Ah, the Bureaucracy
Of the 1.1 billion claims submitted to Medicare in 2010 for hospitalizations, nursing home care, doctor’s visits, tests and physical therapy, 117 million were denied. Of those, only 2 percent were appealed.
More from Susan Jaffe from the Kaiser Health News.
The mystery is that some people actually think this system is efficient.
One out of ten were denied?
The whole thing seems rather futile. Only 15% of appeals are filed by patients; and I’ll bet they are for amounts that many seniors can handle, e.g. $214. No CMS bureaucrat wants to get hauled in front of Congress for sending a senior a bill for thousands of dollars. On the other hand, I’ll bet Medicare makes a trivial amount of money from these situations.
Providers are far more likely to appeal because they have special staff and consultants who can decide when they’re likely to win. If they’re only appealing 2 percent, that tells us that they submit a lot of claims that they know will not stick.
If I am correct there are intermediary steps between denial and appeal so the 2% that are appealed is a meaningless figure. Many of the denials are paid without appeal. The appeal can be difficult and costly both financially and time wise which is one of the reasons that many of the appeals that would win are not made.
Denials are a method of intimidation. Appeals are frequently punitive.
This can’t come off as a popular sentiment but I’d really like to know the reasons behind those denials. It’s a bit unclear if the overprescription problem we have extends to this arena.
@Sebastian Alexander
“85 percent of appeals in 2010 that reached the third level of review, which are decided by an administrative law judge, were filed by health care providers.”
This information actually shows that providers are more persistent and have the resources to make it to the third stage.