• 6
• 02/11/2011
• Robert Forster

Mr. Weiss, it is obvious that you have not managed a healthcare claims payment operation. In the end, claims deny because the plan was billed for something that is not a contractual benefit or the claim is submitted improperly. These are provider responsibilities and in ALL plans painfully detail how to submit a proper HIPAA compliant bill. A better metric is the % of properly billed and submitted claims that are paid within 30 days of billing. Currently, Medicare, Medicaid, and Calif. payers are performing >90% in 30days. The wastebasket term "denied" us meaningless re: performance or where the process is suboptimal. If a physician submits a claim without a patient name, it is denied. Is that the payers' responsibility? Unless you know the process, I would not comment. A claimless system would eliminate this bureaucracy that causes much inefficiency from untrained personnel. Rob MD

• 5
• 02/03/2011
• Robert Weiss

Teachers know that when the majority of a class fails an exam, that this may be an indication that the teacher was not getting the material across properly or that the exam was faulty. May I suggest to Dr. Foster that perhaps the instructions given by some insurers to patients and billers might be inadequate and that may explain the high rate of denials? But in the end, whether the denials are due to willfull desire to maximize profits or inadequate billing and claim instructions, the solution lies with the insurers and not with the patient or the provider who are the ultimate sufferers of the denials.

• 4
• 02/03/2011
• Ace ReDeer

To echo Mr. Forster's point, the responsibility for an accurate claim payments rests across all those involved - the patient understanding the plan in which they enrolled, including network inclusions; the doctor AND nurses who accurately code the procedure; and the insurance company to pay according to the providers contract.

• 3
• 02/03/2011
• Robert Forster

The nurses and their unions should be embarrassed to release a poorly researched and written report to the press to sensationalize exactly what? Their numbers taken from CDMC and CDI are crude apples and oranges and include "denied" claims for ALL reasons:
1. Pacific care gets claims when they should not be receiving most--provider error
2. Patients do not have their insurance-not eligible
3.Claim Form is incomplete or completed incorrectly as required by law
4. Claims codes used are incorrect for serverice rendered
5. Claim has contradictory information
6. Required claim attachments not attached
7. There are hundreds of reasons why claims are denied until submitted correctly and not suspended for fraud or manual pricing.

Given that nearly all governmental/private plans meet prompt pay regulations, the numbers cited are at best misleading and worse purposefully politically misprepresented. Hatti, Payers do not deny claims if medically necessary by disease category. MD

• 2
• 02/02/2011
• Robert Weiss

This agrees with my experience as a lymphedema patient advocate. Not only does PacifiCare deny claims for medically required lymphedema treatment and compression garments, which are covered by statute and by CMS Benefit Policy Manual as "prosthetic devices", but they will fight every ALJ loss up to the Medicare Appeals Council, and then require a subscriber to appeal denials of subsequent purchases of replacements even though Medicare regulations cover replacements. Each appeal ties up the patient's funds for at least 2 years.