I for one can't wait until the movie "Sicko" by Michael Moore is in the theaters June 29th. I rarely go to the theater because the price of a ticket is way too high and viewing the big screen with surround sound sets off my vertigo. BUT I will go for this one. This movie is all about what I have been teaching to doctor's offices for years now....HOW TO GET PAID FOR WHAT YOU DO from an insurance company whose main job is to deny your claim for no reason. 14% of all claims submitted get denied even if you sent everything in correctly. Of those 14%, only 50% of offices appeal the claim. Of that 50%, only 4% get paid on the first appeal. Most offices drop the ball and just write off the charge. FYI - most office's denial rate usually range around 46% - but most of their denial rates are because of stupid mistakes.
I don't like denials. I take it all the way and even fight with ERISA and a patient's SPD (Summary Plan Description - the booklet that your benefits manager has which spells out how your benefits are to be paid). Insurance companies don't like people who use these booklets because they have to pay the claim then. Does that make those offices then use what I teach? Nope....That is called work. And patients - they get upset with us....because the oh so perfect insurance industry can't be wrong. It is the doctor's office and their billing that is wrong.
There are 3 denials that we get: 1. not medically necessary 2. not a benefit under this plan and 3. experimental treatment. When a claim first goes in, the only thing that looks at the claim and pays the claim is a computer which is programmed to deny certain codes. That computer makes the decision that something is not medically necessary or experimental or not a benefit or one of the many other myriad of excuses insurance companies have. It is a computer. Computers do make mistakes and it is the programmers that program those codes into it. It just irks me that offices allow this computer to deny their claim.
Experimental treatment: Another huge one. Medical billing is done by codes put out annually by the American Medical Association. There are different types of codes (a series of numbers, letters and numbers, and numbers and letters. All numbers are called CPT codes. Letters and numbers are called HCPCS codes. Numbers and letters are called temporary codes. Now these temporary codes are not really experimental as they have to have FDA approval to even get a temporary number assigned to it but they are for emerging technology. But the AMA decided to use these codes for 5 years and if the code usage was there, then it would become a permanent code and be converted to a CPT code. In podiatry we have a non-surgical treatment for plantar fasciitis and heel pain. It has been around for 15+ years and a FDA approved treatment. It finally got a temporary code 7 years ago and a permanent code 2 years ago. Do insurance companies pay for it? Some do but most don't. They call it experimental. Every single claim I get a denial for I have to take all the way through the appeal process (3 levels then to a peer-to-peer review) before I finally get it paid. This takes anywhere from 1 to 2 years from the time the service was done before the doctor gets paid. Now I am tenacious. Most offices are not.
So go watch the movie and really find out about what is happening in our great USA with healthcare. Get the real story. This is the only movie of Michael Moore's that is totally right on and what is really going on.
For any of you who bitch about what your healthcare costs....here is what we pay for our health insurance for 3 people: $2800.00 per month for a policy with a $2500.00 deductible and then pays claims at a 50/50 percent. Now do you see why small businesses cannot afford to hire full time people or offer health insurance?
