Strawman ! I never said it didn't exist. I said I don't see any evidence and then cited my personal expertience. To make matters worse YOU site an apocryphal case at the end of your post.
I expressed SKEPTICISM. If you "can't stand" skepticism YOU are on the wrong forum.
Good - then you are in a position to provide evidence in greater quantities then most any individual BUT unless you can cite the fraction of bills that are denied vs not denied - they you have a cherry-picking problem.
Look your organization is a services vendor and the Ins.Co's are your customers. Your contractual dealings with your customer is not at issue. The question is - when does a patient get denied payment for a contractually obligated service. We can all empathize that medical treatment has a lot of gray areas, what is necessary, what is best practice ... but if your Institution cannot generally defend their choice of services as medically necessary - then you and your customer have a problem.
You shouldn't be paid for redering unnecessary services - no matter who is paying ! You should be sued if that's the case. This is off topic.
I'm quite certain there is another side to that story.
Boo-hoo - maybe you need to work in some other field for a while to gain perspective. All contractual relationships have difficult and unforeseen issues. If you ever did work for the DoD you'd realize the no one gets paid a nickel till all the i's are dotted and t's crossed. You can charge difficult customers more as a compliance cost. You can reject the troublesome insurers as customers. If you aren't providing the service as they require then of course they don't pay - duh !
So far it sounds like your organization can't defend it's services as medically necessary and can't manage the paper work needed to document the service rendered. If this was not the case then your Institute would simply take the Insurer to court and get a summary judgment.
So then the market solution is to charge then an added compliance fee in the future to make up for their incompetence and lack of record-keeping. Still off topic.
So I've seen the stats that hospitals lose money on most medicare/medicaid patients, they certainly lose money on average to the uninsured and under insured. AAre you really claiming that also lose money on average to insured patients ? I think that's false. I think you shift the cost to other patient services and that most of the cost-shifting is onto insurance companies.
I see the billing for service before it goes to insurance and I see the ins payment statement.
Nice sob story/apocryphal data point, but at least it addresses the issue.
So in this case it seems clear (from your description) that the service was medically necessary. Why isn't their a lawsuit ? Why doesn't your hospital bill the estate. Buy back the claim from the estate for a minor sum, and then your lawyers can rip the insurance company a new one, or at least collect your due ? If it's as open and shut as you claim there would be a wonderful industry for trial lawyers here - you claim the service was covered except it was judged not medically necessary. You suggest the death proves it was medically necessary. So what is stopping you from collecting ? Look every business has a few bad eggs who refuse to pay their bills. But if they get sued a few times they stop in a hurry.
I *believe* this case is not as you state. I believe that there is something in the contract or the judgment about necessity that isn't quite as one-sided as you present. Otherwise you could personally get rich by buying a few of these otherwise worthless bills from the hospital and hiring lawyers to pursue the case on your behalf.
You've failed to demonstrate a general pattern of patients not getting insurance to cover claims that are contractually covered. If there was a general pattern then even states atty generals would be champing at the bit. You've clearly stated that your institution has trouble demonstrating the medical necessity of their services and keeping acceptable paper work. If you disagree with that characterization then why isn't your institution suing ? This makes no sense.
This entire post is just so insulting and filled with strawmen. I.E. "boo hoo, work for another industry if you think yours is especially bad." Uh, yeah, never said that what we deal with was unique. I was only responding to your skepticism that denials exist.
And yes, it is ridiculous that you base your skepticism off of one single case, your wife's. My problem is not your skepticism. My problem is your skepticism is completely based on your personal experience and not on any actual knowledge about how the industry works. Again, that would be like me saying I am skeptical that domestic abuse exists because my husband never beats me. It's a impractical and self absorbed way to come to an opinion.
If an insurance doesn't agree with medical necessity, it's because we're too bad a hospital to prove it? I work for one of the top ranked cancer hospitals
in the world. The doctors here are at the top of their field. A huge amount of advances in cancer care have come from our facility, and we're at the top of our field in several different services.
You keep saying we should sue the insurers. Sue them for what? They get to decide medical necessity, not us. Their medical directors have that authority and it is right there in the contract. If they deny us, our MDs can do what's called a peer to peer review and argue directly with the medical director as to medical necessity, and we can appeal, but it is ultimately up to the insurance. There is no clause that says they are required to perform services we believe are medically necessary just because we say it is. Now sure, there are times in which the patient can and does successfully sue the insurance company, but an insurance company saying it's not medically necessary when our MDs think it is is not in and of itself grounds for a lawsuit. There are only certain kinds of policies that patients are allowed to sue by law for denied services. In many cases, the insurance only is required by law to let the patient appeal their denial. There is not a law requiring them to overturn the denial on appeal, only allowing the patient to appeal. For some types of insurance policies, there are actually laws on the books that disalow patients from suing if they are denied. What types of policies these apply to depend upon the state.
But sure, Steve, you're right. The reason our sarcoma patient just got denied is because his oncologist, one of the top ranked specialists in the world, has no idea what he's doing and is so incompetent that he just can't demonstrate medical necessity. We must always be the ones at fault, the only reason we are denied is because of our incompetence.
On what do you base your belief that if an insurance says a service is not medically necessary and we can't sue them successfully, and the patient's doctor (or doctors) say it is, it is always the hospital who is wrong, and the insurance is always right on whether or not the treatment actually is medically necessary? And just to prevent yet another strawman, I'm certainly not claiming doctors are always right. But I really don't see how you come to the conclusion that if we can't sue successfully, it means the doctors must be wrong (or at least, are at fault for not being able to be convincing enough that they are right) and the insurance must be right about whether a service is medically necessary. This seems like almost a religious worship of private insurance that is just plain weird to me, especially considering how many policies are out there in which it is simply not allowed to sue.
Now look, maybe you're fine with insurances having the decisions over whether or not something is medically necessary, rather than the patient's doctor - or in many cases, a whole team of doctors from multiple hospitals. And you are certainly entitled to that opinion. Insurance companies are private entities and there is certainly an argument to be made that this
should be their decision, ultimately. That wasn't what I was arguing. I was only stating that denials exist and how they can occur. Nothing more. You read a whole lot into my post that just wasn't there, in addition to callously mocking dead cancer patients for good measure.
You've failed to demonstrate a general pattern of patients not getting insurance to cover claims that are contractually covered.
I never claimed there was a pattern. I specifically stated that when compared to the amount of services that are approved, denials are definitely a small minority (at least to my knowledge). I never argued denials make up X% of services. Only that they exist.
So I've seen the stats that hospitals lose money on most medicare/medicaid patients, they certainly lose money on average to the uninsured and under insured.
Did you not see my other post where I pointed out that Medicare and Medicaid are a big problem because they pay us far less than private insurers, and that I feel that universal healthcare would not work unless we developed a system with a higher compensation rate for government sponsored insurance. We do lose a lot of money on these patients. I specifically said that.
AAre you really claiming that also lose money on average to insured patients ?
No, I said the opposite. I said denials are far outweighed by paid claims. Obviously if I am saying that health insurances typically do pay far more often than they deny, then on average we would not be losing money on claims. Do we lose a lot of money every year on denials? Sure. But on average, as I clearly stated, insurers do pay and we do not lose money on their claims.
All I said is that denials exist. That was the only point of my post, that denials exist, and I listed you examples of some reasons why denials happen.
Yeesh, that was a weird post, Steve. The majority of your arguments were not only against things I never said, and in fact, things I explicitly said were not true (i.e. me clearly saying that we typically do not lose money on private insurers, they usually do pay....and then ask if I'm really claiming that we lose money on average). Or claiming that I think this doesn't happen in other industries and that this is somehow a unique burden hospitals face.
Also, you claimed that I said that you said denials do not exist. I did not say you said they didn't exist. I said that you doubted they existed based on a survey sample of one. I have very little respect for people who come to an opinion, even if it's just "I'm skeptical of this" based on a survey sample of one.
Good - then you are in a position to provide evidence in greater quantities then most any individual BUT unless you can cite the fraction of bills that are denied vs not denied - they you have a cherry-picking problem.
Whar does cherry picking have to do with anything? That would imply I'm trying to make some claim other than denials exist. Here is my statement from post #260:
I really have no idea how many people face insurance denials, and I make no claims as to how big a problem this is because I honestly have no idea. I certainly do believe that far, far more claims are approved than denied, that denials definitely make up a minority of authorization requests and claims.
Did you maybe confuse my post with someone else's or something? I'm asking this honestly because you said so many things I never claimed in the first place that I'm wondering if maybe you conflated my posts with another poster or thread and forgot who you were arguing against.
If you didn't confuse my post with someone else's though...I don't think any further correspondence with you would be productive because I honestly don't know how to write any more simply than I already am. I mean, if something as simple as:
I really have no idea how many people face insurance denials, and I make no claims as to how big a problem this is
is too hard for you to understand, any further discussion with you is pointless.
