Detroit News: It pays to challenge HMOs, Denials of emergency room care

[diamond14]

almost always reversed on appeal, study shows

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Monday, January 26, 2004


It pays to challenge HMOs

Denials of emergency room care almost always reversed on appeal, study shows


By Lee Bowman / Scripps Howard News Service

-snips-

If your managed care plan refuses to pay for a trip to the emergency room, it might pay to challenge the decision.

Denials of emergency room coverage are almost always reversed and claims paid if the decisions are appealed, according to a study of claims at two large California HMOs.

The study, published today in the Annals of Emergency Medicine, analyzed 405 appeals of coverage denials from two health plans from 1998 to 2000. Disputes over emergency room payment made up 52 percent of appeals for services already provided at one plan and 34 percent in the second plan.

Carole Grezenz, a RAND researcher and co-author of the study, said often patients don’t challenge denials that would be reversed on appeal and so “bear the financial brunt” of confusion over whether the visit is legitimate.

http://www.detnews.com/2004/health/0401/26/a01-45564.htm

[diamond14]

1. classic HMO...many emergency patients will be TOO SICK to

challenge the HMO...

emergency patients often are sent home today to save HMO costs, rather than be admitted to the hospital for care....

then, we have to pay for stupid studies, which determine that patients are DENIED payment, until they object...what a brilliant conclusion...

this is why HMO's need to removed from ALL medical care...

[lcordero]

2. an emergency room care claims denial?

I'm surprised that all of these people haven't found themselves on the ugly end of a lawsuit.

[KT2000]

3. It's called Push-Back

A lot of businesses are doing it -things like paying invoices at 90 days instead of 30 - as long as they can get away with it.

Couple years ago the WA State Insurance Commission held hearings about the troubled state of affairs with medical insurance. A couple that I remember

1. Doctors had to hire extra office staff to just keep after the insurance company to pay. Month after month the ins company would say - we have no record of that visit, even after the doctor had resubmitted several times.

2. A whistleblower from the company revealed that workers were required to have clean desks at 5 PM. They just shoved the claims they had not yet processed in the garbage.

Always Push Back!! They (most large companies) are hoping you will figure it is not worth the effort and they make lots of money.

Corporate value system at work.

[Amager]

4. That makes it look like they deny it just to see if they can get away with

it and hope the patient doesn't appeal, but the ones who do are overturned and paid. They save money in the long run by denying them to begin with because not everyone appeals.

How the hell do they justify denying an emergency room visit??

[diamond14]

5. did it for BOTH my mom & dad, and after the last one died, hospitals

and doctors right away put a lean on their house...the insurance company horror, perpetrated on sick and disabled people, truly adds enormously to the stress of people trying to recover, and their caregivers.....it took over 18 months....house remained empty and deteriorating due to medical leans...finally had to personally pay the bills, covered by the insurance company, to sell the house before it further deteriorated....

the insurance companies PREY on the sick, the dying and the people with disabilities...

get those insurance companies OUT of our medical care...this crap adds at least 25% to the cost of all medical care....making HUGE profits off those least able to defend themselves...