A take from someone who used to be employed by the Insurance Industry

[AllentownJake]

Insurance is inefficient for Healthcare.

This situation is for when an insurance company decides to pay the bill.

Prior to service, and insurance company requires a pre-authorization. The pre-auth is reviewed by someone with no medical training. If there is medical training it is reviewed by a nurse. If the pre-auth is denied than the patient can appeal and it is reviewed by a doctor that has never treated the patient. If it is denied again, it is reviewed by a panel of doctors.

A bill will come into an insurance company. The hospital throws every charge they possibly can on the bill.

Each charge has a diagnosis code and a procedure code. Claims adjusters are trained and refer to a book the size of the bible to look at each charge.

The bill is adjusted to significantly lower the price.

If the provider doesn't like the adjustment they appeal. A nurse or doctor reviews the charges, the process follows the pre-auth process mainly.

How many doctors and nurses are currently employed by insurance companies instead of treating actual patients?

I'm disappointed that this system is not being discussed more. It is almost assumed in the debate it is a good system for delivering healthcare.

[area51]

1. To the Greatest Page with you ... hopefully.

Great point about doctors and nurses who could be helping patients.

[KT2000]

2. Good info that should be discussed

But I think there are many who think the insurance company doing what they do is a good thing to keep costs down. That is the real disgrace of this whole issue.
It is getting nearly impossible to shame people for greed anymore.

[annabanana]

3. This OUGHT to be very well known, but in spite of having been a

"victim" of this payment delivery system, I have never heard it described before... Very interesting.

[HamdenRice]

4. You point out an often overlooked problem--mutually assured destruction between hospital & insurer

It's vicious cycle -- not only are the insurers greedy and constantly stiffing patients, doctors and hospitals, but as a result, hospitals have an incentive to gouge insurers by padding bills. As the insurers force the billable reimbursements down, the hospitals inflate the number of reimburseables up.

It's a dumb, dumb, dumb system.

[AllentownJake]

6. The system is nuts

If I could sit down and develop the worst system imaginable...I would be unable to even imagine a system this bad.

[ayeshahaqqiqa]

8. I work for a non-profit health foundation

and we have refused to raise our rates even though we are gouged by insurance companies--I still remember seeing where we'd had the audacity to charge them $46 for an office visit that lasted almost an hour--and were told that was too expensive! This was 50 minutes one on one with the doctor, mind you.

[Vidar]

5. Nice analysis. K&R.

[ayeshahaqqiqa]

7. As one who files the ICD-9 and CPT codes

from those books which are bigger than the Bible, and having to fight over and over and over again with insurance companies, I understand this process far too well. What gets me is when an insurance company has okayed a medicine not on their preferred list for a patient, and then denies coverage for the same medicine when the Doc has to up the dosage! This happened last week--the company was insisting (once again) that the patient go through and try ALL the drugs in a certain category, even though she had tried HALF of them and had had horrible side effects from them. We sent in documentation from the last go round, showing we'd jumped through all their hoops and were only asking for a slight increase in dosage of a medicine that they had approved. We were rejected immediately. Doc took time away from patients to sit down and write a letter--with a CC going to our Congressman. I FAXed it right away--and it was amazing how nice and polite that insurance company got. Our Congressman, a Republican I don't agree with 99% of the time, followed up the next day, making sure things were straightened out, much to his credit (hey, I'm a liberal, which means I will acknowledge when someone from the other side does something good for a change). I did take the opportunity to talk to his aid about the importance of stopping this sort of practice, and I know the words were passed on to the Congressman. He's still totally against single payer, but he gets the importance of having doctors make medical decisions.

[Laelth]

18. Thanks for giving credit where it is due.

Even generally evil Republicans deserve credit when they do the right thing.

:dem:

-Laelth

[1monster]

9. Correction: If the provider doesn't like the adjustment, they BALANCE BILL the patient. If the

patient can't pay the balance all at once, they are turned over to a collection agency who then threatens to sue and bankrupt the patient if necessary.

[livetohike]

10. This accounts for the 36 pages of bills for my broken foot

All of the back and forth administrative B.S. There's a huge cost savings lurking there somewhere.

[dave29]

11. maybe this explains why I was billed $1806 for a urinalysis?

for items marked "laboratory" on my EOB.

There's also the issue of fraud and kickbacks.

[truedelphi]

12. But but but, the President says the insurers are being sensible

And along with Big Pharma, they will discount their prices!

Surely you believe the President!

SIDEBAR - Of course they can reduce their price. If everyone was covered under a national program, they will no longer need a massive workforce to send out letters explaining why you have been retroactively dismissed from their program, why you cannot be eligible for their program, etc.

[Leo The Cleo]

13. Well Look At That

Thanks

[onehandle]

14. Kick. nt

[boppers]

15. Does that make *all* insurance wrong?

Or just the current back/forth system?

anyway, K&R

[madamesilverspurs]

16. Makes even more special

all those ads and commercials where the insurance companies present themselves as saintly altruistic entities. And I am supposed to believe I'm 'in good hands' when both of those hands are digging through my pockets.

[Laelth]

17. K&R with comment.

Forcing people to buy insurance is no more the solution to a failed health care system than forcing people to buy houses is the solution to homelessness.

:dem:

-Laelth

[AllentownJake]

19. Insurance by its nature

is for something that happens rarely. I.E. A hurricane destroys your house or a bread winner dies. Healthcare doesn't happen rarely...or at least it shouldn't.

[Norrin Radd]

20. kr

[jeanpalmer]

21. Health care for profit doesn't work

These bills in the House and Senate are frauds.

It's time to adopt the British no-profit health care system. Would cost about 60% less and provide the same care.

The solution is obvious. But our politicians are bought. Obama is a big disappointment, has provided no leadership here. He's a follower. Has the talker thing down, but lacks the vision thing.

[quantass]

22. How many Docs and Nurses does it take to screw in a .. (nt)

this is rediculuous