges.

Things like that happen a lot. I know after nearly 20 years on Medicare, my Grams religiously requests an itemized list of charges, and she says pretty much every single time finds something on there that was either never performed, or wasn't needed; and she always reports it to Medicare, because she says it's the patriotic thing to do.

Anyway, my knowledge of Medicare is basically limited to my Grams, but I know she's always bitching up a storm about how hospitals are always trying to rip Medicare off, has been at it for decades.  

5) When legitimate Medicare claims are denied appeals are overwhelmingly successful

LordMike wrote:

       1.   If you have a claim denied over stuff that is not covered, you can not only appeal, but you can actually go to a judge!  You can't do that with private insurance.  Most appeals are successful.

 2.  Denials to hospitals and healthcare providers may be higher, but the patient doesn't feel it.  Why?  If the hospital screws up billing, they have to eat the error entirely.  THE PATIENT PAYS *NOTHING* IF THE CLAIM IS DENIED and the patient was not told that the procedure is not covered.  The hospital/doctor has to eat the cost 100%

 3.  As a result of this, hospitals are really good at making sure they bill things appropriately to get paid.  As a result, there are very few problems for medicare patients.

6)
johnsonwax wrote:

This is only denials for bills that were submitted for the exact compensation rate (which can be pretty hard to do with many insurers, but is easier with Medicare). The largest case is that the claim lacks enough information.

But look at the numbers for the other insurers. CIGNA has 250,000 claims over the year? Shit, they process that many in 4 days. This table only captures a fraction of the claims filed.

They break down the reasons for the denials down below:

Medicare

16
132,020
27.8%
Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code).
Medicare
50
99,546
20.9%
These are non-covered services because this is not deemed a ‘medical necessity’ by the payer.
Medicare
109
65,588
13.8%
Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
Medicare
96
40,591
8.5%
Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code).
Medicare
31
27,481
5.8%
Claim denied as patient cannot be identified as our insured.
Medicare
49
18,626
3.9%
These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
Medicare
26
14,751
3.1%
Expenses incurred prior to coverage.
Medicare
B9
14,232
3.0%
Services not covered because the patient is enrolled in a Hospice.

Extended (Optional)

Originally posted to Blue13 on Mon Oct 05, 2009 at 10:10 PM PDT.

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