Do you have any evidence for your claim "insurance denies claims" ? Now of course he insurance relationship is a contractual one. They have limitations on what they pay for - for example they may not cover experimental or woo treatments. They may not cover certain conditions. They may have a dollar limit per year or per lifetime. My experience is that insurers pay in full without any push-bask when the item is covered. Your claim sounds pretty fictional to me - as I've seen insurers eat a quarter million for my wife's treatment in a single year, and circa $10k/yr for decades with no denials at all.
Well, you're lucky then.
I seriously cannot stand how people like you base their entire indea of how health care works on "well I've never personally had this particular problem - so it probably does not exist!" If you're going to claim something isn't happening, using a survey sample of one to confirm that is just bad research.
Well my husband has never beat me. Using your logic, this is evidence that domestic violence does not exist.
I work at the Dana Farber Cancer Institute as a financial counselor, but previously I used to work in the Access Management department there handling denied claims.
All I did was work denied claims.
Whenever a provider calls an insurance and asks if a benefit is covered, they will
always give you the disclaimer that "benefits are not a guarantee of payment." The insurance company
always reserves the right to deny a claim, even if it is a covered benefit - heck, even if there is an authorization on file, the insurance will
still state that an authorization "is not a guarantee of payments. All claims are subject to review and we reserve the right to deny services." It is up to the medical director at an insurance company whether or not a service is "medically necessary." I would get claims every single day that were denied, some for tens of thousands of dollars, some for over 100K, which were a covered benefit for the patient's policy, but which the insurance decided was "not medically necessary" even though their doctor here at the hospital decided it was a medically necessary cancer treatment and it met the patient's policy guidelines.
The other thing insurances do is get really sneaky about authorizations. Some will intentionally make the authorization process as convoluted as possible in order to have an excuse to deny the claim. I'll give you an example situation which I came across more than once.
We'd have a patient who is getting chemotherapy. Chemotherapy required authorization, per the insurance, as did their visits with the MD in general. So we'd get three different authorizations: one for the MD visits, one generally for chemotherapy treatment, and a third for whatever specific chemotherapy drugs the patient would be receiving. But then we'd get the claim denied. Why? Because we didn't get an authorization for some piece of equiptment used to administer the chemotherapy - for instance, the needle of the catheter. Which they never told us required an authorization in the first place. And the insurance would deny the
entire claim. I would see claims for tens of thousands of dollars denied because we didn't have an authorization for a needle or some tubing which cost a few bucks.
Another big thing they do is change things around in such a way that gets claims denied. So for instance, they'll change the claims mailing address - but not inform us of the change. So then we bill the claim, and it goes to the wrong place. Then oh, look, by the time we get the corrected address, the time limit to file a claim has passed, and the insurance doesn't have to pay us at all, and we eat the cost.
Also, sometimes they would just deny a claim for a completely wrong reason. So they'd say "Oh, it was denied because no authorization was on file." But there
was an authorization on file. But maybe the insurance policy has a really brief window in which you can appeal a denial, and as we have so many denials that we need to appeal, we can only get through so many at a time. So by the time a denial would hit our worklist to appeal it, the appeal deadline has passed, and we're crap out of luck even though the denial was for a completely erroneous reason.
We lose enormous amounts of money every year because of private insurances denying medically necessary services to patients. Sometimes the hospital bites the cost, sometimes we bill it out to the patient. Sometimes the patient fights it in court and wins, sometimes they don't. We appeal denied claims, sometimes we get reimbursed, sometimes we're out $300 K on a single patient's denied treatment.
And we're an enormous and very well funded hospital that has the time and resources to fight denied claims. Many other hospitals do not, and either they bite the costs and the patient just gets billed. The patient may not have the ability or resources or knowledge to fight in court. Or maybe the patient dies and the hosptial never gets paid at all.
I have never seen one single solitary private insurance which does not do this - though certainly there is variation and there are a few companies with which these kinds of denials are relatively rare, but they still happen. With some other health insurance providers, it happens all the time (and we're talking major providers, not some rinky dink little insurance company). And I have worked with enormous numbres of insurance companies from all over the country, large and small. Just because this didn't happen to you doesn't mean it doesn't happen. It's not consistent. I could have two patients with identical policies from the same insurer, receiving the same treatment with the same diagnosis - one denies, one doesn't.
Oh, and by the way, how do you know that none of your wife's services were denied? Many times patients aren't even aware of their own denials because both the insurance and the hospital will have policy guidelines on when a patient can be billed for a denial, and when the hospital has to bite the cost. I'm not saying this actually happened, but its completely possible your wife was denied multiple services and you were never aware of it because policy stipulations do not allow you to be billed.
And keep in mind, I'm only talking about denial of claims, after the services are already rendered. We have far, far more services that are denied before the services are rendered - i.e. we apply for authorization for a service, and it is denied as not medically necessary, so the procedure is not done. As an example, we had a 24 year old patient denied by a major insurance company for a bone marrow transplant as "not medically necessary." At the time, the young man expressed to us his deep fear that now he would die because his insurance had denied his authorization. He was correct. He just died a couple weeks ago.
