As a self-employed person in New York, I am at the mercy of the insurance industry. For reasons known only to politicians, but a mystery to me and thousands of other New Yorkers, insurance companies can discontinue our coverage wily nily. Maybe it has something to do with lobbyists and campaign contributions. I don't know.
There is an even more insidious insurance scam being perpetrated on millions of Americans. This is by no means unique to New York, it is an industry wide insurance racket. It was highlighted yesterday in a comment by a fellow Kossack. Insurance companies routinely ignore, disavow, throw away, call it what you will, legitimate claims. Certain states, New York happens to be one of them, mandate that insurance companies review and pay claims in a timely fashion.
New York has what is known as a "prompt pay law." Receipt of a claim triggers a 45 day payment countdown. But, if the insurance company never receives the claim, the legally required time frame for payment cannot be enforced.
I was on the receiving end of these corrupt business practices several years ago. At the time, I was covered by a different carrier than the one from which I was just cancelled. I sent in several modest claims which were never paid. When I called to find out why, I was told the claim was never received. This happened repeatedly.
Well if they don't receive your claim, the prompt pay law never kicks in. So far, so good. Give a big star to the insurance company and a big kick in the ass to the beleaguered insured.
Then I got smart. I sent the claims registered mail, return receipt. Still nothing. I called again and I trapped the insurance company in its own shameless lies. I was holding the little green signed return receipt card.
This is an excerpt from the NYS "Prompt Pay Law"
"This statute is commonly known as the "prompt pay law". It was enacted to provide protection to both patients and health care providers in connection with the timely payment of claims by insurers and health maintenance organizations. Insurers and HMO's are ultimately responsible for compliance with this law despite any contractual delegation of the claims payment process. See Insurance Department Circular Letter No. 12 (2000), and New York Health Plan Assoc., Inc. v. Levin, 187 Misc.2d 527, 723 N.Y. S. 2d 819 (Albany Co. 2001)."
But if the insurance company can disavow receipt of the claim then they have effectively stopped the clock on the 45 day law.
But still, making the insurance company simply acknowledge receipt of a legitimate claim was so impossible that I finally turned to Elliot Spitzer's office for assistance. Can you imagine having to call the attorney general's office to help because the insurance industry feels it can act with impunity in violating its contract with its customers?
Thankfully, I wasn't sick, This is what insurance companies are doing across the length and breadth of this nation to INSURED AMERICANS battling horrendous illness. A sad game of cat and mouse.
I bring this up because when all of this was happening, I kept thinking, I'm losing my mind. This is America, they can't throw these claims in the garbage.
Yes they can, and yes they do!
Read what our fellow Kossack, jrieth says. She worked in a hospital billing department:
jrieth made the following comment yesterday:
"I worked for about four years at University of Maryland Hospital doing accounts receivable for physician billing. I can tell you these insurance companies are cold, calculating machines that do everything they can to reduce payments to patients and doctors in order to reduce their payouts and increase their quarterly earnings.
They would begin systematically denying routine claims for some invented reason (usually coding.) Most physicians office's are still not adapted even to this new dog-eat-dog business style and do not employ adequate back-office support to manage this game. But I can tell you as soon as we held meetings w/ representatives for insurance companies and produuced evidence of their errors, we'd get our payments, but... the next month another routine procedure would just begin having the same issue. And the more nit-picky the denial could be the better, because then it only hits a percentage of the claims and would generally go unnoticed as a policy discrepancy.
In many cases the doctors offices are so clueless how to deal with insurance companies that they just turn their bills around on the patients believing they did not have adequate coverage. In Baltimore City this was particularly dangerous as we dealt with many indigent patients or people on the edge of that line. The state agencies were equally as difficult to work with.
Ask any physician to look at his insurance receipts on regular months and then compare that to the end of the insurance companies fiscal year. In all the practices I worked for we saw claims held up for 60-90 days for the sake of their precious year-end figures... or worse... they would just "lose" the claim. And if you didn't realize it fast enough... "past timely filing.. rejected."
Anyways, sorry this is so long. Here's a book that might interest you. It touches on the topics I've experienced first-hand."
This sleigh of hand goes on all the time. You're not crazy. Insurance companies will do anything to improve their bottom lines including throwing your claims in the garbage.