[QUOTE=Foxy40]
I had to read this entire thread to get a full overview of where Cemetery Savior is coming from. I feel like he/she resides in Oceania and the Party has brainwashed her into actually believing the things he/she writes.
Does the insurances know more than the doctors? OF COURSE NOT. The doctor is familiar with the actual patient, the person..he knows their symptoms, their history, their mood, their appearance. All the insurance company wants is a code and a number to feed into a computer so it can decide on the fate of the patient that is just that, a number.
Later you stated claims are denied because the codes don’t match the procedure. Who the heck is an insurance company to decide what test to run or what the doctor is trying to rule out? You throw out an arbitrary number of 70% of denials are from coding errors submitted by the providers. Coding errors that the insurance company decides don’t fit into the mold they decide to create. I want my doctor to decide, not some stranger sitting at a desk with a computer in front of them determining what is right for me and my health. Most patients feel the same. Cost containment is one thing. Looking for fraud is another. However, the insurance companies do not do this to improve the health care system. It is all done to increase profits. Which is fine. Just call it what it is.
As far as physicians negotiating fees collectively, there is something called price fixing which negates that right. However, there is no such limitation from insurance companies sharing the rates they negotiate with a provider to their advantage.
In my opinion, UHC is one of the worst insurance companies around. They grow bigger as they gobble up more and more employers with their cheaper rates because they scare providers into accepting fees that are barely enough to cover costs. The providers see the amount of lives insured by UHC in the community and feel if they do not join, they will be unable to stay afloat.
Each year my agent gives me a list of rates from other insurance companies for my employees health insurance renewal. Each year UHC comes out cheaper and each year I push that one aside. I won’t work with them professionally so I am certainly not going to subject the people that work for me to deal with them either.
After reading this thread and specifically Cem’s comments, I am convinced I have been making the correct decision.
[/QUOTE]
First, I’d love to live in Oceania, but the commute would be rough.
Second, your posting is all over the map. I’ll address the points sequentially.
[ol]
[li]When I stated that UHC knows more than the doctors, I meant it on a broader plane that in regards to the individual patient. I agree that the individual PCP will have a better insight into the individual patient. However, we have data/information that dwarfs anything even a hospital system might have. Actually, hospital systems purchase our accreted information FROM us. We hire top-tier clinicians (RNs and MD/DOs) who design our processes. Do we approve every procedure requested by the provider…no. It’s my opinion that we are correct in applying our broad-based knowledge to filter out procedures not within the standard of care. If, through doing this, we save our clients money, so be it.[/li][li]In regards to “forcing” providers to sign with our terriby low reimbursement schedule, we certainly don’t do that. If the provider has a fully-booked schedule, then they’d be foolish to sign up with any managed care network. Typically, providers sign up for potential volume. If it’s not there, they can certainly opt out of their contract at the next negotiation point.[/li][li]The codes. When I read your ranting posting, I can see you have no idea what I’m referring to. When I refer to “CPT” and diagnosis codes, I’m referring to the language the providers use to tell us what they’re doing. If you truly believe we should accept and pay whatever any provider sends us, then you should probably stop reading here. If we receive a CPT (process) code for a angioplasty and an accompanying diagnosis code for “broken left leg”, then we’re not going to pay it. It’s simple fraud protection. Let’s get a little less extrme in the example. Let’s say the CPT code is for angioplasty, and the diagnosis is hypertension. Sounds reasonable, right? It’s not. If that doctor really wants to perform an angio on that high-blood-pressure patient, they’re acting outside the scope of standard of care, and is a maverick.[/li][li]As for Kool-Aid, seems you’ve been drinking some as well. I don’t deny that we act to profit. I’d be stupid to say so. what you need to understand is that not all profit-based decisions are “bad” for the member. The processes and procedures we put in place also benefit the member, from Care Management to Subrogation, to Network and Medical Necessity Review.[/ol] [/li]
You, Ms. Foxy40, are too willing to listen to socialist screeds parroted by the ill-informed. Enjoy your paranoid overreactions.
-Cem
