A doctor at Cigna comes clean about insurance company denials.

If you ever wondered why clean claims get denied, a doctor shows us what is wrong with insurers who will do almost anything to increase their profits. The mantra of deny deny deny is alive and well in our insurance system.

I tell our patients, fight for what you believe you are owed.

I recently had the situation with my own insurer, Horizon for a colonoscopy that was supposed to be covered 100% for preventative care. They covered the facility and procedure but the anesthesia was billed against my deductible. I called and they reviewed it and sent the claim to be corrected. Hopefully, this only required one phone call. Doctors who work in this system like me also have the same problems with insurance our patients experience.

Our staff is constantly calling insurers that pay slowly or make obvious mistakes in an already over complicated system. Numerous calls to correct mistakes made by electronic systems designed to make mistakes are the norm. Often, persistence pays off. When it doesn't, patients are asked to do their part otherwise, they will need to pay the bill themselves.

Patients don't trust the system and I cannot blame them, but our office does their best to go beyond the call of duty to help as we are able.

When the patient as the subscriber calls and complains, insurers are often more helpful in resolving a problem, although, it is not unusual to be misinformed by the insurance staffer as well. If the plan is self insured with a large company, often a call to HR may be the only way to solve this and in our experience, often can.

There are helpful resources available to patients such as filing a complaint with DOBI (department of banking and insurance). This tells the state that your insurer in your opinion has acted inappropriately and they must by law respond. This only works with fully insured plans, not those that are self insured which are governed by a different set of laws under ERISA. Half of those who work for large companies are in self insured plans.

The problem with for profit insurance

Recently, Propublica, an advocacy organization reported on a doctor who was pressured to review cases too quickly or she would be fired.

This doctor who had worked with Cigna's reviewed many cases by nurses in the Philippines that had clear errors of judgement that probably were more about insurance company incentives.

My brother in law worked for a workers compensation company that outsourced people to the Phillipines and watched as great employees were replaced with problematic ones in other countries. While he was not a decision maker, he did watch as employees abroad made more errors and often cost more than the insurer thought, just to save a buck. As a regional manager, he was forced to lay off many great employees, only to be replaced by lower cost ones in other countries that ultimately, saved very little and increased the errors in the system.

Not long ago, Aetna did something similar in California and there are many similar stories.

Medicare Advantage plans that are inferior to regular Medicare and a secondary were shown to have been overcharging Medicare. Most patients don't realize that getting into Medicare is a way to partially escape the craziness in the current insurance system of high premiums and deductibles that often hit hospitals early in the year causing cash flow problems. This high deductible nonsense has forced patients financially to delay needed care and become more chronic. The result is higher treatment costs and they just pass it to us the following year. Why can't we expand Medicare to younger people or move toward a more Universal style system the western world already knows works best while controlling costs?

Check out the Propublica article here