Doctors Struggle with Insurance Claims Process: Healthcare Costs Rise

We have spent some time writing about how insurance companies are primarily interested in making profits. To increase profits, these companies will delay and deny claims. The more claims an insurance company denies, the more profits it makes. Insurance company greed is not just focused on personal injury victims, or people seeking treatment. Doctors are also struggling with insurance company tactics and their quest to increase profits. Just as the insurance companies blame lawyers for pushing up healthcare costs through lawsuits, the insurance companies claim doctors are pushing up costs by “over treating” patients and ordering expensive procedures.

When you go to a doctor for treatment, you pay a co-pay that is dictated by the insurance company. The doctors then file a claim with the insurance company, seeking reimbursement for the services provided to the patient. Insurance companies will find ways to deny claims on the doctors’ end just like they do to personal injury victims applying to their insurance company for benefits. Many physicians have had claims denied, delayed or reduced. The insurance companies will claim that certain diagnostics or treatments are not necessary and will subsequently deny reimbursement. Most physicians don’t even appeal denied claims because of the time and money involved in the process. Some doctors have reported a 15 and 20 percent decline in the amount of reimbursement they receive from the insurance companies. Meanwhile, some insurance company profits are as high as $4.7 billion, with their CEOs making upwards of $23 million dollars a year. According to a recent survey or physicians, most doctors believe that the faulty claims process has increased the cost of running a practice, and has increased healthcare costs overall.

Perhaps the most disturbing trend is the insurance companies telling the doctors what treatment is necessary for a given case. The theory being that if an insurance company tells a doctor they provided unnecessary treatment to a patient, they can deny the claim and increase their profits. There was one report of a Texas doctor who diagnosed their male patient with breast cancer. Each year there are around 2,030 reported cases of male breast cancer according to the American Cancer Society. The insurance company denied payment of the claim because it was a “male patient with a female diagnosis.”

Some doctors have sued major insurance companies in an attempt to recoup money for their patient services; this has resulted in some settlements worth millions. However, as long as these companies are making billions in profits, they can afford to settle a few multimillion dollar lawsuits in lieu of changing their policies with respect to claims processing. The American Medical Association is currently working on a program to educate physicians on the claims process. The hope is that with more efficient and timely claims filing, more claims will be approved and healthcare costs will be reduced.


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