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Forum Post: Vermont law illuminates claims statistics

Posted 6 years ago on April 22, 2013, 12:56 p.m. EST by GirlFriday (17435)
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Of all the claims submitted to it last year by health care providers and policyholders, Blue Cross denied 7.6 percent. Cigna denied 21 percent. MVP was in the middle at 15.5 percent.

Most of the claims denied by all three companies were categorized as “administrative,” meaning they were denied because a provider presumably used an incorrect procedure code or made some other clerical error when submitting their claims for payment. It defies reason to think that the doctors and hospitals in Vermont submitted inaccurate claims to Cigna at almost three times the rate they did to Blue Cross.

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[-] 1 points by inclusionman (7064) 6 years ago

Excellent point. Illustrates the inherent flaw of for profit health insurance model.

[-] 1 points by JPB950 (2254) 6 years ago

The problem has been a well known one and extends to all the states. Your Vermont statistics are unusually high compared to the national average. (Nationally - Cigna 3.4%, BCBS 4.6%, Medicare 6.85%)

The actual "winner" in the denied claims race nationwide is Medicare. The feeling is that insurers and Medicare do not want to pay and use coding as the excuse to delay payment or "encourage" doctors to downcode taking a lesser payment as a way to reduce the need for refiling.

Electronic medical records are correcting the problem so all procedures are more likely to be listed and coded properly. In a bit of poetic justice that is leading to higher costs for Medicare and insurers. The software being used finds every legitimate service, codes it correctly and bills for it.

[-] 1 points by GirlFriday (17435) 6 years ago

Your information comes from the Heritage Foundation and the report card kicked out by the AMA---that at this point has no serious credibility. The problem is that they attempted to present this in 2009. The douche at the Heritage Foundation kicked out another article of repetitive shit after Wendell Potters surfaced.

You have a higher success rate of appealing a denial with medicaid. That said, I hope this leads to universal and each and every private insurance company falls on its ass.

[-] 2 points by JPB950 (2254) 6 years ago

Looks like my numbers were an example of a statistic to fit a bias, sorry. Either way, we'll probably see less rejection with the electronic records and complaints from all payers as claims going up.

I think you're right premiums are going to be forced up and insurers may decide to leave the game giving us a single payer.


[-] 1 points by Nader (74) 6 years ago

My dentist was getting a lot of shit from a few insurance companies so now he just doesn't accept any. Everything has to be paid for by the patient. They will help you fill out a claim form to try to get reimbursed yourself but it is all the patient's responsibility. He said he isn't quite as busy as he used to be but his profit margin is higher so he makes about the same amount of money.

Pain in the ass for me for sure but I give him credit for wiping his hands of the insurance companies.

[-] 1 points by JPB950 (2254) 6 years ago

That's pretty common for the dentists, I've never been able to find one that accepted insurance. They all, like yours, took their payment up front and handed me a filled out form.

I know a family doctor that does that in a solo, house-call only practice.