What’d you think of SickO?
Because your plan doesn’t cover optical. If your file were to get audited and they saw that a claim for optical was paid when you don’t have that coverage, there would be major problems. It’s kind of like the zyban vs wellbutrin thing. They are the same medication but some companies won’t pay for it if prescribed as zyban (for smoking cessation) but will as wellbutrin (for depression).
Does that help some?
Would any of these would be denied under “preexisting condition”?
If I get treatment for ingrown toenails and…
a) I am employed continually for 20 years with the same employer, but they’ve switched insurers.
b) I am continually employed for 20 years but at different companies, staying with the same insurer.
c) I am continually employed for 20 years but at different companies, changing insurers as my needs.
Basically, I don’t understand preexisting condition denials. I’m guessing the policy is (theoretically) in place so that people don’t just get a job with insurance now that they’ve learned that ingrown toenails are fatal, get treatment and then quit.
also, are congenital and hereditary defects considered preexisting?
I really can’t answer your other questions, because it will vary by company and state law.
As far as this bit though, denials for pre-existing conditions or excluding coverage for the pre-existing condition are done to save money. Why would you want to offer coverage to someone that you already know needs treatment? The basic concept of insurance is to insure against future, unknown conditions. When you add a pre-existing condition into the mix it changes things.
Like with car insurance, there is a good reason why people who have been in multiple accidents that they were at fault for get dropped and have problems getting covered again. They have been shown to be a bad risk. It’s the same principle, you want to reduce your financial risks by not taking on too many cases where you will pay out more than is coming in.
That being said, pre-existing conditions are not usually a problem with employer-sponsered plans. There may be a waiting period before treatment will be covered on a pre-existing condition but it normally won’t stop you from getting the coverage.
I had an accident on May 1st 2004.
The other party admitted responsibility very shortly after the accident so why did it take 3 years, 2 months and 21 days before I was paid?
It’s the system we deal with. In case that sounds like a cop-out, think about a better way to get the process accomplished. To be honest, I think it’s a pretty good and flexible system.
The CPT Code (“what we’re doing to you”) and the diagnosis code (“why we’re doing it”) have to match for starters. Why? To make sure you and the company are not a victim of fraud. If a CPT code (“What”) says you’re getting a bariatric surgery (lap-band, for example) and the diagnosis code (“why”) says because of migraine headaches, we’re going to deny, and appropriately so. A more common version is when a Chiropractor submits CPT codes for Physical Therapy processes. He’s not supposed to do that, as he’s not licensed to do so.
Another reason we check types of provider against the process (CPT and diagnosis) is to guard against Appropriate Provider issues. In your example, the provider (one assumes a ‘normal’ doctor -MD) is sewing junebugs to your eyelids. Once we determine that he’s doing it for a good reason (CPT+Diagnosis), we review the claim. If that CPT code is an Optical code, we deny. Why? Because, as a ‘normal’ MD, he’s not licensed to provide Ophthamological care. As a normal doc, he is licensed to perform and submit certain (a huge range, normally) CPT codes. If there’s a CPT code that he can use (a surgical code for attaching junebugs, etc.), then if he submits that one, we’ll pay. We’re guarding you against providers doing what they['re not supposed to do.
-Cem
Didn’t see it yet. That’s not a political stance, I’m just lazy and don’t like movies especially. 
-Cem
Pre-Ex was always a tricky concept. **Antinor1 ** answers some of your questions very well, theory-wise (did it surprise you it was rooted in cost?).
In 1999 (I could be wrong on that year), a law named HIPAA took effect, the emphasis on the “P” (Portability). That portion of the law was designed to protect the employment rights of those with existing medical conditions.
The most common Pre-Existing condition limitation is the “6/12” limitation. This refers to the lookback/look-forward components of the provision. When you come onto a plan, the employer (OK, the insurer) looks back 6 months (coudl be 12 months, could be as high as 18 months!). If you received treatment for any condition, then it’s fair game for the Underwriter. The UW will review the condition, decide if the insurance company will experience undue effect from this condition, and then will either apply Pre-Ex, or waive it. If the UW is scared by your condition, they’ll exclude all payment for that condition (as submitted via doctor’s diagnosis code) for 12 months (by far the most common). If they’re not worried (mild hypertension with no complicating factors, a low-cost illness, etc.), they’ll waive the Pre-Ex clause and you can get treatment.
What does HIPAA have to do with this? It’s a Federal (all-states) law that protects those with conditions. It (loosely) states that, if you’ve had credible coverage for a full year prior to enrolling in your employer’s plan, the new insurance company can’t apply a Pre-Ex exclusion. That year of credible coverage can be with varied carriers, varied plan designs, varied sources (individual, group, Medicare, etc.).
Congenital and Hereditary are absolutely eligible for Pre-Ex. They’re probably one of the main sources of creating this Pre-Ex process in the first place. A good example is hemophilia. No insurance company wants to have a hemophiliac…too expensive. If the hemophiliac can get and maintain credible coverage for 12 months, it doesn’t matter…a group will have to take them on.
-Cem
Cemetery Savior, I realize I should have said something before answering questions in your thread. Didn’t mean to just jump in.
Just to give you an idea of my credentials, I started in insurance in 1995 in the auto underwriting department for Nationwide, in my time there I also worked in property/casualty claims, in the reporting, adjusting and claims services areas. I now work in sales for small group health insurance. Sounds somewhat similar to what you describe for yourself…amazing how we get around in this industry.
Along the Sicko lines, are you (or those in the biz) rewarded for denying claims? Are there incentives for denying claims? Is there any sort of correlation between your financial rewards/company perks/career advancement and the denial of claims?
I note that you acknowledge that the reason for not covering pre-existing conditions is financial in nature.
I have never seen or heard from a legitimate source any rewards for denying legitimate claims. That qualifier is an important one, some claims SHOULD be denied because they are not legitimate.
Good question. 3 years seems like a long time to get a claim paid.
Having said that, some of the delay may have been due to the Subrogation process. Most carriers will pay the member’s claim up-front (once they have all of the necessary information, including police report (if it’s an auto-accident), auto insurer, homeowner’s insurer, whatever’s appropriate.), and then pursue the other insurance carrier for the monies.
Some don’t. The delay in your claim could have been due to your insurance company pursuing the other insurance company, and waiting until it all sorted out to pay your providers (or you, if you paid up front).
If this was in England, I’m disavowing al of what I just said…I know nothing of British secondary insurance.
-Cem
Well, it’s a sticky question.
If you mean denying legitimate claims, and then being rewarded for doing so, I have never heard of that, and I’ve been (at various times) a Claims Supervisor and an Operations Manager (the Claims Supervisors reported to me). If that had been the case (two different companies, mind you), I’d have been one of the instigators. Didn’t happen, never even a hint of pressure in that regard.
Let’s work toward a logical reason as to why we wouldn’t do that:
[ol]
[li]When we process a claim, we use one FTE (full-time employee) to review it and pay/deny that claim.[/li][li]If we were to deny the claim for no reason whatsoever, then we would need to use that first FTE’s time, and then a call center’s FTE to answer the complaint. [/li][li]We would then need several other FTEs to run the appeal process, the repeated calls back and forth, a Provider specialist to answer the inevitable call from the provider (believe me, they want to get paid, too!).[/li][/ol]
Makes no sense in all but the largest-dollar claims. On those, the chance of a lawsuit is magnified, and it still doesn’t make sense. On a fully-insured claim, the employee’s company would start complaining. Absolutely not worth it.
Mikey Moore may be playing a semantic game, though. Are we paid to deny claims? In one respect, absolutely! We are paid to administer a health plan, and to deny claims that are incorrectly submitted, against policy guidelines (cosmetic, for example), and experimental. That’s one of the benefits we bring to the client. We know which claims are not to be paid.
Another semantic game? When we used to pay claims “back in the day”, we pended claims with not enough information (or incorrect info). Nowadays, we deny them, and wait to provider replies. It’s very clear (on the EOB) that we’re denying until we receive better info. Claims processors are reviewed on how many claims they process (quantity AND quality) per day. Coudl you construe that to mean they’re compensated to deny claims? Possibly, but I think it’s a weak argument.
-Cem
My husband and I refinanced our home recently and we keep getting offers for insurance to pay off the loan in case one of us kicks the bucket. This would be fantastic as my husband is a Shit Magnet and most certainly will die from a freak accident someday. The problem is the only situation any of these offers cover is if you are crossing the street stone cold sober, get hit by a truck and die immediately. If you don’t die and linger for some six months or get an infection from the injury and then die, you don’t get squat. Or if you took a couple prescribed pills before the truck hit you, you get nothing, much less if you were walking home from the bar becasue you had a few and didn’t think you should drive. Each has many more exclusions. Why would ANYONE sign up? They usually run about $30 bucks a month, but with no medical screening. Woo-hoo.
Sorry - I forgot I had posted a question!
Yes to both you guys, that does explain the process much better. I get so frustrated when I get told that yes, we cover that but make sure your doc codes it as XXX because most people code it as YYY and we won’t cover it that way. It all has a very “wink, wink, nudge nudge” feel to it (hold your hand to left when you sign, that’s the secret to getting the claim paid!) but I think the reason I get frustrated is because I look at it as a personal irritation, and not part of a larger picture. Which I bet is the case for most insurance irritations.
Thanks guys!
ETA - wonder what I can get that would be medically referred to as XXX, cause that sure sounds fun!