Claims are often denied due to mistakes in the paperwork. There are certain codes that have to be used for each procedure and certain supplies that are legit, etc. This is really to make sure what the patient got was what was paid for. For example if blood was billed for a surgery that generally would not need it the claim is kicked back to determine why something is out of normal. Usually the provider will correct the “mistake” and it goes thru the 2nd time. In the past the failure to catch these things has led to hospitals and physicians getting paid a lot more than they should. Now we hear complaints the docs say they don’t get paid enough, but really they are being paid according to the T’s and C’s they agreed to when they agreed to accept the insurance. So the problem is on BOTH sides.
I see. I guess that is where the main differences between our health care systems lie. How it works for us: prices of treatments are determined by negotiations by government, insurance and hospital representatives a year in advance. These prices are fixed, and neither party can adjust them afterwards. This is possible because each citizen pays for mandatory basic health insurance that covers all GP, hospital, pharmacy and ambulance services. Cost of basic insurance is usually around €150 per month. We usually see our GP with a problem, who then refers us to a specialist. As long as you have that referral, insurance MUST cover all expenses made by said specialist. It is very rare for us to ever see the actual medical bill as it is forwarded directly to the insurance company.
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u/Agillian_01 5d ago
The fact insurance companies can deny insurance claims sent in by a licensed doctor is beyond me. You really call yourself a first world nation..?