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The original was posted on /r/maliciouscompliance by /u/mightyhorrorshow on 2024-12-10 23:27:32+00:00.

I work at a health insurance company processing claims. There are a lot of rules and regulations that break my heart. This is my story about one of them.

A claim is submitted for a Durable Medical Equipment (DME) rental for an oxygen concentrator.

Policy says there is a 36 month rental cap with a 61 month reasonable use cap. This means someone can rent an oxygen concentrator for 3 years and have it covered by insurance. Insurance won’t cover another rental until 5 years after the patient started renting the equipment.

I have been told to work my assigned claims. To only work my assigned claims.

My assigned claim was for month 46 of the rental. This is beyond the 36 month rental cap. I have to deny the claim.

Rental history shows that months 1-36 were covered. Somehow months 37-44 were also covered.

I had to deny the claim that I was assigned but I didn’t have to reprocess the history claims that paid ‘in error’.

I’m not expecting any fallout, but I am sincerely hoping that none of my coworkers look too closely.

BTW, I work for a nonprofit health insurance company administering government health programs. This means the government sets the rental and reasonable use caps.

Healthcare reform needs to happen.