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View Diary: Dear Supremes: An Expose of The Health Care Monster By An Industry Insider (100 comments)

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  •  You Are Partly Correct (8+ / 0-)

    The addition of a code not previously agreed upon would potentially add other charges. In this case  the bulk of the charges were for room and board and other incidentals to an inpatinet stay, there was no deliniation by diagnosis . Yes the claim was legally denied .
    You get the point precisely when you ask how was the member suppposed to know? Unlike almost all major expenses, a serious health care event isn't something one can solict "bids" on. Most people don't even have a clue what they'll eventually be charged until after the claim comes in....

    •  So in other words, they can deny anything (7+ / 0-)

      for any reason, and make it legal.

      Say he'd gotten constipated from meds while in the hospital.  Constipation Code XYZ, not approved, throw it all out!

      Calling this "legal" only means they haven't been stopped yet.

      •  I Have Perosnally Worked on Claims (5+ / 0-)

        that were dnied because th patinet's name was misspelled under "no insured by this name." The meber has to submit a copy of either a birth certificate or government issued ID, notarized. This has to be snail malied and cannot be faxed. the member has to submit a sworn affadavit as well, Whole process can take up to two moths to clear up. Meanwhile the proivder threatens the member with a collection agency. All 100% legal

        •  Please get out of that business (1+ / 0-)
          Recommended by:
          glorificus

          Anyone with a conscience should not be polluting their lives with this kind of evil.

          •  It's a job. Diamond81 is providing a real (2+ / 0-)
            Recommended by:
            marina, antirove

            service to insured people, such as this piece here.

            We need to change the system, Diamond can't do it alone.

            I hope more diaries like this are written. As is often said, know your enemy.

            I consider insurance companies the enemy.

            If you do not believe that there is an ongoing war on women, then you aren't paying attention. h/t The Pootie Potentate

            by glorificus on Thu Apr 05, 2012 at 06:30:53 AM PDT

            [ Parent ]

            •  Agreed (2+ / 0-)
              Recommended by:
              Diamond81, glorificus

              Sometimes we stay in a job for purposes such as these, as a whistleblower of sorts; and also because we worry that the next person to fill the job may not be as protective of the client or customer.

              The "corporate ethic" is costing our society as a whole. Greed is not a good basis for a society. As far as we are forced to operate within the corporate-based system, we become complicit in their goals. And so that includes nearly all of us in one way or another.

              It's understandable that people can lose their better angels in this setup, so I applaud Diamond81 for keeping a clear perspective on the ethics, and having the moral courage to share this knowledge with us.

              •  You Pretty Much Nailed it (2+ / 0-)
                Recommended by:
                glorificus, marina

                as to why I stay. I actually love my job, if that makes any sense...

                •  Sure. You are a subject matter expert in a very, (2+ / 0-)
                  Recommended by:
                  marina, Diamond81

                  very complicated field. I'd be proud, too, but I don't know if I could stand up under all the heartbreaking stories you must hear.

                  To me, it speaks well of YOU that you can see the inequities and flat out evilness of the system.

                  Maybe in a couple of years you can explain Obamacare coverage to people.

                  If you do not believe that there is an ongoing war on women, then you aren't paying attention. h/t The Pootie Potentate

                  by glorificus on Thu Apr 05, 2012 at 08:07:46 AM PDT

                  [ Parent ]

                  •  The Only Way I Can Stay (2+ / 0-)
                    Recommended by:
                    marina, glorificus

                    in this business is that I tell msyelf every hour that I work for whoever is on the other end of the phone. In fact I often tell them that.  the longer I stay and the more "tricks of the trade' I learn, the more capable I am at resolving issues like this by learning how to use the system against itself.

                    I love my jon. I loathe who I work for.

                    •  I'm concerned that insurance companies will (3+ / 0-)
                      Recommended by:
                      Diamond81, glorificus, marina

                      start combing through their ranks of claims processors looking for someone with a low rate of claims denials and higher rate of 'fixed' claims in order to identify those to include in the next round of 'downsizing' or to replace with more automation.

                      The motivation to start searching for you might be that  your actions could be cutting into the size of anticipated bonuses to top management and shareholders--don't think this impossible.  I might mention, with my IT background in health & pensions, banking and commodities, that coming up with just that sort of 'data mining' isn't that hard to do. You might not even know an IT consultant with expertise in these ares was contracted to do just this with the claims data. Depending on state of the insurance claims database and logging of claims processor actions and phone conversations, it might be just a matter of days to come up with that.

                      So, please be careful with what you write, to not reveal anything further specific to your company, or class and level of your employment, since if it ends up with you being indirectly 'outed' here, it could be even worse for you, since that could make finding future employment far harder as well as nasty legal suits.  Avoid posting here from work, as all your diary and update processing can be captured by an employer, in easily read 'clear text' format, since dailykos does not use the secure encrypted by SSL https: protocol.

                      Back in the '90s I worked for a data aggregating employer to mine the 'anonymized' claims data the insurer would provide on behalf of employers. The job ostensibly was to identify clusters of diagnoses occuring within their divisions and departments.  I ended up with the impression that this was looking like some sort of prevention effort, and perhaps tied to OSHA, or linked to making health plan improvements, perhaps by providing department specific recommendations.  After I'd done most of the coding and making a pretty clever system capable of taking into account many variables to sift, sort, isolate and locate where diagnoses and treatments occured, I eventually realized this was mostly being used to find AIDS cases and pre-AIDS patients with HIV.  It sort of became apparent when this was one of the test cases used in a live final presentation that was made where I was present in case something went awry.  It wasn't as hard as one might think to cross reference this data with other census, credit and employer data to peg which covered individuals or family members this was, at least figuring it out down to the 'department' level.  At the end, I wasn't sure of the ethicalness of applying this sort of 'cleverness' back then, and, by itself, I suppose it could have been used to help rather than hurt, to let companies know when they need to ensure their employees have a sound awareness of HIV and AIDS and how to cope if having it.  I do know a few employers were more compassionate about using it than others.  I can only imagine that rather than abandoning this sort of data mining, that employers will have sought far greater sophistication in doing this in the last decade.

                      When life gives you wingnuts, make wingnut butter!

                      by antirove on Thu Apr 05, 2012 at 11:17:48 AM PDT

                      [ Parent ]

                      •  Thank You Very Much For... (3+ / 0-)
                        Recommended by:
                        glorificus, marina, antirove

                        your concern and head's up. You are correct that if "outed" I would be fired and probably sued and maybe even prosecuted. I am fortunate that I enjoy a wide lattitude within the purview of my "position."

                        I will say that every syllable I utter over the phone is recorded. Every movment I make is video recorded as well. I had to sign a waiver that every key stroke I make on my work computer is subject to scrutiny. Part of this is industry security protocol due to the senitivity of the information I deal with and part of it is simply a menas of geeting more "production" form me (and my coworkers) as we are evlauted LESS on the actual correct information we give than we are on how long we took to complete the call.

                        I do not however operate unilaterally but I am becoming proficient in the art of "schmoozing" with other employees who have the means and the method and the authority to override certain thngs, so I can get results for my caller. This does not imply anythng unethical, just greasoing the wheels so to speak . You are also correct about a target per centage of negative claim results, But as long as the entirte department stays within the poarameters, it isn't hard to fly under the radar and maybe get a "neutral" claim processed in favor of the consumer, particularly if it is an admin type or error- entry type denial. These are just the realitites........ I admire and appreciate you expertise in the area of IT

          •  I am Pleased You Had Such a Strong (1+ / 0-)
            Recommended by:
            marina

            revlusion toward my post. It is normal to want a face to put on something lke this.

      •  And this is the reality into which Republicans (8+ / 0-)

        want to force senior citizens.  How many eighty year olds with serious medical issues do you know that could negotiate this swamp?

        “when Democrats don’t vote, Democrats don’t win.” Alan Grayson

        by ahumbleopinion on Wed Apr 04, 2012 at 09:00:59 PM PDT

        [ Parent ]

        •  I Could Not Agree More And In Fact.... (5+ / 0-)

          Since Medicare is mandatory primary for ANY group coverage with less than 20 employees, many seniors believe their group sitll covers them until their claims get dened by the company who does not inform them of this until after the fact. One cannot cancel oup coverag until the open enrollment period or a qualifying event such as sepration from the comapny. They pat maybe an enitire years' worth of wasted premium and then, have to fightwith meducare to get a "late enrollment" to get meeicare at all after this,. Tragic.

          I this was in any way confusing to you, that is precisel the poit Thanks for illustraing

        •  So true, I am one of those seniors, (2+ / 0-)
          Recommended by:
          basquebob, glorificus

          and I am totally confused, and I don't confuse easily.

    •  it means can't afford a lawyer (2+ / 0-)
      Recommended by:
      glorificus, Diamond81

      so screw him, it can't bite us back.

      fact does not require fiction for balance (proudly a DFH)

      by mollyd on Wed Apr 04, 2012 at 11:22:58 PM PDT

      [ Parent ]

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