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Posted on 2. July 2010

Denied By Mistake! A Reimbursement System That Needs Fixing

By Ronale Tucker Rhodes, MS

Remember the movie John Q. in which Denzel Washington plays the father of a young boy who takes a downtown Chicago emergency room hostage when he learns that the heart transplant his son needs won’t be performed because his health insurance doesn’t cover it? That may seem to many people like a pretty drastic measure to take. But, is it? With the countless refusals by health insurers to cover immune globulin (IG) treatments, I’m betting that many of you have felt like going to extreme measures as well.

It will interest you to know, then, that you’re not alone. According to the American Medical Association’s (AMA) annual National Health Insurer Report Card, one in five health insurance claims is wrongly handled, creating billions of dollars in unnecessary administrative costs, slowing down payments to doctors and frustrating patients. Mishandling of claims includes those processed with errors resulting in them being underpaid, overpaid or incorrectly unpaid .

The main problem appears to be that “each insurer uses different rules for processing and paying medical claims, which cause complexity, confusion and waste,” says former AMA President Dr. Nancy Nielsen. “Simplifying the administrative process with standardized requirements will reduce unnecessary costs in the health system.”

Eight companies were evaluated in the report, with Conventry Health Care rated the best with an accuracy rate for processing and paying claims of 88.4 percent, while Anthem Blue Cross Blue Shield rated the worst with a score of only 74 percent.  The overall accuracy rate was 80 percent . Each percentage point improvement represents $778 million in savings in unnecessary administrative costs.

According to the report, denials of insurance claims remained a sore point for physicians who called for insurers and employers to provide clarity about what is and what is not covered. The percentage of claims denied ranged from 0.7 percent to 4.5 percent. For John Q.’s son or for those who need a life-saving treatment such as IG, claims denial can have life-threatening results.

We know that many of you have some frightening insurance claims denial stories. We also know that in many, if not most, cases, those denials were reversed simply because errors in claims processing were resolved. Supporting standardization of claims requirements seems like such a simple solution, doesn’t it?

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Categories: Need to Know

Comments (1) -

Eugene Richardson
3:30 AM on Saturday, July 03, 2010

Denial in 2004 almost cost me my life as my breathing difficulties became life threatening not to even mention the other horrific symptoms from my diagnosed CIDP and Autonomic Neuropathy.  Not medically necessary Medicare said, and then strung out the doctor for over two years before he was paid.  The even more horrific part was that NO ONE at the hospital (Holy Cross in Fort Lauderdale) cared, were not truthful on why I was being refused, and it was only because of my wife's determination that I received the infusion at the emergency room at Imperial Point Hospital just in the nick of time.  I have no doubt that left alone the system DID NOT CARE.  

The second tier problem this causes is that hospitals, at least in Florida continue to refused to provide IVIg therapy to all new patients because of the cost and reimbursement issues.  Every month I hear of patients still turned away at infusion centers in Florida in spite of all our work to resolve these issues.  

My blessings to you in your work on our behalf as folks who DO CARE.

LtCol Eugene B Richardson, USA Retired
CIDP patient due to exposure to Agent Orange in Vietnam 67-68 as confirmed by Board Certified Neurologist Dr. Waden Emery III of Lighthouse Point, Florida

  

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