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Started By
Message
re: A Doctor at Cigna Said Her Bosses Pressured Her to Review Patients’ Cases Too Quickly.
Posted on 5/6/24 at 7:37 am to Eurocat
Posted on 5/6/24 at 7:37 am to Eurocat
quote:
Some of her colleagues quickly denied requests to keep pace, she said. All a Cigna doctor had to do was cut and paste the denial language that the nurse had prepared and quickly move on to the next case, Day said. This was so common, she and another former medical director said, that people inside Cigna had a term for these kinds of speedy decisions: “click and close.”
I know we like to all pile on tort lawyers for their contributions to the problem of insurance premiums. And they deserve it. But just remember that this happens at all insurers for all types of insurance claims. They play a role also. Rainmaker is, although obviously dramatic for movie purposes, instructive on this.
This post was edited on 5/6/24 at 7:40 am
1
Posted on 5/6/24 at 7:38 am to Eurocat
Sounds like the hospital version of Rainmaker by John Grisham where the insurance company in question was denying all claims initially and then paying out only if they had a serious one and fought for it.
Posted on 5/6/24 at 7:40 am to LSUfan4444
quote:
If my doc orders a test or procedure that he/she feels is warranted,
Let me expand a little bit more.
How do you feel physicians would feel about a reimbursement system that would pay them more on the effectiveness of their treatment?
So, let's say your doc orders procedures where prior authorization is no longer required and then there is a post op follow-up within 30 days of procedure and then scheduled thereafter to review success and failures. If the patient displayed improved health outcomes the physician could not only keep what they made from the original procedure but earn bonus payments along the way since that patient is now experiencing improved health BUT if the the services showed no improvement, the payment can be recouped?
This post was edited on 5/6/24 at 7:45 am
Posted on 5/6/24 at 7:43 am to supadave3
quote:
I agree with the posters here that say if it’s meets the criteria of a partnered doc, it should be covered.
I do agree that fi something meets criteria it should be covered but thats not really what the article is describing. It's describing something that doesnt meet criteria.
If there is something that a medical director reviews because it already doesn't meet standard criteria (meaning the nurse who initially reviewed it flagged it for denial) that decision falls to them. Another medical director reviewing the same case could have a different opinion and approve it so for those cases that are denied, the patients do have appeal rights to have the request reviewed by third party review sources which are clinicians for another opinion.
Posted on 5/6/24 at 7:49 am to LSUfan4444
quote:Only the healthiest, wealthiest people would have access to serious care.
Let me expand a little bit more.
How do you feel physicians would feel about a reimbursement system that would pay them more on the effectiveness of their treatment?
So, let's say your doc orders procedures where prior authorization is no longer required and then there is a post op follow-up within 30 days of procedure and then scheduled thereafter to review success and failures. If the patient displayed improved health outcomes the physician could not only keep what they made from the original procedure but earn bonus payments along the way since that patient is now experiencing improved health BUT if the the services showed no improvement, the payment can be recouped?
Posted on 5/6/24 at 8:00 am to Pikes Peak Tiger
quote:Even if the policy says, "We don't cover this test/procedure"?
If my doc orders a test or procedure that he/she feels is warranted, and I pay my premiums, the insurance company should STFU and pay.
Can you imagine how much your premiums would be if the policy just said, "We will cover anything a doctor feels is warranted"?
This post was edited on 5/6/24 at 8:05 am
Posted on 5/6/24 at 8:07 am to LSUfan4444
quote:
do agree that fi something meets criteria it should be covered but thats not really what the article is describing. It's describing something that doesnt meet criteria.
Actually, what it's describing is they outsource the decision to s-hole countries and want an American MD to rubber stamp the denial without actually looking at it.
In the Humana case I mentioned earlier they were using a software program that was denying 50 claims per minute. Nobody was looking at the claims and AI isn't at the point where it can make accurate decisions.
Posted on 5/6/24 at 8:09 am to LSUfan4444
quote:
So, if your doctor orders something that he profits from, then someone else pays for regardless of effectiveness, that should be enough? People are so much more fiscally liberal than they realize. Just gimme shite someone else pays for and I am good.
What an odd argument to justify denying care. Why do you keep claiming someone else pays for that? Patients pay with their monthly premiums. It’s not charity care or Medicaid.
Posted on 5/6/24 at 8:10 am to Eurocat
quote:Found the problem. Possibly the most oversaturated nursing labor market in the world.
nurses working in the Philippines
This post was edited on 5/6/24 at 8:17 am
Posted on 5/6/24 at 8:13 am to Flavius Belisarius
quote:Patients don't pay for their own health costs with their monthly premiums. If they did, insurance companies would just put each person's premiums in a distinct conservative interest-bearing account, then use the balance of that patient's account to pay for that patient's care. Insurance companies would effectively be banks, and your level of care would depend on your contribution in.
What an odd argument to justify denying care. Why do you keep claiming someone else pays for that? Patients pay with their monthly premiums. It’s not charity care or Medicaid.
By paying their monthly premiums, patients are guaranteed a certain level of care, whether they use it or not. No more, no less.
And if private insurance companies are required to cover literally everything a doctor orders, premiums will go up exponentially to a point where the overwhelming majority will be on Medicaid anyway.
This post was edited on 5/6/24 at 8:23 am
Posted on 5/6/24 at 8:14 am to mahdragonz
quote:
Do hospitals give the exact price for treatment?
Have you ever tried to get an absolute price on something at a medical facility.
quote:
mahdragonz
You morons opposed the reforms that would have made cost "menus" mandatory, instead opting for the Obamacare that has made costs much much worse.
This post was edited on 5/6/24 at 8:15 am
Posted on 5/6/24 at 8:20 am to Eurocat
People use arguments like this as a reason private insurance is better than single payer. The corporate/government partnership insurance system we have now is no better for people.
Posted on 5/6/24 at 8:37 am to LSUfan4444
quote:
So, if your doctor orders something that he profits from, then someone else pays for regardless of effectiveness, that should be enough?
If it’s medically warranted then yes. If it isn’t, he’s guilty of malpractice and neither me or the insurance company should have to pay.
Example: my brother was having some chest discomfort with exercise and was referred to a cardiologist. The cardiologist ordered and echocardiogram and cardiac CT to look for coronary artery blockages.
Echo was ok. The CT showed mild blockage that led to him being placed on a new medication and may require stent of it gets worse.
Insurance company is refusing to cover the CT and said he has to pay because it was an unnecessary test
So in short, he had a test that showed an abnormality that led to an intervention (new medicine). But the insurance company says “no we aren’t paying because it wasn’t necessary”
What kind of BS is that?
That’s the kind of thing most of us are talking about.
Posted on 5/6/24 at 8:38 am to Gravitiger
quote:
Even if the policy says, "We don't cover this test/procedure"
If it is a reasonable test/procedure given the patient’s symptoms then the insurance company should pay.
They should not be telling the doc who is seeing the patient what they can and can’t do.
Posted on 5/6/24 at 8:38 am to Eurocat
quote:
Deny, deny, deny.
Great Benefit
Posted on 5/6/24 at 8:42 am to Eurocat
So denying coverage is essentially up to dancing tiktok nurses??
Posted on 5/6/24 at 8:47 am to rmc
My late mother recently got the full 100 days of inpatient rehab allowed by her Medicare Advantage plan. I was surprised, as were the people at the facility. They said it almost never happens.
Posted on 5/6/24 at 8:51 am to Pikes Peak Tiger
quote:Except reasonable doctors disagree all the time about what is reasonable treatment. That just incentivizes insurers to only work with doctors whose recommendations are a priori reasonable to them.
If it is a reasonable test/procedure given the patient’s symptoms then the insurance company should pay.
They should not be telling the doc who is seeing the patient what they can and can’t do.
They aren't telling the doc what they can or can't do. They are telling the doc what the patient agreed for them to cover or not. It's up to the doc to perform the procedure or not at that point. Doctors then make their own economic decisions regarding patient care, just like insurance companies do. Funny how absolutely necessary treatments sometimes become optional once the doc realizes it won't be covered and the patient can't cover the self-pay.
This post was edited on 5/6/24 at 9:12 am
Posted on 5/6/24 at 9:06 am to THog
quote:
So denying coverage is essentially up to dancing tiktok nurses??
In the Phillipines.
Posted on 5/6/24 at 9:08 am to SouthEndzoneTiger
quote:
Doctor writes him a script for crutches, a walking boot, Viagra for his ED, and a splint for his finger that has been giving him problems after injuring it at home.
No way he sees a doctor. More than likely he sees an NP
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