Slow pay and claims denials: welcome to the world of managed care.
In markets heavily penetrated by managed care, case managers are facing a disturbing trend: Health plans are denying claims at an alarming rate for what many consider to be medically necessary care. Slow payment and increased scrutiny of hospital utilization review also have been reported. In Maryland alone, the state's largest insurer, Blue Cross and Blue Shield, denied $29 million in hospital claims and 13% of all inpatient days in 1997, leading the state hospital association to file a grievance alleging that BCBS and other insurers are denying claims simply to cut costs. Experts argue that the trend toward claims denials and slow payment is likely to increase the administrative burden of case managers who perform utilization review, and could negatively affect patient care.
D002140:California; D017408:Guidelines as Topic; D007345:Insurance Claim Review; D007349:Insurance, Health, Reimbursement / Q000639:trends*; D007350:Insurance, Hospitalization / Q000639:trends*; D007902:Length of Stay / Q000191:economics; D008329:Managed Care Programs / Q000191:economics*; D008396:Maryland; D008404:Massachusetts; D014481:United States; D014600:Utilization Review