Is it ture that insurance companies have entire departments devoted to finding methods of avoiding payment on?

Question

medical claims???

or do employees receive bonuses as incentives to deny care???

Answer 1

absolutely not. Insurance reps don't get rated on how much they pay out or not. They are expected however before handing out your benefits checks to have written documentation in their file verifying the amount of the bill, that the charge is related to the ax, that the dr. is licensed, and that the amount you are being charged is not excessive.
There are independent companies who market to insurance companies who review dr. charges to see if the dr's are charging more for patients who are insured by auto policies than, say, those that they treat under insurance policies, and those companies can get a % of the amount they save on the dr's bills.

Answer 2

Well it depends on what you are talking about, honestly. Adjusters are taught to back up their work. And to investigate the claim to verify the facts of the loss. If a claim is fraudulant, they will try not to pay, or turn it over to a special investigations unit to investigate further.

As far as on the front end of a policy, the underwriters are there to make sure that the risk is in good shape, that there are no outstanding claims, that there are not a whole bunch of claims, etc. Each company has different measurements on what is a good risk. If you don't qualify they will not keep the risk, or write it in the first place. However they are not designed to "not pay out" medical claims. Underwriters do not work claims...adjusters do. And unless you have a bad adjuster they are taught to pay what you owe - nothing more, nothing less. If they owe they will pay it. If they don't, or the claim is fraudulant, then they don't.

But to say that there is some people within an insurance company that sit there and say we are not paying out just because, is ridiculous. There must have been some reason they did not pay, if you are speaking from personal experience...

Answer 3

Not at the company where I work. We have an entire department established to handle customer appeals and work on getting them settled in a way that will better the member whenever possible. If we error, it is best to do it in favor of the member. Also, our claims department has a specific time frame to pay claims or our company has to pay interest on the amount owed (I think that is a state mandate). Our bonuses are based on membership enrollment and retention. It is stressed often that we are there to serve the customer because without them we wouldn't have a job. However, there is also an entire department devoted to keeping customers honest and avoiding insurance fraud.

Answer 4

Yes, they are called underwriters. Their job is devoted to protecting the company from bad risks. There are many people who will try to lie to get things covered, often out of desperation.

While this may seem extremely cold, insurance companies are businesses, not charities. They also have a group of people to protect who actually followed the rules. Paying unnecessary claims puts a burden on everybody in the risk pool. People pay premiums with the expectation that the caretaker (the insurance company) will protect the integrity of the risk pool.

Answer 5

No. But there is an entire department devoted to paying ligitimate, covered claims - the claims department.

Answer 6

If a claim is payable, the co will pay it. if it is not payable, it will be denied.
Often, there is doubt. that's where a claim is investigated, and ins co
'd hire many people to do this.
A co gains nothing by not paying valid claims, but no company will pay an invalid claim.

Answer 7

Absolutely; so many people create slip and falls solely for the purpose of collecting big monetary rewards. Insurance companies would go broke without investigating all claims thoroughly.

Answer 8

No, it's not true.