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I was pleased to read the article chronicling Mark Christensen's struggle with a denied medical claim ("The care was crucial. He had insurance. The hospital billed him $155,493," Oct. 28). I was pleased not for Christensen but that the Star Tribune would see fit to bring this topic to public attention. What the public likely does not realize is that denials like this are not rare but common. They create angst for patients and for medical care providers, often unnecessarily. They add expense to the medical care system and often result in delays of treatment. And in the end the denials are usually overturned, as they were in Christensen's case.
I am an orthopedic surgeon at TRIA specializing in hip and knee replacement surgery. I deal with payer denials for preauthorization for surgery commonly. These denials occupy time when I should be caring for patients rather than appealing denials that have no basis. I have never failed to have a denial overturned. So why do payers keep wasting their time and money issuing denials that in the end are rarely upheld? Because there is no penalty for them to do so. When the denial is overturned they simply have to pay for a service that they should have paid for in the first place. I would propose, as a solution, that payers incur some sort of financial penalty if a denial is subsequently overturned. Perhaps Empire BlueCross Blue Shield would have thought twice about denying Christensen's claim if, for example, the overturned claim would require increased reimbursement (like perhaps $200,000).
Paul Johnson, Eden Prairie
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On Nov. 7 the Star Tribune published a story about Bright Health and its claims processing "errors" ("Bright Health fined over claims errors"). I think anyone who reads the article will come away with the belief that Bright Health was engaged in intentionally avoiding paying claims for which it was responsible. Two thoughts about this. First, Bright Health executives should be held accountable for this unacceptable behavior.
Second: All health insurance companies have a goal of minimizing claim payouts in order to enhance their bottom line. This behavior puts patients who are ill in the double jeopardy of being ill and also being at risk of financial disaster if the insurance company denies their claim for payment. Why do we allow insurance companies to decide which claims are valid? In our public safety systems, the police, the prosecutors and the judges are all separate from each other to prevent conflicts of interest. When a person is ill and a doctor orders tests or treatment, the insurance company should not be allowed to practice medicine by deciding if the care is appropriate. Insurance companies have a clear conflict of interest being the arbiters of what gets paid. There should be a totally independent process to monitor doctors for proper care and to settle claim disputes. Insurance companies should not be allowed to deny claims from properly licensed doctors, hospitals and clinics.