Even when they are a doctor, it doesn't matter.https://www.propublica.org/article/cigna-pxdx-medical-health...
Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method, spending an average of 1.2 seconds on each case, the documents show.
1.2 seconds! Well they're sure putting that med school knowledge to use, huh.
Yep. Don't worry, though; if they slip up anddofund your expensive treatments, all of a sudden they havelotsof time to focus on you.
https://www.propublica.org/article/unitedhealth-healthcare-i...
At one point, court records show, United inaccurately reported to Penn State and the family that McNaughton’s doctor had agreed to lower the doses of his medication. Another time, a doctor paid by United concluded that denying payments for McNaughton’s treatment could put his health at risk, but the company buried his report and did not consider its findings. The insurer did, however, consider a report submitted by a company doctor who rubber-stamped the recommendation of a United nurse to reject paying for the treatment.
But the records reviewed by ProPublica show that United had another, equally urgent goal in dealing with McNaughton. In emails, officials calculated what McNaughton was costing them to keep his crippling disease at bay and how much they would save if they forced him to undergo a cheaper treatment that had already failed him. As the family pressed the company to back down, first through Penn State and then through a lawsuit, the United officials handling the case bristled.
Horrifying. Those "insurers" are absolute scumbags. Poor guy, I feel awful for him.
Those "insurers" are absolute scumbags
It’s complicated. On the other hand are fraudsters and private-equity owned hospitals maxing the bill button. If the insurer is lax with payouts, it depletes its capital and could be left insolvent. It’s a scummy system more than a system of scumbags. (To be clear, there are scumbag insurers. But it’s reductive to cite that generally, or designate it as the source of the system’s troubles.)
Taking 1.2 seconds to review claims means they arewithout any question"doing something wrong".
"Remaining solvent" doesn't seem to be the goal, rather "maximising quarterly bonuses regardless of lives destroyed" seems a more fit description.
Taking 1.2 seconds to review claims means they are without any question "doing something wrong"
Nobody said they aren’t. The point is, given the volume of claims, to do a proper analysis, we’d need a material fraction of doctors doing insurance reviews (instead of seeing patients). So we get a reliance on heuristics.
If you’re lenient, you get targeted by fraudsters. So we get a bias towards denial. (Nobody is getting a material quarterly bonus for denying a few more claims. That nonsense occurs at the level of PBMs and other scale operations.)
We have a system where doctors and nurses review medications and treatment options for patients. It's called _the medical system_. You know, the one where I can go see my doctor, talk to them about what's going on, and work with them to create a treatment plan that suits my problems and my goals.
Why do we need to bolt on a secondary system that sucks up an untold wealth of time and money?
Small potatoes.
https://www.axios.com/2023/06/14/medicare-advantage-overpaym...
Overpayments to insurers administering Medicare Advantage plans now exceed $75 billion a year due to aggressive coding of patients' health conditions and easily-achieved bonus payments tied to quality, researchers with the USC Schaeffer Center for Health Policy & Economics found.
Insurers are not the ones coding, it is the healthcare providers. And the government is the one deciding to pay.
If anything, that would mean more claims should be denied.
Looking at the study, it seems like the government made some erroneous assumptions about who would be taking advantage of the policies the government created, resulting in the extra costs. (Third paragraph of “policy context” section).
https://healthpolicy.usc.edu/research/ma-enrolls-lower-spend...
Nope.https://www.nytimes.com/2022/10/08/upshot/medicare-advantage...
Anthem, a large insurer now called Elevance Health, paid more to doctors who said their patients were sicker. And executives at UnitedHealth Group, the country’s largest insurer, told their workers to mine old medical records for more illnesses — and when they couldn’t find enough, sent them back to try again.
Each of the strategies — which were described by the Justice Department in lawsuits against the companies — led to diagnoses of serious diseases that might have never existed. But the diagnoses had a lucrative side effect: They let the insurers collect more money from the federal government’s Medicare Advantage program.
Eight of the 10 biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to the federal audits. And four of the five largest players — UnitedHealth, Humana, Elevance and Kaiser — have faced federal lawsuits alleging that efforts to overdiagnose their customers crossed the line into fraud.
That is just clear fraud, and I don’t understand how that is a lawsuit instead of felony charges for everyone involved.
If a business can't handle its own scale without negatively affecting its customers, it should probably stop growing. It's the same issue we see with Google accounts being seemingly randomly terminated.
Since that probably won't happen, heuristic usage should at least come with penalties attached, otherwise the incentives are lopsided. If an airline's overbooking heuristics fail and get you bumped, you either get put on another flight and/or receive financial compensation. If an insurance company's "heuristics" fail and deny a legitimate claim, there should be a penalty. If Google terminates your account because of a mistake, they should pay a fine. They shouldn't be allowed to have their cake and eat it too.
If a business can't handle its own scale without negatively affecting its customers
The scale probably helps. The point is if every billable decision is medically reviewed for more than a few seconds, a material fraction of the healthcare workforce needs to be diverted from patients to review.
There is simply no solution, given the current industrial structure, to avoid some combination of non-expert, high-speed review without making even stupider trade-offs.
Sounds like we need to replace the structure, given that it's not fit for purpose.
Sounds like we need to replace the structure, given that it's not fit for purpose
We soundly agree. Health insurance, where risk is pooled, makes sense. Health "insurance," where payments are pooled with a bunch of needless intermediation, is unnecessary.
*(catastrophic) risk pooling
If you’re lenient, you get targeted by fraudsters.
So in this scenario, it sounds like the fraudsters are the medical insurance companies, and the group being lenient are the regulators.
A place taking (on average) 1.2 seconds to review each claim shouldn't be in business.
That is not necessarily true.
As another commenter pointed out, average review time is likely a misleading figure, since the overwhelming majority of decisions are made automatically, using predetermined rules engines.
So nearly all decisions take zero seconds, and a small minority take much longer, leading to anaverageof 1.2 seconds, when in reality, those claims that are reviewed manually take far more than 1.2 seconds to review.
As the other commenter put it: “(most cases take 0 time) + (a low number of cases take non-zero time) = 1.2 seconds on average.”
I think you could make fundamentally the same argument for a great number of the issues in the world today. It's a huge web of banal evils. That doesn't mean that it excuses the behavior of any given cog in that machine though. If we allow blame to be passed on indefinitely because everything is broken then nothing will ever be fixed.
If we allow blame to be passed on indefinitely because everything is broken then nothing will ever be fixed
Or we can skip scapegoating and fix the system. This is a fundamental lesson from aviation crash analysis: the goal should be a better system,notassigning blame.
I suspect the Germanwings Flight 9525 crash investigation assignssomeblame to someone. There's a difference between accidents and deliberate action by motivated actors.
suspect the Germanwings Flight 9525 crash investigation assigns some blame to someone
Read the synopsis [1].
Blaming the co-pilot would be fruitless. He's dead. There's no chance for retributive justice. And if he's the problem, the problem's solved: he's dead. Nothing more to do. Except, of course, there is. Blaming him is simply an unproductive emotional comfort.
Instead, the report examines the crash's root causes. The "co-pilot’s probable fear of losing his right to fly as a professional pilot if he had reported his decrease in medical fitness to an AME." The "financial consequences generated by the lack of specific insurance covering the risks of loss of income in case of unfitness to fly." The "lack of clear guidelines" on when conditions need to be reported.
Addressing these factors helps prevent the next problem. Blaming the co-pilot actually does the opposite.
[1]https://bea.aero/uploads/tx_elydbrapports/BEA2015-0125.en-LR...
3.2 Causesblames the copilotin its first sentence. They absolutely tackle other failings of the systems and processes for it to get to this point, but there’s blame here, for a deliberate malicious act.
Remember, the insurance companies are HAPPY to pay higher prices (in fact they have forced many small ObGyn into more expensive hospital practice) as long as their competitors do too!
Health Insurance companies grow their bottom line by growing the topline cost of healthcare since they're margins are limited.
United healthcare in 2022 had $324 billion revenue (up from $75 billion in 2007) and profits of $20 billion (both up >15% year on year). There is absolutely no risk that they become insolvent.
https://www.statista.com/statistics/214504/total-revenue-of-...
https://www.healthcaredive.com/news/unitedhealth-2022-earnin...
The thing is the insurers aren't writing nasty letters to/suing dishonest providers and CCing the patient, they're dumping the problem on the patient.
I'm assuming that the drs who end up as insruance claim evaluation drs are the Dr. Murphy's of the world who everyone decided it would be better if they weren't actually practicing medicine.
Yes. Which makes it darkly ironic that the end result is them practicing medicine on tens of thousands of people a month each.
How are these guys allowed to stay in business? Hospitals and insurances make many "mistakes" in their favor and leave it up to the patient to navigate this kafkaeske bureaucracy. I understand making some honest mistakes but this stuff is just plain fraud.
Fraud is an American norm, that's why lobbyists make big bucks. One of the US Senators for Florida was CEO of a company that was convicted of 14 counts of defrauding Medicare and had to pay $1.7 billion in fines, but he just said he knew nothing about it and went on to become Governor and later Senator for his state.
https://en.wikipedia.org/wiki/Rick_Scott
Meanwhile a Democratic Senator from New Jersey is credibly accused of taking bribes from Egypt (evidence included literal bars of gold discovered in his home pursuant to a search warrant), but he refuses to resign.
Corruption is endemic in the US, it just has good lawyers and PR people.
Setting US standards by the citizens of Florida and New Jersey is a bit outside the bell curve...
I'm quite sure I could find examples from every state, I just picked the two most egregious examples that sprang to mind.
I'm sure you could find singular examples in any state. That's how exceptions work.
In Florida, though, my experience has been that corruption is far more endemic and culturally accepted.
There's a reason no president has ever come from Florida politics -- despite being the 3rd most populous state (more people than NY!) -- the skills and acceptable approaches down here don't fly in the rest of the county.
F.ex. the publicly-regulated utility covering most of the state (FPL) financed a third party candidate (up to $3m) in a state senate race. That candidate didn't campaign, but did happen to have the same last name as the incumbent, who had been critical of FPL and pushed reform efforts. The incumbent lost by 32 votes. [0]
Or the (again regulated-FPL-adjacent) takeover attempt of the sole remaining city-run utility company in Florida (JEA) that collapsed in a flurry of federal charges over kickbacks and undeclared secret bonus clauses. [1]
And this is just "business as usual" in Florida.
Shady stuff happens in other states, sure, but at least people elsewhere have the decency to be ashamed about what they're doing.
[0]https://www.orlandosentinel.com/2022/07/22/operatives-workin...
Awesome, do Chicago next.
The combination of paying of pocket or face horrific medical consequences along with ERISA limiting legal claims makes it unlikely the insurance companies face any consequences to their actions.
Unless you're a wealthy litigation attorney who has friends that will rack up enormous bills as insurance takes it to federal appeals court.
https://www.propublica.org/article/blue-cross-proton-therapy...
One thing that's especially egregious about the situation in RadOnc is that there are plenty of situations where the doctors and physicists have already planned a treatment, billing $xxx per hour, and only then it is denied by insurance, so the hospital counts this as a loss and plans another inferior treatment, increasing the cost, in order to offer a "cheaper" procedure as demanded by the insurance company. The losses are of course amortized to drive up the cost of all treatments while the patients are given inferior care.
It's absolutely infuriating. A friend who is a therapy physicist left the country and went back to work in Canada taking a 40% pay cut because he couldn't stand it anymore.
I think the best analogy I can come up with is your kid touching a hot stove. You tell them not to, but they do anyway, and then when they learn that it really hurts, they stop doing it. Regulations are like that. Regulations are a SUPER hot stove. The employees at the insurance company want to touch the stove as often as possible. They get paid extra the closer they come to touching it. But, as more companies get burned by the stove for failing to meet the regulation's requirements, they learn that being in pain is bad. Then, they stop trying to touch the stove.
So this ProPublica article is great; they say to someone relatively important at the insurance company, "hey, the individuals you wronged are actually well-connected enough to get journalists involved" and the companies get REALLY SCARED, because step 2 after the newspaper article is published is every junior US Attorney in the country tripping over each other to cart them off to prison as quickly as possible. (OK, it's probably a fine. But shareholders do not like your stock when you are routinely fined, and CEOs are paid in stock. See why competent people might get involved when that's at risk?)
You can read this article as "evil companies are evil", but I read it as "evil companies are learning". There will be eventually a day when your entire claims packet is on the same website as your EOBs, and you can click a link to report a mistake. The companies will have to act on your reported mistakes, because a paper trail that says they did something illegal is super bad for the shareholders. It takes time, but journalism like this is what gets it started. If you feel depressed, don't. The system is slow, but the system is working. This is what we have democracy and a free press for!
"There will be eventually a day when your entire claims packet is on the same website as your EOBs, and you can click a link to report a mistake. The companies will have to act on your reported mistakes, because a paper trail that says they did something illegal is super bad for the shareholders. It takes time, but journalism like this is what gets it started. If you feel depressed, don't. The system is slow, but the system is working. This is what we have democracy and a free press for!"
When will that be? In 100 years?
I always felt that every insurance company should report anonymized aggregate percentages for denied claims in some fashion. Not sure how much that would help but it could shine more light on the issue.
An interesting number would be the number of successful appeals after denial. If that number is high it would indicate that they are denying too often.
>...spending an average of 1.2 seconds on each case...
How are these guys allowed to stay in business?
Afaik, that's exactlyhowthe ACA was written -- there's a ceiling to non-care expenses that insurance companies can include in premiums.
One consequence of this is pushing insurers to be hyper-efficient. One consequence of that is the average case needing to take 1.2 seconds.
Granted, that likely includes a huge amount of happy path cases that flow through automated rules engines, which effectively take no time.
So really, it's more like (most cases take 0 time) + (a low number of cases take non-zero time) = 1.2 seconds on average.
In many cases these doctors aren't practicing physicians, iirc the reviewer in the article hadn't practiced for 25 years. They just need someone with an MD to sign off on the denials.
My view is that these people and companies are practicing medicine and should start being held to the standard of care.
Since you have some experience in the field, How do you see your views becoming reality?
Sadly the practicing side and the regulatory side are different enough that I basically don't have much insight into why my views are wrong. (I mean, presumably if my views were right, some enterprising lawyer would have applied the theory already.) E.g., if there is legislation that is acting as a barrier, we could get our representatives to change it. If these folks remain boarded and are practicing outside of the norms and scope, then we could get our medical licensing boards to take action as well.
Afaik, medical review professionals are acting more as expert witnesses (with a crushing case load).
They get privileged access to your medical information and directly impact the treatment plan you get. They are practicing medicine.
They get access to whatever records transmit to the insurance company and they provide a medical opinion on the necessity and adherence to accepted standards of care of given treatments.
That's not the same as what doctors and nurses do.
Seems pretty similar to what a doctor might do.
They get a bunch of test results and a first opinion (from doctor) then they issue a new (second) opinion of no treatment. Doctors give out second opinions all the time; it's a thing patients do when they want to make sure the first one is correct.
If you lack that insight, how do you know your views are well formed enough to not be gibberish?
Or is there a possibility that they could lead nowhere?
Ya there is a Grisham novel about this exact thing. I hope the people involved in Cigna all have their spouses leave them, their children disown them, and then get their car towed.
What's the name of the novel?
What if their spouses and children like having food and health insurance of their own?
I've had doctors who automatically refile the claim multiple times in a row because of this. I'd get a letter from insurance saying it's denied then 2 weeks later another saying it's approved.
I think the solution to most problems is make the c-suite criminally responsible for errors. Things will resolve themselves
I think an even better solution is for our society to just admit that health insurance companies can't exist as for-profit entities that have to answer to Wall Street first and foremost.
Think about it. A health care company collects money under the premise that "these premiums you're paying will cover you if something bad happens". If that something baddoeshappen (and for most people, it never will), that money should be available to pay for whatever happened. The insurer, now concerned about their margins and profits more thanproviding you the service that you've already paid them to do, just gets to trot out some poorly paid rep with no medical knowledge to override the medical advice of a trained medical professional. Now, you're not only injured, you're paying out of pocket for a service that won't actually do what you've paid it to do. The only winner here is the insurer's C-Suite and stockholders who get to brag on quarterly earnings calls that they've denied tens of thousands of claims (and they even get fiscally rewarded for it!).
In a more modern and honest society we would call for-profit insurers what they actually are: a racketeering organization operating under the guise of fraud.
That does not solve the root problem.
The root problem is healthcare is an extremely complex field, requiring extremely specialized knowledge that takes extreme investment to get. And everyone wants it, the demand is infinite and the demand has no elasticity.
So a buyer of healthcare has a problem. They have no idea what they are buying, and have no idea if the seller is scamming them or incompetent. So you need a second opinion. But as stated above, people who can provide this opinion are few and far between.
It is not like paying $100 to get a second opinion on your car. It is more like paying $500 to $10,000 or who knows how much to get a second opinion.
So the root problem is people simply cannot afford the level of healthcare they desire. Everything else is just papering over that intractable problem.
They have no idea what they are buying, and have no idea if the seller is scamming them or incompetent.
It's worse than that, important healthcare decisions are often made while you are unconscious, and you just have to pay for whatever choice was made. Not only do you not know what you're buying, you don't even know a purchase is being made.
I am convinced that it doesn't make sense to discuss healthcare as if it is a market. Patients are not "buyers". You pass out, some random person calls 911 and they send a private ambulance, you wake up at the hospital, and now you owe money to the ambulance company. In what sense have you "bought" anything? There has to be more to the definition than just "money is involved". We don't talk about the parking ticket market or the taxation market (just move to a different country if you aren't satisfied with your taxation provider!), and we shouldn't talk about the healthcare market.
important healthcare decisions are often made while you are unconscious, and you just have to pay for whatever choice was made
This is a problem, but it's not a major driver of health care expenses. Emergency care is around 5% of total spending:https://www.healthaffairs.org/doi/10.1377/hlthaff.2022.01287
It looks like that figure doesn't include ambulance charges, which is the example I had in mind when I wrote that sentence. It also doesn't include decisions made during non-emergency surgery, which still might be necessary to stay alive even though you aren't in the emergency department. It of course doesn't include medication and followup care resulting from whatever unconscious decisions were made.
Regardless, I don't believe determining an exact percentage is relevant to this discussion. I'm not an economist, but every definition of "market" I can find says something like "a system where two parties can engage in a transaction". If there's a significant chance that one of the parties is unconscious and/or about to die, they are not engaging in a transaction any more than a mugging victim is. 5% is the chance of rolling a 1 on a d20, that is certainly significant.
Can you link one such definition?
In economics, a market is a composition of systems, institutions, procedures, social relations or infrastructures whereby parties engage in exchange.
-https://en.m.wikipedia.org/wiki/Market_(economics)
A market is a place where parties can gather to facilitate the exchange of goods and services.
These don't imply that 'parties' have to be conscious or actively making any decisions?
That is a good point, but unless people work for free, someone is selling and someone is buying. While you might not have explicitly bought anything, your agent (whether it be family or the government) did buy something.
More broadly, anytime you are dealing with limited resources (including time), you have to be buying and selling (i.e. there are opportunity costs to making a decision).
We don't talk about the parking ticket market
You cannot buy a parking ticket, so this is not comparable. However, people do often calculate the cost of legally parking versus the probability * cost of potential fines.
or the taxation market (just move to a different country if you aren't satisfied with your taxation provider!)
This happens all the time, but everyone may not have the means to do it. It was one of the factors for my relocation within the US.
Even businesses use it to determine where to expand or close operations. Warren Buffett mentioned it in his annual letter some years ago.
I agree that someone is buying and selling, what I mean is that it doesn't make sense to talk about healthcare recipients as participants in a market. Obviously firefighters purchase equipment and sell their labor to the government, but we don't refer to homeowners as buyers in a firefighting market. If we forced them to pay a fee after being saved from a fire, that wouldn't somehow constitute a market. The same is true for any other essential government service: we created socialized systems because they can't function as markets.
You cannot buy a parking ticket
Exactly, just like you can't buy an unexpected medical bill. You still have to pay it though.
The fact that rich people sometimes choose to accept a parking ticket or choose to purchase citizenship in a more favorable tax environment is not evidence of a market, in fact it's the opposite. If 99% of "buyers" are forced to participate but have 0 decision-making power, and a handful of rich people are able to (sometimes) shop around, you are not describing a market.
I think this conversation is going off track. For the purposes of determining prices for healthcare, there exists a market, even if the person receiving the healthcare is not paying.
The root problem is healthcare is an extremely complex field, requiring extremely specialized knowledge that takes extreme investment to get. And everyone wants it, the demand is infinite and the demand has no elasticity.
I'm sorry but this statement flies rather in the face of 22 other industrialized modern nations that have managedsome typeof publicly funded healthcare. The United States being theone that hasn't,along with also being the richest nation in that group, along with already spending the most among that group per patient by a wide, wide margin and getting by far and away the shittiest service in return.
We're also unique in that we're the only nation which hosts slap fights between hospitals and insurers that last months and leave patients wondering as they recover from whatever went wrong for them if they're going to owe $20 or $20,000.
Now, do those other 22 nations have completely perfect healthcare systems? No, of course not. But to say "well it's just too complicated" and throw up your hands is just shit. You know what else those other nations don't have? They don't have people going bankrupt from being in a car accidentthat wasn't even their fault.
And you know what is also unique among the United States? We're the only ones in that group who have several corporations with fully seated C-suites raking in billions of dollars off a service people literally cannot live without. So it seems to me, removing that part first is a solid first step.
The grandparent comments are discussing the approval or denial of claims, which also happens in countries with other systems of publicly funded healthcare. It might not be called a claim and done by an insurance company, but the government will have some type of system to evaluate appropriate/affordable expenses.
The problem of insufficient resources exists in other countries too, but of course they may be managing it better.
A health care company collects money under the premise that "these premiums you're paying will cover you if something bad happens"
That's not the premise of insurance, though. The premise of insurance is that a large group of people pools their money (through paying premiums), out of which the people in need of assistance get paid. It's not that you'll be "repaid" your premiums in services. It's pooled risk, not a kind of savings or investment.
In order for it to work financially, most people have to never have claims in excess of what they paid in. The whole point is to be able to cover exceptional and rare disasters.
I think one of the ways that health insurance (at least in the US) has gone horribly wrong is that it became a means to pay for routine medical things rather than just exceptional ones.
I think one of the ways that health insurance (at least in the US) has gone horribly wrong is that it became a means to pay for routine medical things rather than just exceptional ones.
Then why isn't this a problem in any country with socialized medicine or other required health "insurance" things? They have increasing costs but not nearly to the extent the US experiences.
The cost of childbirth in the US is insane. It is literally cheaper to fly to another country,pay out of pocket the purposely inflated "tourist medicine" price, hang out in a nice hotel for a few days, and then fly back!
It is literally cheaper to fly to another country, pay out of pocket the purposely inflated "tourist medicine" price, hang out in a nice hotel for a few days, and then fly back!
I can top that...
In my part of the US west coast, if you need to have two dental crowns done, it's cheaper to fly to Taiwan and have it done there than to have it done locally.
As a bonus, the quality of care and materials will be much better and the dentist may even actually apologize for having to charge you at all.
In my part of the US west coast, if you need to have two dental crowns done, it's cheaper to fly to Taiwan and have it done there than to have it done locally.
This is exactly what I do.
I would take the kids back to my home country, pay out of pocket for any treatment, and have a nice holiday in the process.
Last time we went back, I was chatting with the dentist and casually told her about the treatment costs in the US - she was flabbergasted. Markup prices in the US seem to be 500%+ of those in many European countries.
There's a number of reasons.
- malpractice insurance
- cost of living difference
- government rationing of care in public systems
- lower capital expenses for nice looking buildings and top-of-the-line equipment
- unpaid bills turn into higher prices
Countries with socialized medicine have their own problems. It can be great for average people with average problems, but outside those lines you run into things that would be trivial in a US healthcare setting.
Obviously, it varies by country, and there are plenty of things I hate about how healthcare works in the US.
Total cost of planned C-section as a private patient (that is, paying significantly more than public insurance) in Germany, including 3 day hospital stay (short because pre-vaccine, pre-quick test Covid times): about 5000 EUR.
That’s not what I paid out of pocket; that’s what the hospital cheerfully billed and collected from my insurance company, and what I theoretically could have opted to pay myself to retain my annual reimbursement level (3 months of premiums after several no-claims years on a higher-deductible policy)
I think one of the ways that health insurance (at least in the US) has gone horribly wrong is that it became a means to pay for routine medical things rather than just exceptional ones.
This is solved by high deductible health plans.
In order for it to work financially, most people have to never have claims in excess of what they paid in. The whole point is to be able to cover exceptional and rare disasters.
This is where the problem is. Humans will have health problems and will have claims, especially after age 50. Which means (assuming a stable population), the present value of premiums has to equal the present value of all the healthcare you will need (until you get to Medicare, age 65). Which is a large number, especially considering the obesity/hypertension/diabetes/heart disease rates.
Which means premiums are effectively just another tax (except they are no longer mandated). A big wrinkle here is declining proportion of younger populations to pay for older populations, so the premiums young people pay for healthcare older people receive now, but when the young people are older, there will be fewer younger people to pay for them, so it is also a marginal “age” tax, where the younger people pay for more than what they will receive. Exactly the same as Medicare taxes.
This isn't solved by high deductible health plans, because they just kick the can down the road by letting customers self-segregate into different risk profiles.
- Young with no health issues? HDHP.
- Suddenly get sick or are older with medical needs? Wait until next year's open enrollment and switch to a higher tier plan.
Guess which risk pool has to pay out more in claims (against a neutral population average). And therefore has to increase premiums.
The issue is that we should categorically bannon-catastrophichealth insurance.
Everyone gets an order-of-magnitude yearly disposable income * 2 deductible plan.
Everything else is out of pocket.
Surprise! Suddenly discount options appear. Suddenly hospitals are competing on price. Etc.
ACA does not permit segregation of risk pooling based on plan choice. The subsidy from young to old will remain no matter what due to the statutory age rating factors, and the subsidy from healthy to sick remains due to the restriction barring use of health history to price premium.
The issue is that we should categorically ban non-catastrophic health insurance.
This is basically banned as all ACA compliant health plans have to have out of pocket maximums, which are limited by law (currently ~$10k/$18k for single/family).
However, there was a political compromise to allow non ACA plans due to some extremist “religious” factions, which I doubt had anything to do with religion.
The root problem will remain however, because the supply of doctors and non patented medicines relative to demand is very low, and hence prices will not come down.
I expect we might be tripping over my misuse of terms of art re: risk (sorry!) and your proper use?
If we look at two plans: (Plan HB) an HDCP bronze plan and (Plan P) a traditional platinum plan.
Each can set premiums on the basis of their expected payouts, no?
So if, for the last 5 years, plan HB had an average participant age of 35, few health complications, and low payouts and Plan P had an average participant age of 55, more health complications, and high payouts... Plan HB could set lower premiums and Plan P could set higher premiums (against all-of-population neutral rates), no?
Or am I misunderstanding limits on actuarial use under ACA?
(Disclaimer: I haven't done much work on the actuarial side)
In order for it to work financially, most people have to never have claims in excess of what they paid in.
I don't this needs to be true. If you say pay 10,000 and they invest that and it returns at 10,500 at the end of the year then if your claim is 10,300 they've technically made $200 still.
Given that they're raking in billions in premiums I think they have access to better rate of returns than each of those individuals could've done on their own.
I think one of the ways that health insurance (at least in the US) has gone horribly wrong is that it became a means to pay for routine medical things rather than just exceptional ones.
I really am surprised that most insurance networks don't become more vertically integrated. Like manufacture their own drugs, hire their own doctors, etc since a lot of their expenses are extremely predictable.
Given that they're raking in billions in premiums I think they have access to better rate of returns than each of those individuals could've done on their own.
Not really, as far as I know claims reserves have to be kept highly liquid (Treasuries or High Grade Corporate Bonds maybe?, especially for a health insurer which pay out almost all the premiums it collects every year.
They are not going to be invested in VC/PE/REIT/etc.
That's not actually how the industry works in the general case. Health "insurance" companies no longer provide much insurance. Instead they mainly just create provider networks and administer claims on behalf of self-insured group buyers (mainly employers and unions). The remaining fully insured market is relatively small.
Health insurers have low profit margins. You can read their audited financial statements for the publicly traded ones. Some are even non-profit. The Affordable Care Act (Obamacare) set a minimum 85% medical loss ratio. The insurers have to cover their operating costs and profit margins out of the remaining 15%. Even if we were to replace commercial insurers with some sort of "Medicare for all" system that would have only a marginal impact on costs to patients and availability of care.
The real drivers here are the big employers. They are the ones ultimately paying most of the bills, and they insist that insurers ration care to control costs.
The Affordable Care Act (Obamacare) set a minimum 85% medical loss ratio. The insurers have to cover their operating costs and profit margins out of the remaining 15%.
That's also a perverse incentive though. With capped "profit" windows, how is a company to make more money? Well if healthcare costs increase, then premiums need to. 15% of 1.3X is bigger than 15% of X, after all. And healthcare providers are unlikely to object to higher prices.
And what if your insurer gets involved in vertical integration - perhaps Kaiser style, perhaps less formal? Now you get to reduce the actual cost to you (the insurer) by removing the middleman, and you get increased profit by keeping the price the same. It might show up on a different ledger on your books, but nonetheless...
And what if your insurer gets involved in vertical integration - perhaps Kaiser style, perhaps less formal? Now you get to reduce the actual cost to you (the insurer) by removing the middleman, and you get increased profit by keeping the price the same. It might show up on a different ledger on your books, but nonetheless...
Regulators are not this dumb or corrupt.
This is not a big money making business, as evidenced by Buffett/Bezos/Dimon’s foray failing:
https://www.latimes.com/business/story/2021-01-04/buffett-be...
UNH stock has doubled since 2020. Someones making big money.
Because the risk of removing ACA legislation is gone. It’s a company with very reliable revenue that will keep up with inflation with relatively low liability.
And despite that Unitedhealthcare has grown from ~$70 billion revenue in 2007 to $320 billion in 2022 and is making a $20 billion in profit (which I'd argue is a pretty healthy profit). So I guess the health insurers are just working around the system.
You're mixing up UnitedHealthcare with it's parent publicly traded company UnitedHealth Group. They sell other services and technology products unrelated to medical insurance, and those contribute a lot of the net profit. Medical insurance is a high volume, low profit margin business.
https://www.sec.gov/ix?doc=/Archives/edgar/data/0000731766/0...
It is reasonable to criticize insurer profits but overall those are only a small part of much larger systemic problems in the US healthcare system. Even if profit margins were somehow cut to zero that would have only a marginal impact.
The real drivers here are the big employers. They are the ones ultimately paying most of the bills, and they insist that insurers ration care to control costs.
Are US costs reasonably described as well controlled?
Please Google “medical loss ratio”
I agree if you stop at “health insurance companies can’t exist.” Being a nonprofit doesn’t stop you from being parasitic or malevolent.
Enthusiastically agree, but considering how much political lobbying comes from health insurance giants I have no hope of it happening in my lifetime.
I think that, and making the doctor who denies the claim responsible personally and professionally as if they were providing care to a patient.
To play devil's advocate: Wouldn't that just result in healthcare systems being run by people too incompetent to realize the liability they're signing up for?
That seems more likely (apriori) than healthcare systems magically becoming efficient, responsible, and ethical actors.
It'd be funny if they rubber-stamped all suppository claims. Like, we'll just cover it if it has anything to do with your ass.
Ironically I did want to try this steroid suppository foam in the throes of a bad IBD flare but my doctor said not to bother because insurance companies never cover it.
The world would be a much nicer place if the default for the insurance company was to cover your ass lol
Thats why you ask for an exception and appeal the denial or get a specialist and try it with them. I don't think mine have ever been denied but I also have a long rapsheet of tried meds. If you rattle off a list of 2 or more previously tried meds, I'd be surprised if they can sustain a denial. You just might have to appeal or try something to add to the list of what to bring up as evidence to try something different (uncovered)
I recently sued my health insurance company in small claims court and won. They claimed my out of network costs were above the norm. The insurance company tried all kinds of tricks trying to get the case thrown and delaying. Took me four trips down to the courthouse but finally got them in front of a judge who knew they were full of shit and sided with me.
Interesting one I heard once from my dad.
'your policy is denied you are not covered for this because only your spouse is' 'thats interesting that is not how I wrote myOWNpolicy' 'uhhh we will get back to you' They approved it. But not before denying it.
He sold these policies for a living. He mostly quit exactly because of this sort of noise.
I had an instance where the hospital had coded my spouse's eye issue as "routine" -- so it was not covered by medical insurance, because your vision insurance is supposed to cover that. Our vision insurance wouldn't cover it, because they only permit one visit per calendar year.
The doctor that treated my spouse literally published a paper about the case, so uh... not routine. I gotsuperlucky with the insurance person, though -- she actually called the hospital for me and got them to re-code it.
Had literally the exact same issue with my spouse, but without the luck of finding an insurance person who cared. At the end of the day, it wasn't worth the $200 to continue fighting it (had already invested ~5 hours into phone calls back and forth between the clinic and insurance company).
Infuriating to say the least.
So even if you know the grounds for denial, sometimes the reason is bullshit and flies in the face of the insurer's own policies.
This is a feature health insurance companies, not a bug. Their entire purpose is to collect as much premiums as possible while paying out a little as possible.
It would be interesting to see exactly what was coded on the electronic claim in order to understand where the fault lies. Insurers certainly make some errors when processing claims and don't always follow their own coverage rules correctly. But equally providers (including pharmacies) sometimes make data entry errors. There are distinct NDC codes for every minor variation of a drug, and sometimes only a subset are covered.
Unfortunately when either side makes an error the patient gets stuck trying to fix it.
There was a lawsuit years ago where someone sued some hospital administration or insurance company for practicing medicine without a license for denying some claim.
I think this set a precedent, so if a doctor is not involved, there's a problem.
EDIT: can't find the case
I think if they'd tried to run the claim as the suppository version, the error would've been more obvious.
Gotta tell the insurance company where to stick it? :)
The people who denied your insurance claims were literal criminal who need to be arrested and jailed. If their local municipalities don't prosecute on your own, you're [almost certainly] legally entitled to make a citzen's arrest with as much force as necessary to bring the criminal fraudsters denying your assets to justice..
ok great, so I should get to know why things get denied.
Maybe... they just can't deny without a reasonable alternative that your doctor agrees with? Like fine deny name brand prescription for generic.
The idea that your Doctor... who actually knows what is going on wants to do something and your Insurance can just say no is ridiculous.
If we are so worried about Doctors doing unnecessary things to get money from Insurance than lets tackle that also.
Payer coverage rules typically do include that. This is known as step therapy. If a physician requests prior authorization for a branded medication then the insurer might deny it and recommend trying the generic alternative first.
A lot of these issues arise because providers fail to review payer coverage rules before deciding on a treatment plan. And in fairness to providers, this takes extra time which they don't get paid for and the rules are inconsistent between payers. The new HL7 Da Vinci Project prior authorization burden reduction standards can help automate this to an extent by giving providers an API to check coverage rules in real time.
https://www.hl7.org/fhir/us/davinci-crd/
At a fundamental level, medical insurance has to involve some form of cost control and care rationing. Much of what insurers do is preventing waste, fraud, and abuse by verifying that treatments are medically necessary as per current best practices and balancing costs versus benefits. Unfortunately, patients sometimes get caught in the middle.
Much of what insurers do is preventing waste, fraud, and abuse
Medical insurers are the waste, fraud, and abuse.
I'm not sure what you mean there. Even Medicare in the US and single payer systems in other countries have strict rules to prevent waste, fraud, and abuse. They will refuse to pay claims that don't comply with coverage rules. In many cases those are even more strict than US private medical insurers.
What I mean is that what insurers do is try to screw people out of money and receiving necessary treatment to line their own pockets. Here’s a fairly concrete example:
https://www.propublica.org/article/unitedhealth-healthcare-i...
Insurers do deny some claims and authorization requests, but in most cases this doesn't line their own pockets. Rather the opposite. Most large employers are now self insured, and the medical "insurance" companies just administer claims. Due to the 85% minimum medical loss ratio imposed by the Affordable Care Act (Obamacare), insurers actually makemoreprofit when they approve more treatments.
When claims or authorizations are denied it's generally because large employers have been pushing back to control their own costs. Unfortunately, many consumers don't understand this market dynamic and direct their blame in the wrong direction.
Apologies, but this is complete bullshit. They make money by denying expensive claims, regardless of whether or not people actually need the treatment, and optimize for this despicable behavior.
I have given you accurate information. If you choose to remain ignorant then that is your affair. The reality is that payers that offer health plans to self-insured employers don't make money by denying claims.
No, you’ve intentionally tried to deflect and deceive across this entire thread, as is obvious from all the downvotes and comments you’ve received. It’s quite bold to lie and say insurance companies don’t deny claims to make money, since there are only myriad news stories, court cases, books, films, etc about them doing so, but you do you.
US government employees would be doing the same things for Medicare and Medicaid and Tricare.
Outsourcing that work to “insurers” helps keep the heat off the politicians.
Not true for Medicare. How it works is that Medicare splits the US up into regions (can’t remember if it’s currently 5 or 7). For each of these regions, a private medical insurance company handles all of the claims paperwork and the money for said claims comes from Uncle Sugar. This is also why it’s disingenuous when folks trot out the “claim dollars per Federal employee” argument for Medicare.
Note: I’m not talking about Medicare Advantage which is a separate program whereby Medicare pays the premiums for private health insurance plans.
It seems like we are in agreement.
A lot of these issues arise because providers fail to review payer coverage rules before deciding on a treatment plan. And in fairness to providers, this takes extra time which they don't get paid for and the rules are inconsistent between payers. The new HL7 Da Vinci Project prior authorization burden reduction standards can help automate this to an extent by giving providers an API to check coverage rules in real time.
I'm sorry but how with a straight face can you really write this paragraph. The Doctor, the person who is seeing you needs to check a system of what you they are authorized to do for you? That is dystopian.
FFS we had an episode of this on Star Trek Voyager showing how bad this system is and yet that is exactly what we do.
What you are describing id disgusting, end of story. There is no justification of any of this.
Are there corrupt doctors? Sure. But insurance should not have a right to say what can and cannot be done if here is a good reason and it should be an actual discussion instead of Insurance having all of the power. ALL
You're arguing with the wrong person. I gave you accurate information about how the system works today, and a reference to technical information that hackers can use to mitigate certain problems. And I can do that with a straight face.
Technically insurers don't say what treatments can and cannot be done. Their role is purely financial. Patients can always pay out of pocket, and some do. But in practice an insurance denial does sometimes leave low income patients without access to care.
Ultimately though there does have to be some system for rationing care. Demand is effectively infinite and resources are finite. Even countries with single payer or socialized medicine restrict which treatments they make available, and often restrict patient access to expensive treatments by imposing queues.
I didn't claim that the current system is a good one. I have no power to change it. Any real solution will have to be mainly political so complain to go take your proposals to Congress.
"A lot of these issues arise because providers fail to review payer coverage rules before deciding on a treatment plan"
A system wherein the trained professional with direct access to the patient has to defer to a board of anonymous bureaucrats to determine the course of treatment is absurd. These issues don't arise because "providers fail" they arise because the system is built to fail and the burden falls on everyone except the people making the rules (and the profit).
I’ve long believed that denials that come from an insurance company should be required to:
- come from an individual doctor (not just be signed off, but the doctor originates the denial)
- the doctor must be personally named and identified to the patient as the party responsible for the denial
- that doctor is *personally* and *professionally* liable for harms that befall the patient from a wrongful denial
I'd add a requirement that said doctor have practiced in the relevant specialty within the last decade.
This simply incentivizes a rapidly revolving door between practice and insurance, with a likely effect of making the actual practioners as a populace more friendly to the insurance companies in general (in expectation of quid pro quo).
There's something deeply wrong when a gastroenterologist who hasn't seen a patient in person for decades can deny a neurosurgical procedure.
Maybe you make it like jury duty; if you're a practicing doc, you periodically get randomly assigned some appeals in your speciality to review.
Thecurrentsystem already has a massive quid-pro-quo; if you aren't willing to spend 1.2 seconds to deny tens of thousands of claims a month (not an exaggeration!https://www.propublica.org/article/cigna-pxdx-medical-health...), they'll find someone else. The docs and companies doing these "independent" reviews are completely captured by the industry already.
Maybe you make it like jury duty; if you're a practicing doc, you periodically get randomly assigned some appeals
Or send appeals to a committee of randomly-rotating reviewers. The state could administer the service to promote fairness and lessen the cost to the insurer.
As someone close to the insurance industry I suspect this would just lead to a revolving door of Doctor Nicks that get cushy jobs for life and sip margaritas by the pool while their "reputation is ruined" - we need a better approach than this like (similar to Canada) having national guidelines for treatment that for the payer to act responsibly. You don't want to know just how many bodies UHC is willing to throw under a bus in order to make .5% more money.
reputation is ruined
By personally liable, I don’t mean “their reputation is harmed”, I mean “forced to file for bankruptcy, and will be paying off the court imposed damages for the rest of their life”.
By professionally liable, I mean medical licenses being torn up, and their right to practice medicine being permanently revoked due to committing medical malpractice.
I mean, these people need to be medical doctors, that are treated as making a medical decision, with all the requirements and liabilities that come from that.
When Dr. Nick spends 1.2 seconds reviewing a patient’s file before issuing a denial, I’m proposing that being a life ruining decision for Dr. Nick.
Set it up so if you make a mistake, you're suspended from being able to issue any denials for a month. Make a second mistake, 2 months. 3 mistakes, 4 months. 4 mistakes, 8 months... In a 40 year career each Doctor Nick would only get 9 mistakes. Maybe a month suspension for a first offense is too harsh; let's say a day instead, that's still only 14 mistakes in a career. Is the money saved from that handful of extra denials going to justify the cost of taking care of those doctors for life?
My childhood doctor in the late 70's hated insurance companies over this. I'd hear him on the phone arguing with the insurance company reps asking if they had a MD Degree and would like explain the denial to him. Interesting to hear back in the day.
I have to imagine many do, it sucks since what the hell are their options. I would like to think that most doctors at least care somewhat. I can't imagine how they feel if they think someone truly needs something and insurance just says no.
I know my sister at one point was having some critical medication for her denied so the doctor just kept giving her sample packs.
I went through an issue with a medication for me and it was still never resolved.
In many cases that issue can be resolved through an appeals process. But this takes extra time for providers, and they don't get paid for that.
Insurers may also require step therapy. Try a cheaper treatment first, then if the patient fails to respond they will authorize a more expensive option.
I call bullshit.
I went through multiple appeal processes, my doctor tried to file multiple on my behalf, I called, and nothing.
They don't care.
Sounds like you had a good doc. These days it seems like the insurance companies have won- every doctor I talk to has the most beaten-down expression when I ask them about coding and their relationship with insurance companies. For most I talk to, they got into medicine to help people, but find themselves spending a frustrating amount of their time fighting with insurance.
Yeah, he was a cantankerous one. Always telling my Mom to quit smoking while he himself would be smoking at the same time. The 70's were an interesting time to be a child.
the youtube channel dr glaucomflecken did a series on this that were pretty funny
https://www.youtube.com/watch?v=Vp7u58R41N8&list=PLpMVXO0TkG...
The idea that your Doctor... who actually knows what is going on wants to do something and your Insurance can just say no is ridiculous.
Death panels for a captive market, so it's all good.
Republicans were a couple decades too late when they said single payer or Obamacare would bring death panels. We already have death panels wifh medicare, medicaid, and workplace insurance.
It'd just be changed to a federal-government sanctioned death panel system. Probably with an expected goal of deaths, and if the target isn't being met, methods to be encouraged to bring it about...
Republicans were a couple decades too late when they said single payer or Obamacare would bring death panels. We already have death panels wifh medicare, medicaid, and workplace insurance.
It'd just be changed to a federal-government sanctioned death panel system. Probably with an expected goal of deaths, and if the target isn't being met, methods to be encouraged to bring it about...
It's not how healthcare work in other industrialised countries.
It’s even worse than that: now they have a bunch of corrupt medical practitioners who they use to rubber stamp denials to make them more legally defensible. Most often, they’re literally just clicking “CONFIRM” on some machine-generated auto-denial.
Very much so. They'll get presented with several bullet points of reasons for denial based on their system, and be asked "do you see any need to disagree with this reasoning?" rather than any form of differential workup.
"Like fine deny name brand prescription for generic."
This is bad too if you have more experience or misfortune with chronic medication usage.
You can't sue for medication side effects from generic medications.
I know this is a low-quality comment, but this may be the #1 thing Hacker News has taught me over the last decade: USA health/insurance system is an Orwelian nightmare multiplied by a hundred. No straight-up evil guy with a vision and mission statement could imagine and successfully implement something as brutal as apparently we've systemically created ourselves through a million small steps.
I'm a bright guy but I don't know how I'd live with thecognitive workload, stress and uncertaintyover having to deal with all of this (the networks, the uncertainty over price and bills, the bills coming for weeks and months after care, the myriad involved parties, the rules and limits and interpretations and just... everything). More to the point, I don't understand how anybody, on any party or political spectrum, can say "Yup... this is a reasonable system that helps people and needs no change".
> I'm a bright guy but I don't know how I'd live with the cognitive workload, stress and uncertainty over having to deal with all of this (the networks, the uncertainty over price and bills, the bills coming for weeks and months after care, the myriad involved parties, the rules and limits and interpretations and just... everything).
When you have a real issue, it takes hundreds of hours to deal with it. Smart employers know that this eventually comes out of company time and productivity, esp since most of these calls need to take place during business hours.
Smart employers will advertise "100% paid health plans, etc, etc."
Penny-wise employers, even white-collar jobs/offices, will often provide the bare-minimum coverage, and pretend it has no effect.Except it does.You can see it when your cubicle-neighbor is on a 2hr call with insurance, etc. I've had colleagues who will block a 4hr meeting on their calendar titled "calling insurance companies to figure out bills" as open protest. I've had people in the office just spend a day or two on the phone with doctors' offices, visible, both out of desperation and as a subtle form of protest for the organization's choices in health plans.
Health insurance tied to employment is the second biggest scam in American history after Reaganomics. It forces people to stay in crappy jobs to maintain coverage and fucks with collective bargaining rights.
We need universal, single payer healthcare.
Health insurance tied to employment is the second biggest scam in American history after Reaganomics.
And yet, sadly, even the "liberals" push for tying it to employment.
Mostly the liberals. In 2008 Mitt Romney pushed for ending the favorable tax treatment of employer-based plans (https://www.commonwealthfund.org/publications/fund-reports/2...), which was instantly attacked by the left for "taking away your insurance". Then the ACA set up the marketplace for individual plans which was good, but also inexplicably added employer mandates.
It's the same problem as ending subsidies for higher education and tax deduction of mortgages. In the long run it might be the right thing to do, but in the short term, without offsetting factors, it would cause measurable harm beyond what we should be comfortable tolerating.
It started as a reaction to a market distortion during/after WWII. There was a government-imposed salary cap during the war (Stabilization Act of 1942), so private companies had to get creative to attract talent. One thing that stuck was offering additional health insurance to employees. The rest is history.
Further reading:https://www.chicagotribune.com/opinion/commentary/ct-obamaca...
If universal healthcare was adopted during the Truman administration, wonder what employers would move on to as their major bargaining chip to woo talent.
I worked with some coworkers who emigrated to the USA a few years back. They all shared similar fears about the US Healthcare system. Once we showed them how it worked, how to use our insurance company's website, and how to confirm that services were authorized they had no real problems.
HN, Reddit, and the rest of the internet have become really good at sharing horror stories, but increasingly many of those horror stories are either misleading or based on old laws that no longer apply. A popular trick on Reddit is for people to post the part of their bill that goes from their provider to the insurance company and say "This is how much it costs to have a baby in the United States!". However, nobody actually pays the amount that gets billed to the insurance company. They pay an amount determined by their insurance deductible, co-pay, and out of pocket maximum. Once you go past the out of pocket maximum for a year, everything is covered 100% in network.
We even recently had new laws against surprise billing, which plugs many of the holes that created those horror stories about going into a hospital and discovering you were out of network after the fact. Technically there are still holes where this can happen, but if you look carefully most of the horror stories online are from many years ago.
Is the system perfect? Of course not. However, in practice people aren't going bankrupt every time they go to the doctor like you'd think from Reddit posts. When it comes to pre-authorizations, these tend to get negotiated between your doctor's office and the insurance company. Doctors offices know how to push pre-authorizations through if they want to put in the effort, but many some will shrug it off because it's not billable time for them.
However, nobody actually pays the amount that gets billed to the insurance company...
While mostly true, the system always strikes me as insane when I see the amounts billed to my insurer alongside the amounts "allowed" or paid by my insurer (or paid by me until we hit the deductible). I'm talking about the negotiated rates, I guess, not even co-pays. I regularly see things like $8,889 billed and $149 "allowed."
I recently emigrated to the USA and I hate the healthcare system here. It feels like the system is we tie everyone down to train tracks, then we hire someone to semaphore to the conductor to pull the brakes just in time. Most of the time, for people who can afford a good signaler, the locomotive stops a few inches before it turns them into strawberry jelly, so no-harm no-foul, the system works?
The signaler, conductor and roper all work for different faceless corporations constantly trying to screw each other and/or you though, the semaphore language is so complicated no human being can speak it, and the message in it can't be known until the locomotive is a few hundred feet away though. You can only choose 1 of 2 options for every role too, so everyone involved is terrible.
Sure we closed some of the loopholes where the locomotive could start again after braking, or the signaler could refuse to do their job because the brakes were offbrand. Really though what I'd like is to just not be in mortal peril at all, which is not the same thing as barely avoiding getting liquified by a steel behemoth by a complex confluence of forces beyond my control.
What about the 5 million people in my state who don’t have health insurance? Should they be worried about their medical needs?
Thanks, but more money isn't worth the stress of dealing with that bullshit. I'm not moving one inch from Europe.
Especially, I have no interest whatsoever in having my health insurance tied to my job.
They pay an amount determined by their insurance deductible, co-pay, and out of pocket maximum. Once you go past the out of pocket maximum for a year, everything is covered 100% in network.
You know how much deductible, co-pay, and so forth we paid for my father's 3 month long stay in the ICU with leukemia and chemotherapy? $0.
Thankfully, the ACA made insurance mandatory for everyone. Not only do we have a garbage system, we're obliged to participate in it.
1. You have always participated in it, regardless of whether or not you pay an insurer.
2. There are no penalties for not having insurance, that part of the ACA has been torpedoed.
3. The people who torpedoed it have no intentions of fixing a damn thing about this country's medical system.
This is sarcasm, right? The individual mandate was struck down.
In my opinion, this was a brilliant strategic move by those opposed because it guarantees the eventual financial inviability of all of the ACA. Decreasing the size of the risk pool by allowing people to opt out will guarantee that it won't work long-term.
It's a low-quality comment but no worse than every other comment in this thread that similarly indicates zero understanding of how insurance actually works.
Your claims are paid with the money collected from your, and other members', premiums. Everyone wants insurance that covers every single claim with few questions or limits, but that insurance company would quickly have to make the choice between dramatically increasing premiums or going out of business.
Every time a government entity mandates that insurance plans cover additional services, the cost of care goes up and subsequently so do premiums. When premiums go up, people / businesses shart shopping around and leave the pool, meaning the risk is spread out among even fewer (likely sicker) people and the premiums go up even more.
The alternative is just having everyone in one giant "single payer" pool so risk is minimized, with participation mandatory. Then, that entity (government probably) would just pay all the claims because in theory there would be less incentive to watch the bottom line. In reality, we've already tried this: Medicare is the largest single-payer health insurance system in the world, plus we have 50 Medicaid single-payer systems at the state level and additional single-payer systems at the federal level (Tri-Care and VA benefits). All of these systems face the same fiscal challenges and have been implementing every cost control measure they can think of for the past 2 decades. Medicare has been trying to move from Fee For Service (FFS) to outcome-based reimbursement for a long time now.
Those of us who know, know: the problem is COST in the system. Healthcare is EXPENSIVE.
I don't think that government-run health insurance (i.e. Medicare, Medicaids, Tricare) == "single-payer" healthcare system, especially in terms of the effects described by the parent comment.
My perspective is being under Tricare. You can imagine it like a closed system in which Tricare beneficiaries just go to Military Treatment Facilities (Defense Health Agency and service-run hospitals and clinics) for everything, and everything done in those facilities is covered with no questions asked and no bills or money changing hands. But that isn't how it works in practice. A large amount of stuff, like most specialty care, gets referred to places "out in town" (at local, for-profit, civilian providers). Most ER and urgent care visits happen out in town. At times, my wife and kids have been on Tricare Select which works like a PPO and involves all the usual discussions about who does or doesn't take Tricare, in-network or out-of-network, whether something needs pre-authorization or not, why a claim has been denied and how to appeal it, whether we've reached our annual deductible or catastrophic cap, etc.
So under Tricare, I think I feel more protected from profit-driven shenanigans and expensive mistakes than most Americans, but there's still a "cognitive workload, stress and uncertainty." I think a true single-payer system means that you don't have this (because it works like the closed system described above).
My wife is very effective contacting insurance companies and getting our claims approved. She spends hours on the phone but we usually get our way. This requires understanding our benefts, the CPT codes and denial reasons. She used to do this working for a high net wealth family office for the entire family's medical expenses.
We were trying to think of a way that she could offer this skill as a service for people. It would require some difficulties with HIPAA, but I think there is a opportunity here to help people.
I don't understand how anybody, on any party or political spectrum, can say "Yup... this is a reasonable system that helps people and needs no change".
The commonality between this and (including, but not limited to) homelessness is that the tragedy is laundered into political ammunition used against their opponents in the next election. I dislike the trite expression "Don't let a good tragedy go to waste", but I'll say it to preempt the reply. But it's true: if you can't use human suffering (denied medical coverage | no place to live) to attack your party's enemy, you are less powerful as a candidate.
The other factor is lobbying. These companies (just like in many other industries) have US congress bought and paid for. The suffering aspect keeps people distracted and divided, so we never really hear about campaigns to end lobbying (because it would apply to both major political parties). Instead we joke about it and roll our eyes at how ridiculous it is (but still told to "get out and VOTE!" as if that somehow matters). My opinion is that it should go beyond financial contributions. Industry and trade groups should not have access to congress at all, it should be citizens only.
The reality for people with a well paid white collar job or a union or that work for the government or a non profit or in healthcare is that everything is fine. The employer pays for 100% of the premium. With insurance like Kaiser you pay your copay and that is all. Everyone at Kaiser in network, most directly employed, no surprise billing. Pre auths are easy when everything is in network. Your out of pocket max is as low as $2k.
More to the point, I don't understand how anybody, on any party or political spectrum, can say "Yup... this is a reasonable system that helps people and needs no change".
Nobody says that, and no one proposed the current system as is, either. Its not even a conscious, mutually unsatisfactory, compromise between competing visions, its simply the current state of an ongoing battle between multiple radically opposed views in a political system which is not good at resolving disputes of this kind, where some elements are successful attempts at implementing sabotage of broader components with the hope that the resulting failure will help politically support a conpletely different design.
If you study the history of how the system came to be, it turns out to be a combination of: Drs like money, and (like most things in the US) racism.
> More to the point, I don't understand how anybody, on any party or political spectrum, can say "Yup... this is a reasonable system that helps people and needs no change".
1. Many of the most painful core issues dont manifest until you have a real issue. So people assume it will work for them, until it does not.
2. There is so much money being made on the other side that there is a huge push for lobbying to keep the system in place.
isn't that kind of pointless? they are denying your claim because its their goal to reduce costs. any justification is just going to point to some made up excuse or insanely complicated internal policy designed for obfuscation. you could demand they publish those policies, but how are you going to guarantee that they are finite and parsable by humans? look a the text of voting referendums for an example, or cell phone contracts.
any justification is just going to point to some made up excuse or insanely complicated internal policy designed for obfuscation.
I don't see how you can claim that without seeing all the records in question. Maybe it was deliberately obfuscated,maybe someone just screwed up. Guess what, human error is a thing. In fact, the article itself showcases a bunch of human errors -- those of people not knowing that their employer is required by law to provide claim files within 30 days.
you haven't fought a claim yet, have you.
Its beyond infuriating, especially when you are on the hook for a large bill
Beyond infuriating is when the Dr requests pre-approval then does the procedure andthenthey deny it. And keep denying they approved it even after the hospital has revealed they record all calls with insurance companies, and they have the recording where the procedure was pre-approved.
Eh, we're currently fighting to get some claims covered. Before a certain date, all the claims are denied; after a certain date, all the claims are approved. The claims are all for the same thing, related to the same procedure (physical therapy after a joint replacement).
Could the claims have been rejected due to a simple human error? Sure, it's plausible. Was there another human error that caused the claims to be rejected after we appealed? Maybe, but probably not. Could a third human error cause the claims to be rejected again after our second appeal? Seems pretty unlikely.
Yeah, in your case it seems reasonable that the denials are malicious.
I guess I'm not seeing why the poster I was replying to declared that getting access to the claims file was useless. Wouldn't getting access to that file make iteasierto prove that claims were wrongfully denied?
There might also be a teakettle on the far side of the Moon.
It would be really nice to know IF my claim was denied. Health billing is so messed up.
If it's an expensive procedure and you want to know what the cost will be you'll usually want to submit for prior authorization before the procedure. In an emergency this isn't an option but for any other treatment this can give you a lot of clarity about what your out of pocket will be - doctors (or their offices) should be able to handle this if you ask.
I had a doctor once recommend a temporary treatment that would be provided by a third party. I called the third party and asked how much it would cost; they had no idea. I called my insurance company and asked how much it would cost; they had no idea. I called my doctor and asked how much it would cost; they had no idea.
Literally nobody involved in the entire chain of providers had any idea how much it would cost. The best advice anybody could give me was to get the treatment, then look at the bill afterwards. (Oh, and nobody had any idea when I might get a bill either-- my wife is still receiving bills from the birth of our most recent child, 18 months ago.)
my wife is still receiving bills from the birth of our most recent child, 18 months ago
I've been dealing with this as well, and the uncertainty has been the most frustrating thing.
Medical bills from the same institution should be required to be high watermarks - i.e. if you give me a bill in March, you can't send me a bill in April that has charges from February that _weren't on the bill from March_. It feels like fraud (and maybe it is, but who has time to figure that out?)
Prior authorization does not come with any binding guarantees, insurance companies can and do reneg on their promises all the time.
This is true - but they'reusuallymore predictable. Absolutely nothing in the US healthcare market is guaranteed. And, tbh, in healthcare there can always be complications - a simple surgery or treatment might turn into something much more extensive if things weren't as they appeared initially or there's some abnormal response to treatment.
I'm currently fighting this exact fight with Blue Shield
I was getting nowhere until I started connecting with and then publicly shaming their executive leadership on LinkedIn. If you do that, you get transfered to their "executive relations team" who still are unable to get things done, but it's at least a different department you can file grievances that go nowhere with.
Thanks for the heads up. Time to give my money to someone else...that is probably just as bad, but hey "I'm doing my part".
Gladly!
Another funny anecdote. They have a 1.1 star yelp review. The San Francisco DMV has 1.8. 1.1 is a statistically significant difference thsn 1.8. They have almost 800 1 star reviews on yelp, as a non profit!
My wife is very effective contacting insurance companies and getting our claims approved. She spends hours on the phone but we usually get our way. This requires understanding our benefts, the CPT codes and denial reasons.
She used to do this working for a high net wealth family office for the entire family's medical expenses.
We were trying to think of a way that she could offer this skill as a service for people. It would require some difficulties with HIPAA, but I think there is a opportunity here to help people.
I wish articles like this would clearly indicate what country's laws they are referring to. This article appears to only be directly relevant to the United States.
Is this not an American site?
While it is, the users are from everywhere and so is the content.
A lesson learned from hard experience and unfortunately too late: get your own illness benefit insurance. If you have it through your employer you can't sue the insurance company since you're not a party to the contract. They don't even need to talk to you, only your employer.
I was preparing to possibly have to do this, but it looks like I've narrowly avoided it. My family has a procedure scheduled Dec 4, and my work insurance is changing plans Dec 1. Got pre-approved with previous plan, previous insurance company is exiting health insurance totally. New plan needs 15 business days to approve it, and can't start that until we get group numbers, and there's a holiday in here.
But, the doctor has been able to get us in due to a cancellation, before the insurance expires.
Back in 2005 I was working for Dupont and had a mandatory hearing test. I asked for the results and was told that was the property of the company and I couldn't have access to it. I felt at the time it unethical to withhold information regarding my health. Now I'm wondering if it was illegal too.
Well more recently I had a urine drug screening for a job. I passed obviously but I was curious about the results and the drug testing company also told me it was the property of the company.
This problem is going to get even more fun as AI driven Prior Authorization denials get more prevalent.
I had my FSA provider PayFlex deny a medical co-pay as "Not Medically necessary."
Isnt it lovely when a Private Equity firm decides what is or isnt medically necessary? They were obviously using some automated system to try and deny claims, to hell with false positives.
The best thing is to just repeatedly submit the legitimate claim until it goes thru. There seems to be some non-determinism in these systems and the same thing will sometimes be accepted and sometimes rejected. Bless my wife for taking care of this insanity.
In my experience, knowing why a health insurer denied a claim isn't useful; it just becomes a maze of medical billing codes and definitions that always ends at "insurer wins."
yeah I've personally chased the "why did you deny me?" line for over two years before they just came back with "we don't believe you nor your doctor that you have narcolepsy and nothing will change that (even though we're currently covering your less expensive narcolepsy medications)". hanged fire until I hit my 26th birthday and then they were off the hook entirely
Potentially useful context: If you’re not covered by a small employer, your claims are typically being self-insured by your employer. Your employer uses Cigna or BCBS for administrative functions, but they set the tone for the amount they’re willing to pay. That’s why you’ll see differences in coverage even though you ostensibly have the same insurance provider in the same state.
And, importantly, these "ERISA" plans are exempt from state laws and regulations (although they do have to abide by federal laws and regulations).
Why? Because fuck you, that's why. Sue us, see whose legal budget runs out first -Every insurance company
We are arranging deck chairs on the Titanic with the dystopian US health system. Like who here legitimiately believes this is a good system?
The entire system is an exercise how capitalism fails where there's inelastic demand. Health insurance companies exist to extract wealth from consumers and governments by not providing health care to increase profits. It's that simple. There is a direct link between denying prior authorizations and increasing profits [1].
Fun fact: Obamacare (ie the ACA) snuck in a ban on physician-owned hospitals [2] thanks to lobbying efforts. Just more artificial barriers and rent-seeking to increase profits.
Health insurance companies continue to consolidate (eg requiring prescriptions are filled by their PBM-approved pharmacists, buying up medical providers).
It is utterly insane to me that anyone can defend this system who isn't a major shareholder in United healthcare. Yet ordinary people do, which usually comes down to "I don't want to lose my insurance", which is so insanely short-sighted and selfish, it blows my mind.
[1]:https://www.healthleadersmedia.com/revenue-cycle/cost-denial...
[2]:https://www.fiercehealthcare.com/providers/hospital-groups-a...
you might be interested in whole series
Presumably this means "know their excuse". We already know thereason: so they can make more profit.
As a physician, my patients are continually stymied by the preauthorization requirement for CT scans and procedures by some insurors. This ridiculous hurdle adds weeks of delay sometimes. And there is no real quality assurance or data assessment regarding the necessity of the procedure. I have to call, go through a phone tree, the delays are frustrating and unecessary. I didnt go to school and residency for 10 years to justify a job deemed necessary by some corporate second guesser. This is just a process added by an MBA that adds no value to the patient care. It is the result of trying to apply Adam Smith's precepts of a free market economy to a. market where the consumers have no choice. No one chooses the illness they have. A capitalist model serves this market poorly. And the whole idea of making a profit off of someone's illness to pay shareholders is wrong.
Insurance companies should not be able to override a patient's doctor in making a determination of what's not "medically necessary".
Surprised disabled people don't do citizens' arrests on insurance company account administrators and executives, using heavy assault weapons when necessary to leverage force with their disabilities..
Not quite the same thing but many people report when a hospital bill seems high, and they ask for an itemized bill, magically the charges get reduced.
Is there a way to filter out these misery parades via keyword?
I know heartless Europeans, but besides bureaucratic tips, there seems little to hack and it's all in all a daily downer to see sentient being beeing mutilated and thrown away cause it's cheaper. And then the whole population treats it like some selfflaggelating religious thing.
Yes I brought it on my self for clicking.
One thing that's bit me in the ass repeatedly with insurance claims is that the people approving/denying claims aren't doctors, and the people you have to fight to appeal a denied claim aredefinitelynot doctors. So even if you know the grounds for denial, sometimes the reason is bullshit and flies in the face of the insurer's own policies.
I spent months fighting a claim for mesalamine DR tablets (and getting nowhere) only to discover that the insurance personnel were treating it as a different claim for mesalamine EC capsules—a totally distinct formulation. Any doctor or pharmacist could tell you that they're not equivalent. But they had different approval criteria in the insurance system, and even though I met the criteria for the former (the drug I wanted) they kept denying me for not meeting the criteria of the latter (the drug I did not want).
But those are both oral forms. I think if they'd tried to run the claim as the suppository version, the error would've been more obvious.