nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
See here for more discussion.

Saturday, July 3, 2010

Is Denial Of Coverage Always Bad?

Of course not.  What we're concerned about is denial that fails to deliver on a "promise of care."

Denying coverage occurs for a lot of reasons.  The politicians would like you to believe it occurs because evil insurers want to increase profits.  Some do, most don't.

I've run a healthcare system.  Here are some of the most common reasons a payment gets denied:
1.  The patient, doctor, or hospital submits a duplicate claim  (Yes, in my experience that's the most common occurrence--and it always gets straightened out).
2.  The claim got submitted to the wrong insurer.  (Silly, but it happens all the time.  People get confused about their insurance card, carry around old ones, etc)
3.  The patient chose a "catastrophic only" plan and now expects coverage for routine care.  (There are many wrinkles on this:  the patient thinks certain things should be in the plan, but never bothered to check before choosing it, or they are tied to an employer plan that doesn't cover the specific thing they want, etc)
4.  Somebody in the convoluted process of filling out the paperwork, from the patient to the doctor to the office or hospital insurance administrator, the employer, the insurer, Medicare, Medicaid (the list of people who have to complete a form and pass it on is endless) makes a mistake in the name, procedure, social security number, address, date of service, etc.

And that covers most of the denial of care.   Go to the Government's New Health Care Website, where they talk about denial of care.  The discussion is all about "arbitrary" and "outright" denial (by evil money-grubbing insurance companies, of course). 

That DOES occur, but not commonly, because it's more expensive to pay lawyers and fines when insurers try to do this.  Insurers make more money to just follow the rules, as best you can, and their profit margin is fairly low compared to most industries (they rank 86th).

This is more of the "demonization" politics by the Administration.  Maybe some of you know someone who works for an insurer.  99% of them are just people who work in a cubicle and process paperwork.  The highly overpaid executives are a drop in the bucket when it comes to health care costs.  Take all their bonuses away and it won't pay for one hour of medical care in this country.

We need tighter controls on fraud.  Medicare is under-resourced to track down pizza parlors who try to file $3M in Medicare claims.

But you should realize that "denial of care" comes about for a lot of reasons, not just because insurers do bad things.  The data on the government's website make no allowance for all the reasons I gave above.  They make it sound like all of the denial is bad.  That's false.

Doc D

No comments:

Post a Comment


What I'm Reading - Updated 3 May

Blog Archive