Medicare WORST at denying claims!

This AMA data¹ was released awhile ago and I haven't made time to comment or present some of the interesting findings. I understand many commentators (such as Glenn Beck) have mentioned it.

We've heard over and OVER and OVER again about those evil insurance companies and the liberals cry about empathy needed or that health care coverage is actually a RIGHT.

So the AMA data show the claims, denials and % of denials -- would it surprise you that Medicare rejects more claims than their private insurance counterparts?

From the report:

Description: What percentage of records submitted are denied by the payer for reasons other than a claim edit?

A denial is defined as: allowed amount equal to the billed charge and the payment equals $0.

Payer / Count of records / Denied records / % of claim lines denied
Aetna 637,239 / 43,317 / 6.80%
Anthem 250,070 / 11,546 / 4.62%
CIGNA 263,728 / 9,060 / 3.44%
Coventry 20,487 / 590 / 2.88%
Health Net 4,975 / 193 / 3.88%
Humana 143,026 / 4,142 / 2.90%
Medicare 6,938,431 / 475,566 / 6.85%
UHC 1,127,691 / 30,177 / 2.68%

Date Range: 03/01/2007 – 3/10/2008


Page 11 of the AMA report explains some of the denials and 20% of the Medicare Rejections are simply designated as "NOT MEDICALLY NECESSARY"

So the government, just like private insurance is already engaged in an intense analysis for cost control and evaluating what your doctor believes is needed. Most of the rejections from the private payers come before the claim process (e.g. pre-existing conditions) and those payers have contracts, fee schedules and payment arrangements with the physicians, hospitals, laboratories etc...

Medicare gets a pass for being the biggest culprit on denying coverages.

This is in large part why so many seniors have enrolled in secondary insurances like AARP's Medigap or Medicare Advantage. They are designed to pick up the tab for the NON-COVERED services and prescriptions that MEDICARE DOES NOT COVER.


Is the health care reform going to fix this?

The answer is a resounding NO!

More government intervention, another government run "public option" will be crippled by the same problems, cost control measures etc...

The health care reform bills cut Medicare coverages further, targeting Medicare Advantage directly and will reduce choices for seniors.




1. http://www.ama-assn.org/ama1/pub/upload/mm/368/reportcard.pdf

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