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Home / News & IndustryManaged Care Insight and Analysis
Updated: March 23, 2010
California Insurers Deny 21 Percent Of Claims, Drawing State Probe

More than 1 of every 5 requests for medical claims for insured patients, even when recommended by a patient’s physician, is rejected by California’s largest private insurers, according to data released by the California Nurses Association/National Nurses Organizing Committee (CNA/NNOC).

Researchers analyzed data reported by the insurers to the California Department of Managed Care and found that from 2002 through June 30, 2009, six of the largest insurers operating in California rejected 47.7 million, or 22 percent, of all claims for care.

The findings have led to a statewide probe by state Attorney General Edmund G. Brown, Jr. as to how insurers pay claims.

"These high denial rates suggest a system that is dysfunctional, and the public is entitled to know whether wrongful business practices are involved," he said.

Brown’s deputies are pouring over HMO records and conducting interviews with individuals knowledgeable about HMO claims activities.

Leading the way in claims denials was PacifiCare, 40 percent in the first half of last year, followed by CIGNA’s 33 percent. PacifiCare is in the middle of an administrative law hearing to determine if it mishandled fees and claims.

"The reality for patients today is a daily, cold-hearted rejection of desperately needed medical care by the nation’s biggest and wealthiest insurance companies simply because they don’t want to pay for it," said Deborah Burger, RN, CNA/NNOC co-president. "Every claim that is denied represents a real patient enduring pain and suffering. Every denial has real, sometimes fatal consequences."

Address: California Nurses Association/National Nurses Organizing Committee, 2000 Franklin Street, Oakland, CA 94612; (510) 273-2200, www.calnurses.org, www.calnurses.org/nnoc.


  This article was taken from:
The Executive Report on Managed Care

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