The “90% of medical claims” is such a weaselly metric. Yeah, if you have a small-cost claim like your annual physical or basic x-rays they pay, but if you need anything that costs money, that would push you over your deductible, they deny. Saying 90% just isn’t meaningful if most claims are small-dollar.
Claim is also a later step in the process. The first step is prior authorization. So they could deny the prior auth that leads to work not being done which leads to no claim to count as a denial. Or a patient doesn’t submit the claim because it had a denied prior auth, so again no denied claim. 90% on claims is a terrible percentage.
The “90% of medical claims” is such a weaselly metric. Yeah, if you have a small-cost claim like your annual physical or basic x-rays they pay, but if you need anything that costs money, that would push you over your deductible, they deny. Saying 90% just isn’t meaningful if most claims are small-dollar.
Claim is also a later step in the process. The first step is prior authorization. So they could deny the prior auth that leads to work not being done which leads to no claim to count as a denial. Or a patient doesn’t submit the claim because it had a denied prior auth, so again no denied claim. 90% on claims is a terrible percentage.
This is people’s lives they’re fucking with
I wouldn’t be surprised if they also carefully selected the “medical” part. Drug prescription? Medical. Post-intervention recovery? Not “medical”.