Originally Posted by Eric5273

My ex-girlfriend Sophia, who a few X5World members met last fall, has provided me with plenty of first hand experience on how the system works.

Sophia works as a private consultant for a number of doctor offices. She works on commission only, and she helps them collect the many insurance claims that the insurance companies deny on a regular basis. She knows the rules/laws, and tells me that 95% of insurance claims that are denied are being illegally denied. So even though she is not an attorney, she sends them letters citing legal statutes and quoting laws, and threatens legal action if they do not comply. She collects on over 75% of the claims she is given, and she gets paid based on what she collects.

The insurance companies have entire departments with hundreds of employees whose sole purpose is to find loopholes and reasons why they can deny care. Every single claim passes through these departments, and they deny every possible claim they can come up with any sort of reason to deny, no matter how rediculous or illegal each denial is.

You know how many claims Sophia works on that are Medicaid or Medicare (i.e. government) claims? None. Do you know why? Because those claims are rarely denied, and when they are, it is simple to remedy the error.

If the system worked like it should, Sophia would be out of a job. My understanding of this from her, is that most doctors have someone in-house who takes care of this stuff, but usually this person really has no idea what they are doing and thus they do not manage to collect on most of the denied claims, and the doctors simply take a loss on these, or end up going after the patients for the money.

Originally Posted by Eric5273

My ex-girlfriend Sophia, who a few X5World members met last fall, has provided me with plenty of first hand experience on how the system works.

Originally Posted by soccerjunky

Eric this statement is just plain false

"You know how many claims Sophia works on that are Medicaid or Medicare (i.e. government) claims? None. Do you know why? Because those claims are rarely denied, and when they are, it is simple to remedy the error."

Originally Posted by soccerjunky

Eric this statement is just plain false

"You know how many claims Sophia works on that are Medicaid or Medicare (i.e. government) claims? None. Do you know why? Because those claims are rarely denied, and when they are, it is simple to remedy the error."

Originally Posted by Eric5273

This is what she tells me. She says years ago when she worked in doctors offices and handles those claims, they were easy, and now none of her clients turn any of those over to her because the amount of work required is so little that it's not worth it for them to give her commission on those, so they have their own people handle those. They only give her the claims that their own people have been unable to collect on.

BTW, she also tells me that 90% of doctors offices have nobody there that knows what they are doing with regard to this stuff, and that even the doctors are usually clueless as to how to get paid on such claims.

Either way, doctors should not have to jump through such hoops to get paid on work they have done. A single payer system will assure that.

I can tell you that Sophia takes a nice big chunk of all the money she collects on those claims. More money for her means less for the doctors.

Originally Posted by Eric5273

In today's news:

http://www.latimes.com/business/la-f...0,230916.story
California fines two health plans $13 million
Anthem Blue Cross and Blue Shield also agree to restore coverage to patients whose coverage was canceled after they became ill.

Anthem Blue Cross and Blue Shield -- two of the state's biggest health plans -- agreed Thursday to pay a total of $13 million in fines and to offer new health coverage to more than 2,200 Californians the companies dropped after they became ill.



That Liberal Cali government....always causing trouble for the big corporations. I suppose a "free market" system would be one in which the goverrnment would not get involved.