More about Third-Party-Multi-Payer Insurances gaming the system
| By Michele S - Jan 16th, 2008 at 12:04 am EST |
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Categories: Peace & Social Justice, Affordable Healthcare, Consumer and Worker Protection
Categories: Peace & Social Justice, Affordable Healthcare, Consumer and Worker Protection
The delaying and denial of claims takes a heavy toll on providers and hospitals. The following account by a New York doctor in 2007 relates the nature of delay tactics practiced by multipayer insurances (http://www.ama-assn.org/...).
As stated on the AMA Web site, "Prompt pay laws have been established since the late 1990s by states to relieve problems of delayed payments by most private health care plans to providers." However, just as they have bypassed statutes requiring insurances to be not-for-profit in Minnesota, so, too, do insurances often bypass this requirement.
Says one doctor:
"In New York, where I live,the law requires that clean claims must be paid in 45 days. But, as you might imagine, the insurance industry has found legal loopholes, and payment delays are the norm for doctors around the country.
"I guess things are so bad for the nation's doctors, that the AMA has an on-line booklet appropriately entitled '15 Steps to Protect Your Practice from Abusive Payment Tactics.' Like most complicated issues in life, there are myriad complexities to the crisis involving third party payments to doctors. But I'll give you a sense of what my friends who are doctors tell me.
"They say that getting paid is more often than not a take-no-prisoners battle. An insurer will reject a claim for the smallest reason. If a claim is submitted with every T crossed and every I dotted, as sure as night follows day, the insurer will require reams of additional information on the patient and the procedure. Almost nothing gets paid without a fight. Some describe the fight as a smoke and mirrors Kafkaesque nightmare.
"Imagine this sort of scenerio playing out in doctor's offices and hospitals across the nation. Imagine the costs associated with an army of claims specialists who are employed simply to pry payments out of the hands of the for-profit insurers. Physicians charge that one of the most common practices leading to long lag times is insurers' refusal to pay claims they say aren't 'clean.' They also ask patients to send unnecessary information before they'll pay, doctors alleged."
One doctor reported that an insurance company denied a claim for procedures performed on both of a patient's knees during one office visit, arguing that the claims were duplicative. Insurers also have asked his patients to provide accident information, even though it's already provided on a claim form, or information about pre-existing conditions. Health plans often won't send a copy of the request, so the doctor's staff can't help patients get the information. One claim for hand surgery included the surgeon's name and license number, but the insurer denied payment because the claim didn't state the doctor's degree.
"Most of it is really ridiculous -- standard form letters in their system that they shoot off and hope the provider doesn't address," explained an office administrator. "A lot of these claims get paid down the road, but they hold the funds 30 to 90 days longer than if it went through with a 'clean' claim," she said.
As stated on the AMA Web site, "Prompt pay laws have been established since the late 1990s by states to relieve problems of delayed payments by most private health care plans to providers." However, just as they have bypassed statutes requiring insurances to be not-for-profit in Minnesota, so, too, do insurances often bypass this requirement.
Says one doctor:
"In New York, where I live,the law requires that clean claims must be paid in 45 days. But, as you might imagine, the insurance industry has found legal loopholes, and payment delays are the norm for doctors around the country.
"I guess things are so bad for the nation's doctors, that the AMA has an on-line booklet appropriately entitled '15 Steps to Protect Your Practice from Abusive Payment Tactics.' Like most complicated issues in life, there are myriad complexities to the crisis involving third party payments to doctors. But I'll give you a sense of what my friends who are doctors tell me.
"They say that getting paid is more often than not a take-no-prisoners battle. An insurer will reject a claim for the smallest reason. If a claim is submitted with every T crossed and every I dotted, as sure as night follows day, the insurer will require reams of additional information on the patient and the procedure. Almost nothing gets paid without a fight. Some describe the fight as a smoke and mirrors Kafkaesque nightmare.
"Imagine this sort of scenerio playing out in doctor's offices and hospitals across the nation. Imagine the costs associated with an army of claims specialists who are employed simply to pry payments out of the hands of the for-profit insurers. Physicians charge that one of the most common practices leading to long lag times is insurers' refusal to pay claims they say aren't 'clean.' They also ask patients to send unnecessary information before they'll pay, doctors alleged."
One doctor reported that an insurance company denied a claim for procedures performed on both of a patient's knees during one office visit, arguing that the claims were duplicative. Insurers also have asked his patients to provide accident information, even though it's already provided on a claim form, or information about pre-existing conditions. Health plans often won't send a copy of the request, so the doctor's staff can't help patients get the information. One claim for hand surgery included the surgeon's name and license number, but the insurer denied payment because the claim didn't state the doctor's degree.
"Most of it is really ridiculous -- standard form letters in their system that they shoot off and hope the provider doesn't address," explained an office administrator. "A lot of these claims get paid down the road, but they hold the funds 30 to 90 days longer than if it went through with a 'clean' claim," she said.
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