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Medicare has highest denial rate
Posted by: swampy
Date: October 06, 2009 11:34AM
[www.ama-assn.org]



Quote

Of the eight insurers listed, Medicare is most likely to reject a claim, sending away 6.85% of requests. This is more than any private insurer and double that of the private insurers’ average!

In short, the AMA is endorsing a plan whose closest existing example is the most frequent denier of claims. How the public option exemplifies “delivering care to patients” is unclear.

Ah yes, those evil private insurers. Say again?



If you don't stand for something, you'll probably fall for anything.t
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Re: Medicare has highest denial rate
Posted by: JoeH
Date: October 06, 2009 11:51AM
Read their definition of "denied". It is very broad, basically any procedure which is not paid whether for reasons of not being covered, or just failure to be properly documented.
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Re: Medicare has highest denial rate
Posted by: mattkime
Date: October 06, 2009 11:52AM
My first question -

Is denying a claim the same as denying coverage?



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Re: Medicare has highest denial rate
Posted by: $tevie
Date: October 06, 2009 11:53AM
Almost a third of the Medicare denials are labeled as "16 Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code)." To me that sounds like something that was fixed simply by resubmitting the claim.



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Re: Medicare has highest denial rate
Posted by: swampy
Date: October 06, 2009 12:31PM
Are you saying that private insurance doesn't deny coverage because of lack of "information needed for adjudication" or bad "remark codes" and other paper work goofs? These things only happen on Medicare applications for payment?

I don't buy your argument.



If you don't stand for something, you'll probably fall for anything.t
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Re: Medicare has highest denial rate
Posted by: michaelb
Date: October 06, 2009 12:32PM
I haven't ever seen studies or discussion on the question, but I would guess this is true. Medicare has lots of problems and obviously needs reform. Denial rate is only a small part of it though and most reforms may work to increase the denial rate (in order to reduce medicare fraud and abuse). I would like to assume that by creating this thread and pointing this out, Swampy supports health care reform that includes a substantial reform of Medicare; but of course I know that these posts are really just a jumble of incoherent and contradictory regurgitations from what is heard or posted elsewhere.

I should note that Medicare has its complex ABN process, so beneficiaries are only liable for these denied charges if the provider gives them advance notice in writing in advance. Most of the time that doesn't happen, so providers get stuck with these bills most of the time, not beneficiaries. No such protection exists in the private health care realm.
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Re: Medicare has highest denial rate
Posted by: mattkime
Date: October 06, 2009 12:33PM
>>I don't buy your argument.

I'm still trying to figure out what your argument _IS_.



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Re: Medicare has highest denial rate
Posted by: $tevie
Date: October 06, 2009 12:36PM
I was looking at the long list of reasons for each group and what percentage was used of the reasons each group presented. Excuse me for reading.







Edited 1 time(s). Last edit at 10/06/2009 12:36PM by $tevie.
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Re: Medicare has highest denial rate
Posted by: Dakota
Date: October 06, 2009 12:49PM
Looks like people praise Medicare for denying payments (to buttress the efficiency argument etc.) and doing exactly the opposite to private insurers to prove their greed.



After you discover you're riding a dead horse, your best strategy is to dismount.
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Re: Medicare has highest denial rate
Posted by: lafinfil
Date: October 06, 2009 12:53PM
Can you restate that in English so it makes sense



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Re: Medicare has highest denial rate
Posted by: Rolando
Date: October 06, 2009 01:44PM
Quote
Dakota
Looks like people praise Medicare for denying payments (to buttress the efficiency argument etc.) and doing exactly the opposite to private insurers to prove their greed.

Looks like people who love Private Health Care for making a profit by cutting costs hate it when Medicare does the same.
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Re: Medicare has highest denial rate
Posted by: Dakota
Date: October 06, 2009 03:24PM
Quote
lafinfil
Can you restate that in English so it makes sense

Sure. Medicare cutting costs good. Aetna cutting costs bad. Now, here is your coloring book. Get busy.






After you discover you're riding a dead horse, your best strategy is to dismount.
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Re: Medicare has highest denial rate
Posted by: mattkime
Date: October 06, 2009 03:31PM
>>Sure. Medicare cutting costs good. Aetna cutting costs bad. Now, here is your coloring book. Get busy.

Please cite where that was said in this thread.



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Re: Medicare has highest denial rate
Posted by: Rolando
Date: October 06, 2009 03:58PM
Quote
Dakota
Quote
lafinfil
Can you restate that in English so it makes sense

Sure. Medicare cutting costs good. Aetna cutting costs bad.

I wonder how many people had to die to cover the head of Medicare's multimillion dollar salary, bonuses, perks...
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Re: Medicare has highest denial rate
Posted by: swampy
Date: October 06, 2009 04:26PM
Quote
mattkime
>>Sure. Medicare cutting costs good. Aetna cutting costs bad. Now, here is your coloring book. Get busy.

Please cite where that was said in this thread.

Please go read the chart in the opening post and quit being so stupid.

One more time... who has the highest denial rate. Aetna or Medicare?

Too bad you have to be treated like a second grader, matt.



If you don't stand for something, you'll probably fall for anything.t
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Re: Medicare has highest denial rate
Posted by: mattkime
Date: October 06, 2009 04:32PM
you didn't answer my question

>>Sure. Medicare cutting costs good. Aetna cutting costs bad. Now, here is your coloring book. Get busy.

Please cite where that was said in this thread.



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Re: Medicare has highest denial rate
Posted by: Dakota
Date: October 06, 2009 07:39PM
Quote
mattkime
you didn't answer my question

>>Sure. Medicare cutting costs good. Aetna cutting costs bad. Now, here is your coloring book. Get busy.

Please cite where that was said in this thread.

I read between the lines. How many times have we heard Medicare has only 4% overhead(whatever that means)? Now we learn how they get to that. By denying claims.



After you discover you're riding a dead horse, your best strategy is to dismount.
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Re: Medicare has highest denial rate
Posted by: mattkime
Date: October 06, 2009 07:40PM
>>I read between the lines.

You misread.

>>Now we learn how they get to that. By denying claims.

Reading between the lines again?



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Re: Medicare has highest denial rate
Posted by: Dakota
Date: October 06, 2009 07:49PM
Another liberal signature; denying who they are and what they said. When they run for office they are fiscal conservatives and support the troops. Once they get in , well, we get we have now.



After you discover you're riding a dead horse, your best strategy is to dismount.
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Re: Medicare has highest denial rate
Posted by: mattkime
Date: October 06, 2009 08:09PM
Sometimes I think you're a random message generator.
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Re: Medicare has highest denial rate
Posted by: lafinfil
Date: October 06, 2009 08:17PM
his own private babblefish



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Re: Medicare has highest denial rate
Posted by: Ted King
Date: October 06, 2009 09:54PM
Quote
Dakota
Quote
mattkime
you didn't answer my question

>>Sure. Medicare cutting costs good. Aetna cutting costs bad. Now, here is your coloring book. Get busy.

Please cite where that was said in this thread.

I read between the lines. How many times have we heard Medicare has only 4% overhead(whatever that means)? Now we learn how they get to that. By denying claims.

I think you need to connect more of the dots so as to explain how the relationship between low overhead and the denial of claims leads to your conclusion. For example, isn't the percent of total overhead savings that comes from denying claims an important bit of information that needs to be established? If that percent is very low, then it would not seem be to be justified to claim that Medicare's low overhead is due primarily to denying claims. Perhaps (and perhaps more likely) there are other factors that have a much greater effect on Medicare's low overhead relative to private insurers (given their practices).
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Re: Medicare has highest denial rate
Posted by: Dakota
Date: October 06, 2009 11:24PM
Overhead can mean a zillion things and can be calculated in a zillion ways. It is just a talking point for Schumer to throw around. Medicare, the public option in all its grandeur, is headed for bankruptcy. They can have zero overhead and still wouldn't make a difference.



After you discover you're riding a dead horse, your best strategy is to dismount.
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Re: Medicare has highest denial rate
Posted by: mattkime
Date: October 06, 2009 11:30PM
>>Overhead can mean a zillion things and can be calculated in a zillion ways.

Actually, I think it has a very simple and straight forward definition.

Premiums - Healthcare Servies = Overhead

(assuming no profit)



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Re: Medicare has highest denial rate
Posted by: Ted King
Date: October 07, 2009 01:03AM
Quote
Dakota
Overhead can mean a zillion things and can be calculated in a zillion ways. It is just a talking point for Schumer to throw around. Medicare, the public option in all its grandeur, is headed for bankruptcy. They can have zero overhead and still wouldn't make a difference.

Point out an irrelevancy that may or may not be correct. Ad hominum. Think Medicare, which operates in the free market, should for some reason be considered as headed for bankruptcy if it doesn't raise taxes or cut services, but private insurers facing exactly the same situation respond to rising costs by raising premiums or cutting back services are thought to be merely responding to the free market and not necessarily headed for bankruptcy.



Edited 1 time(s). Last edit at 10/07/2009 01:04AM by Ted King.
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Re: Medicare has highest denial rate
Posted by: DCrunch
Date: October 07, 2009 10:27PM
Anyone here on Medicare? I've been on Medicare for three years and have never had a claim denied. Knock on wood?
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Re: Medicare has highest denial rate
Posted by: swampy
Date: October 08, 2009 10:06AM
Quote
DCrunch
Anyone here on Medicare? I've been on Medicare for three years and have never had a claim denied. Knock on wood?

Yepper



If you don't stand for something, you'll probably fall for anything.t
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Re: Medicare has highest denial rate
Posted by: mattkime
Date: October 08, 2009 10:34AM
>>Anyone here on Medicare? I've been on Medicare for three years and have never had a claim denied. Knock on wood?

Thats exactly the confusion that swampy either aims to create or is enveloped by.

Its not Medicare denying claims for patients. Its Medicare denying payment to doctors due to incorrect paperwork.

As michaelb noted above, the only way this can come back to the consumer is if you sign paperwork saying that you know its not covered.



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Re: Medicare has highest denial rate
Posted by: Dakota
Date: October 08, 2009 10:40AM
Quote
mattkime

Its not Medicare denying claims for patients. Its Medicare denying payment to doctors due to incorrect paperwork.

OK, so I throw this out too,

Its not Aetna denying claims for patients. Its Aetna denying payment to doctors due to incorrect paperwork.



After you discover you're riding a dead horse, your best strategy is to dismount.
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Re: Medicare has highest denial rate
Posted by: mattkime
Date: October 08, 2009 10:44AM
Dakota - I completely agree!

While these numbers do illustrate a problem with the system, it is minor compared to other problems such as -

1) Patients being denied care all together
2) Skyrocketing costs
3) Growing number of uninsured



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Re: Medicare has highest denial rate
Posted by: $tevie
Date: October 08, 2009 10:48AM
This all goes back to what I said earlier. One can read through the pdf file that Swampy linked to and see detailed explanations of every chart. In fact, the chart Swampy posted has very little to do with refusing to cover treatments and very much to do with paperwork problems, for all the companies listed. Again, this is predicated upon the concept of reading the pdf. Sorry for any inconvenience this may create.



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Re: Medicare has highest denial rate
Posted by: lafinfil
Date: October 08, 2009 08:01PM
My sister worked her way through college as a medical billing specialist for a local clinic (200+) docs and the
bulk of her work was resubmitting Medicare claims. The problems are / were largely due to a
incorrect coding on the part of the submitter (clinic) largely based on improper DRG assigned by the doc.

When my dad was sick her services in deciphering his bills was invaluable because most the docs
were still submitting under incorrect DRG codes.



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