They aren't even very good at getting reimbursements done properly

[eridani]

http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2010/11/30/BUSR1GJ01V.DTL

State regulators Monday fined seven of California's largest health insurers nearly $5 million for systematically failing to pay doctors and hospitals fairly and on time.

The California Department of Managed Health Care issued the fines following an 18-month audit in which investigators looked at a small but statistically significant sample of claims. The investigation found the plans were paying on average about 80 percent of the claims correctly, far below the legal threshold of 95 percent.

<snip>

In addition to the fines, the companies must pay the doctors and hospitals restitution that is expected to run into the "tens of millions of dollars," Ehnes said. The plans will also be required to come up with a plan to correct the problem and submit to future audits.

Five of the insurers, excluding Anthem and Blue Shield, were also found to have improper provider appeals processes.

When doctors and hospital officials try to dispute a claim, they often have to deal with the same individual who originally denied the claim in the appeals process, Ehnes said.

Comment by Don McCanne of PNHP: What services do the private insurers provide for us? Processing claims? They won't even do that right 20 percent of the time, according to this California audit. The total of $5 million in fines that they were assessed is so paltry that they have no incentive to discontinue their highly profitable policy of delaying and denying legitimate claims.

Let's have the members of Congress fire the insurers and set up our own national health program - an improved Medicare that covers everyone. If they won't do that then let's fire them, replacing them with responsible elected stewards who will.

My comment: National HCR totally lacks ANY requirement that insurance companies pay claims correctly and on time.

[LaurenG]

1. Health insurance companies are one of the most devious business out there.

One of the really big insurers has played a huge role in putting solo practitioners and small groups of family practitioners out of business. Even when they do pay and pay on time they contract differently with the small docs. The reimbursement is pathetic in comparison. Try having to see 32 patients a day just to meet your overhead and still give good patient care by following not only AMA guidelines but corporate insurers guidelines as well. One of the big insurance companies won't even approve physicals for their members and if they need routine blood work done the tests are not covered and we routinely see $500.00 plus bills being passed back to the patient because their expensive insurance won't cover it.

It's a greed run world, the greedy have won, at least for now.

[Divernan]

2. I'd say they are the deadliest business out there.

Remember, everyone, their claims people routinely deny many of the more expensive claims, particularly involving expensive testing, meds and procedures. They know that statistically, most people are too ill-informed, uneducated, exhausted, easily intimidated, just too damn sick from whatever's wrong with them to understand the complex, in-house multi-phase appeals procedure. And the appeals process is so lengthy, that people who do try to fight for the health care they are entitled to under their policies, die before the appeal process can be completed (understandable, since they haven't been able to get the care that would have saved their lives).

Lucky me! My blue dog congressman, Jason Altmire, was a lobbyist for an international hospital chain, and is the darling of Big Health Insurers.

[Recursion]

3. Medicare denies claims at a higher rate than any private insurer

And has a freakishly byzantine appeals process. Simply making the government run something doesn't automatically make it better.

[eridani]

4. Those are almost always questions of ID

And my HMO has far less hassle with Medicare than with private insurers.