Unfortunately, the public is being misled as a result of the California Nurses Association's (CNA's) selective disclosure of data that misrepresents the truth.
The data cited by the CNA refers to claims for reimbursement that have been denied. Characterizing all "payment denials" as denials of coverage is inaccurate and irresponsible. Payment denials do not accurately represent whether an individual actually received care. Out of all eligible requests for coverage submitted to CIGNA HealthCare of California in the first half of 2009, more than 95.9 percent were covered and the person received the care recommended by the doctor.
A closer examination of CIGNA's Schedule G, which is filed with the DMHC and is the document CNA refers to, firmly supports the notion that the payment denial numbers have little to no bearing on coverage. Specifically, Schedule G shows that CIGNA received 218,424 claims for payment in the first six months of 2009 and denied reimbursement (often times only partially) for 71,493 of those claims. 37,749 (or 53 percent) of the payment denials were denied because CIGNA already paid for the service through a process referred to in the industry as "capitation." This refers to a process where per capita payments are made to a medical group and payment responsibility for the claim lies with the medical group. These denials are known as "misdirects" because the doctor misdirected a bill to CIGNA that should have been directed to the medical group. If CIGNA were to pay a misdirected payment claim, it could result in the doctor receiving two payments – one from CIGNA and one from the medical group. 24,759 (or 37 percent) of the payment denials were denied because they were duplicate billings that were previously paid by CIGNA. Again, if CIGNA were to pay duplicates it would result in a doctor being paid twice for the same service. Such overpayments would be a driver of unnecessary and excessive waste in the health care system, inflating costs, representing needless spending and contributing to administrative burdens that are expensive and not in the consumers' best interests. CIGNA agrees that the public should know how often coverage is denied, but saying that payment denials equate to coverage denials does not achieve that goal. At CIGNA we are proud of how we administer benefit plans. In fact, nationally out of all eligible requests for coverage submitted to CIGNA in 2008, more than 99 percent of the time the services were covered and the person received the care recommended by the doctor.
It is CIGNA's mission to improve the health, well-being and sense of security of the people we serve. As the facts demonstrate, we help make it possible for patients covered under our plan to get the health care they need.
First and foremost, in terms of claims denials, no care has been denied. Claims are processed after care is provided. The CNA is wrong in saying that patient health is at risk. The CNA's mischaracterization of health plan data lacks a true understanding of the data plans submit to the state. The information they used for the report includes claims that are returned for a number of reasons that ultimately have no impact on the care a patient receives nor does it result in a physician not being paid for covered health care services. In PacifiCare's case, 80 percent of the claims are attributable to PacifiCare's unique, delegated model in California. Under this model, medical groupsare delegated and responsible for paying claims. Physicians will often bill PacifiCare for services that fall under delegated agreements. While those claims are denied, they are forwarded to the appropriate medical group for payment, therefore having no impact on consumers. Of the remaining 20 percent, 95 percent of those were denied because the member was ineligible, meaning they were not insured under a PacifiCare plan and we were not responsible for payment.
"Kaiser Permanente is not a typical insurance company with a claims-based system, and thus the claims analysis performed by the study was incorrectly applied to us. Kaiser Permanente provides more than 40 million patient services each year, only a fraction of which were included in this study. Fewer than two percent of those services involve claims payments that are denied, not the 28 percent reported in the study."
Kaiser Foundation Health Plan, Inc.
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