Us vs. Them: Insurance edition

Them:

Insurance companies have to maximize their revenue because they answer to their boards. They are in no rush to fix claims systems that make copious errors and delay payments to providers. There are hundreds of claims processing software programs out there. Some are acceptable, some are useless. None are really good or efficient. And there is the human error factor. A careless mistake by an apathetic claims processor can create payment problems that could literally last for years.

These generate hundreds of provider appeals, totally clog the appeals and grievances systems and breed enduring ill will on the part of providers who are trying to make a living

Us:

There are doctors doing cardiac catheterizations on patients who blatantly do not meet Medicare criteria for payment. The Medicare criteria are there for a good reason. Anyone who doesn’t meet them should not have a catheter snaked into their heart. There are other, safer interventions to try first. If the patient didn’t meet the criteria, the procedure wasn’t paid for. More millions in lost revenue.

Read more about it, via a depressing post on Dr. Kevin, written by a former insurance and hosptial executive:

Health care reform analysis