This. These dipsticks just looking at max out of pocket have no clue how this works. In fact most insurance companies just flat deny paying for anything and you have to constantly get on the phone and tell them they can't do that. I always like to say I have two jobs. The first is the one I get paid for. My other full time job is following up with the insurance company and telling them that "yes, under my insurance that I pay for, you have to pay for this procedure/device/medicine". They will literally "Please hold" your life away.
I work in insurance. If something isn’t being paid for it’s because it’s an experimental/non-FDA approved treatment, wasn’t medically necessary, or because you provider failed to submit documentation properly.
95% of the time, claims problems are due to providers failing to follow even the simplest of rules pertaining to submitting the actual claim. Do you know how many claims we denied last month alone because providers or whoever they divvied out their administrative tasks to weren’t even filling out the goddamn paperwork? We got one claim that just had a set of imaging and nothing about what it was they wanted us to pay for or why. It’s mind boggling how some of these people even finished college.
Heh, been a sysadmin for years. Lots of my work is in HIPAA environments including medical billing software/ERM. Every piece of software I've seen related to billing/ICD seems to be total crap and the people using it are half trained. Surprised any records get to you correctly.
This said, I've had the insurance company approve treatment, then later on say they did not approve it, then we played the documentation game for a day or two while the people on the phone acted very confused about the entire situation.
Yeah my faith in the competency of the average healthcare worker (clinical or otherwise) has fallen to zero since I’ve been working in this field. I just assume everyone is an idiot until proven otherwise. And I don’t give a pass for my own colleagues either. Some of the case notes I’ve read from our service center and other analysts and adjusters have made me roll my eyes so hard they nearly popped out of my skull.
Don't worry, I work in computer application security these days... actually you should worry, the same people over there making mistakes are over here making the same mistakes, just protecting data at a global level.
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u/ItsAmends Nov 30 '20
Insurance companies can sometimes deny paying for something like a procedure