Unfortunate, but necessary information https://t.co/J2hzuy3MxM
Unfortunate, but necessary information https://t.co/J2hzuy3MxM
UnitedHealthcare Tried to Deny Coverage to a Chronically Ill Patient. He Fought Back, Exposing the Insurer’s Inner Workings.
Patrick Ruckerpropublica.org
But the Cigna review system that blocked van Terheyden’s claim bypasses those steps. Medical directors do not see any patient records or put their medical judgment to use, said former company employees familiar with the system. Instead, a computer does the work. A Cigna algorithm flags mismatches between diagnoses and what the company considers acc... See more
Patrick Rucker • How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them
On average, it takes three attempts and resubmissions to have a claim adjudicated to the fullest extent that the provider or patient can achieve.
David Uhlman • Hacking Healthcare: A Guide to Standards, Workflows, and Meaningful Use
Claims submissions are typically limited by the payer to a set number of denials (after which they will not pay) as part of the contract between the facility and the paying organization.
David Uhlman • Hacking Healthcare: A Guide to Standards, Workflows, and Meaningful Use
That payer returns a complex document known as an explanation of benefits (EOB) that defines on a code-by-code basis what was paid, what was not paid, and categorical reasons why.