[HN Gopher] Cigna saves millions by having its doctors reject cl...
___________________________________________________________________
Cigna saves millions by having its doctors reject claims without
reading them
Author : metadat
Score : 336 points
Date : 2023-03-25 16:06 UTC (6 hours ago)
(HTM) web link (www.propublica.org)
(TXT) w3m dump (www.propublica.org)
| [deleted]
| honkycat wrote:
| But hey: at least they owned the libs this month by passing a
| disgusting anti-trans bill.
|
| That is what is important right? Not stopping the massive
| corruption from every mega-corporation in every sector that is
| making our earth uninhabitable and our lives miserable. Lets
| hyper focus on people's sexuality.
| mdmglr wrote:
| Maybe to speed things up patients can opt to have ChatGPT read
| the claim and make a decision. /s
| readme wrote:
| it would probably benefit patients
| Ekaros wrote:
| AIs are wrong at least some of the time... That means they
| will approve some claims. Not deny all of them.
| loeg wrote:
| > His claim was just one of roughly 60,000 that Dopke denied in a
| single month last year
|
| 60,000 / 20 workdays in a month / 8 hours in a workday => this
| guy rejected about 375 claims per hour, on average. Over six
| claims a minute. He spent less than 10 seconds on each claim, for
| a full month of work time.
| hotpotamus wrote:
| I wonder how many claims a minute GPT4 will be able to achieve?
| 01100011 wrote:
| Soon, a GPT/LLM will auto-deny an order of magnitude more than
| that!
| Centigonal wrote:
| Less than 10s/claim is actually an upper bound, since chances
| are there's meetings, coffee breaks, and other overhead.
| CogitoCogito wrote:
| Dr. Cheryl Dopke should lose her medical license.
| kwhitefoot wrote:
| Her employer should be jailed as well, all the way to the top
| of the company. Such behaviour cannot exist without at least
| the tacit agreement of everyone higher in the chain of
| command.
| SapporoChris wrote:
| "A Cigna algorithm flags mismatches between diagnoses and what
| the company considers acceptable tests and procedures for those
| ailments."
|
| "Cigna said its review system was created to "accelerate
| payment of claims for certain routine screenings,"
|
| This sounds like simple automation with an error rate that is
| acceptable by Cigna. Of course it's not acceptable to anyone
| wrongfully denied a claim.
|
| Now that's an issue I don't see in the article. How many claims
| were wrongfully denied? I can't get worked up about the
| situation when critical information is missing.
| ahi wrote:
| They are not legally allowed to automate this. These cases
| MUST be reviewed by qualified medical personnel.
| colordrops wrote:
| This rate is pretty ridiculous. I wouldn't be surprised if
| there is automated software or a farm of non-medical staff
| working behind the name of the doctor, similar to how shady
| contractors will "rent" the license of a legitimate but retired
| contractor.
| prepend wrote:
| I mean supposedly the doctor also approved some so their review
| rate is even higher.
| pontifier wrote:
| Automatic rejection is a tactic used by all sorts of con artists.
|
| If they say no and you never come back then they don't have to
| worry about you anymore.
| charles_f wrote:
| I _somewhat_ get why you 'd build such a system when on the other
| side you've got pharma and labs pulling for useless medication
| and tests through doctor presents and "seminars". What's beyond
| me* is how health insurances get to be the deciding entity when
| there's such a blatant conflict of interest in the matter, which
| gets abused as it is here demonstrated.
|
| If you get a home insurance claim, at least here in Canada the
| insurance company has to use an external adjuster. Even though
| it's not perfect, it seems a widely better solution to handling
| claims.
|
| * it's not beyond me, it's probably just the result of lobbying
| lostmsu wrote:
| I am surprised commenters here did not read into the nuance:
|
| > A Cigna algorithm flags mismatches between diagnoses and what
| the company considers acceptable tests and procedures for those
| ailments. Company doctors then sign off on the denials in
| batches, according to interviews with former employees who spoke
| on condition of anonymity.
|
| Before grabbing the pitchforks, it is important to be sure if
| their policy is reasonable or not. Whose fault is it if doctors
| ask clients to perform expensive tests, because they can't be
| bothered to actually think and figure out what test would be the
| most optimal?
|
| Now even if the doctors really overprescribe tests, I don't think
| the client should be responsible. Instead, the insurance should
| pay, but kick the doctor out of their network.
| sidlls wrote:
| I don't think we should trust the soundness of their algorithm.
| I've worked in the healthcare space before, and the perverse
| incentives involved should make everyone extremely skeptical of
| insurance companies' motivations, procedures, and algorithms.
| lostmsu wrote:
| From the description it sounded like something trivial. E.g.
| given the diagnosis, there might be a cheaper known way to
| get to it. I am a layman, but for instance that could be
| ordering an MRI when an ultrasound would suffice.
| salawat wrote:
| Fuck that.
|
| You know what that incentivizes?
|
| Not testing at all. You know what that leads to? Bad outcomes.
| I'm all for selection pressure toward more efficacious, less
| invasive, less dangerous tests. Writing an insurer a blank
| check to blanket deny millions of claims _without checking or
| reading up_ though? Nah. That 's profiteering.
|
| You want to run that algo in parallel and dift through the
| claims that would change, individually weeding out the actual
| false positives? Kosher. Just YOLO'ing it on prod and
| trottingbit out in front of investors? Hell no.
| soared wrote:
| It's insane to trust an insurance company to make healthcare
| decisions. I was denied an MRI when I tore my hamstring off the
| bone, and so my doctor had zero info on what my treatment
| options should be. I went to physical therapy when I possibly
| should have had surgery.
|
| I'd so much rather 10% of people overpay for unnecessary tests
| than the other 10% of people be denied potentially necessary
| care.
| lostmsu wrote:
| Oh, you can have that. Just pay 10x for insurance to cover
| your 10x more expensive tests.
| camhart wrote:
| Why can't healthcare be fixed?
|
| I'm self employed, pay a crap ton of money for "good" insurance,
| and it's horrible. It's very difficult to find good doctors in
| network. Everything gets rejected from insurance and the Dr has
| to appeal it multiple times in order to sometimes get them to
| budge. It's absolutely broken, and even more so for those on
| individual and family plans (ie not through an employer).
|
| Last year I was with United Healthcare, this year Blue Cross blue
| shield. Both are horrible. Both are massive companies.
| d1str0 wrote:
| Not trying to be a shill, and would happily discuss my entire
| healthcare experience with Kaiser, but I highly recommend them
| if you have the option. Obviously, don't change unless you do
| research etc. and again happy to discuss my experience with
| them for anyone interested.
| javajosh wrote:
| _> Why can't healthcare be fixed?_
|
| Because doctors and patients won't fix it. Doctors can charge
| whatever they want. They could see more patients, charge less,
| and charge cash. They could do their own diagnostics during the
| visit. People from other countries will be shocked to know that
| US doctors never do their own diagnostics, and instead refer
| patients to other providers, which require their own payment
| and paperwork, another round of appointments.
|
| Putting the patient through all that for an ultrasound is
| "standard practice", which also happens to be maximally
| profitable for multiple providers and their associated office
| staffs, and the enormous industries that exist to service this
| deeply problematic "standard practice".
| kofejnik wrote:
| It is working as intended. All parts of the system co-evolved
| to extract maximum value from you.
| eapressoandcats wrote:
| In the US at least the underlying problem is that we pay more
| for basically every medical procedure, drug, and device, so you
| end up paying more to get less. Largely this is due to having
| engineered a shortage of doctors combined with no negotiation
| on drug and medical device prices.
| ratg13 wrote:
| Once you get rich or in politics, healthcare is no longer a
| problem, so you don't see it.
|
| Even this thread is full of Americans trying to tell other
| Americans that the US system is "better" than Europe
| thallium205 wrote:
| Insurance companies deny medical necessity claims because the
| procedure and diagnosis code combinations don't align with what
| is pre-determined to be medically necessary. One of the big
| reasons why this happens that nobody ever talks about is because
| the _doctors office does not code the claim correctly_ and it
| gets denied. The patient is pissed and blames the insurance
| company, the doctor is pissed and blames the insurance company,
| but in reality its the biller /coder in the back office who
| screwed it up.
| borissk wrote:
| All right, US insurance companies deny millions of valid claims
| not because of greed, but because "the doctors office does not
| code the claim correctly". It's just an unforeseen side effect
| that said insurance companies end up with billions of annual
| profits and patients sometime die...
|
| Your post remains me of how Russians often react on their
| forums to posts regarding the corruption in Russia. There are
| undeniable proofs of how corrupted Putin regime is. All
| ministers, members of president administration, local
| administration, judges, generals, etc. end up owning multi-
| million properties both in Russia and Europe/USA, but many
| regular people find the stupidest excuses of how the system is
| fair and just, but "the doctors office does not code the claim
| correctly".
| thallium205 wrote:
| I've worked in healthcare revenue cycle management for over a
| decade. If you don't accurately tell the insurance company
| what you're doing and why you're getting denied. Doesn't
| matter if it's health, auto, home, etc. There are thousands
| of codes, millions of combinations, and all being mostly hand
| coded by minimum wage workers. There are constant fuck ups
| most of which don't require anyone but a computer to review
| to know it's wrong. But okay cool conspiracy.
| borissk wrote:
| Even if we assume you're right, the way that the system is
| setup and the fact that there are constant fuck ups, but no
| effort to fix them are not accidents. Yes, there are
| conspiracies out there (surprise, most people are not
| angels) and the US health system is definitely one.
|
| Check out the insurance companies profits. Those are
| directly linked to denied customer claims. Claims are not
| denied en-mass, by accident obviously - unless you're a
| complete fool.
| courseofaction wrote:
| Jail the executives.
| RainbowFriends wrote:
| Revoke the medical licenses of the doctors who rubber stamp the
| denials.
| dragonwriter wrote:
| In addition, states (as the pirnary regulators of insurance)
| should adopt a rule that if an insurer has a policy which
| directs, incentivizes, or which managenment knows or should
| reasonably know results in denials without good faith review,
| the state then has a cause of action against the insurer for
| damages of equal to triple the amount _originally_ denied
| without appropriate review (whether or not later paid), and
| will, if necessary, pierce the corporate veil to recover it
| and, separately, each medical reviewer who is found to have
| denied a claim without good faith review shall be fined an
| amount equal to the value of claims so denied _and_
| prohibited (regardless of whether their medical license may
| later be restored) from being responsible for medical review
| of insurance claims in the state in the future.
| ncallaway wrote:
| I genuinely think every health insurance denial should have to
| come from a named doctor at the health insurance company who is
| personally and professionally liable for the health outcomes from
| a denial.
|
| Deny someone life-saving care without a sound medical reason?
| That's a malpractice lawsuit and a potential loss of their
| medical license.
| kube-system wrote:
| That doesn't make any sense.
|
| Insurance _claims_ are submitted to insurers after providers
| have already performed the care.
| thallium205 wrote:
| What about prior authorizations?
| kube-system wrote:
| The article is about claims, which are a difficult thing
| than pre-auths.
|
| There are some restrictions on pre-auths and when an
| insurer can require one. If you are in need of immediate
| care to save your life, they are not required and your
| provider will give you care before even telling your
| insurance company about it.
|
| The grey area with pre-auths is with nonemergency care that
| could lengthen someone's life. There are requirements by
| law for appealing these denials but yes, this is where
| those stories about "I can't get my cancer treatment" come
| from.
|
| This is not the situations in the article, though.
|
| What's shitty about the actions in the article is that many
| people don't even realize that erroneous health insurance
| denials are common and they just accept the denial and pay
| out of pocket. It is very common to get a denial, send in a
| challenge like "no this should be covered" and then they
| pay.
| theGnuMe wrote:
| There's some doc on twitter who was denied by insurance and he
| filed a board complaint against the insurance doc claiming
| malpractice. I think he won.
| d1str0 wrote:
| Know any more details? This seems rather promising.
| theGnuMe wrote:
| https://twitter.com/generalorthomd/status/16320748163785072
| 6...
| rgblambda wrote:
| So the law says a Doctor must review the claim. An algorithm does
| what effectively is a pre-review of each claim and the Doctor
| just clicks accept without even checking a single sample in each
| batch of pre-reviewed claims. This cannot possibly be legal.
| sheeeep86 wrote:
| You can attack the management, but also you should look at the
| people doing the action. If medical doctors participate in such a
| scheme I feel that the medical schools should strongly consider
| revocation of degrees as an option. Clearly these doctors are
| violating their oaths.
| prophesi wrote:
| I wish I was surprised. Automated decision-making with little to
| no human oversight is the dream of risky bets (policing,
| insurance, loans, etc).
| catchnear4321 wrote:
| Any "health insurance" in the States do otherwise?
| snozolli wrote:
| _"Put yourself in the shoes of the insurer," Howrigon said. "Why
| not just deny them all and see which ones come back on appeal?
| From a cost perspective, it makes sense."_
|
| Something about "do no harm" comes to mind.
| throwawayce wrote:
| I work for Cigna, and recently went through cancer treatment.
| They rejected every scan and treatment until my doctor
| challenged. My first doctor couldn't figure out how to challenge
| and it set back my initial treatment.
|
| Then last year the CEO did a town hall with a tear jerker clip
| show about how evicore is helping cancer patients. But evicore is
| the part of Cigna that kept rejecting my treatment. It was
| incredibly insulting, and I've been ashamed to work there since.
| nine_zeros wrote:
| Brutal.
|
| Once you get the treatment and feel better, please share it
| with your local news stations. This is the kind of story that
| should take the company out of business.
| borissk wrote:
| The local news station probably receives a big part of it's
| budget and profits from medical ads. It won't run any
| material that can threaten it's main income.
| dcow wrote:
| What would be the problem with requiring all healthcare to be
| non-for-profit? You can still have it privatized, but you can't
| ever be in a situation where you're trying to maximize profits.
| Someone poke holes in the idea...
| Nihilartikel wrote:
| Sounds great, but to make it happen on a legal level, the
| public would have to mobilize enough money to out lobby the
| vast interests already enjoying complete regulatory capture.
| Also every advertisement block would have a 2 minute propaganda
| segment showing a grandmother suffering due to 'sclerotic non-
| profit ineptitude' that is inevitable when the god given
| American profit motive is stripped away.
| AnthonyMouse wrote:
| The incentive to maximize profits (i.e. minimize costs and
| maximize number of customers) is the _benefit_ of a privatized
| market. The profit-minimizing mechanism is supposed to be
| competition, because then people switch away from plans that
| have a poor balance between price and rejecting claims. But
| because most plans are tied to employers, that part doesn 't
| work.
|
| If you had a non-profit with no competition it would be little
| different than the government, i.e. susceptible to regulatory
| capture and with poor incentives to constrain bureaucratic
| inefficiency.
|
| Non-profits in a competitive market would be better, but so
| would for-profit insurers in a competitive market. The problem
| isn't that somebody is making money -- a service is being
| provided and somebody is getting paid one way or another -- the
| problem is it's too hard to switch so bad providers
| proliferate.
| blakesterz wrote:
| "We thought it might fall into a legal gray zone," said the
| former Cigna official, who helped conceive the program. "We sent
| the idea to legal, and they sent it back saying it was OK."
|
| Reading this article is just maddening. I've been dealing with
| different insurers for the past 7 years or so, and it's my
| experience they must all do something similar. Anyone with any
| kind of serious health condition is regularly driven CRAZY
| dealing with insurance. It's just an insane and broken system.
| geerlingguy wrote:
| I have Crohn's disease, and I'm fairly certain dealing with
| health insurance's ineptitude directly led to multiple
| hospitalizations and a major surgery last year.
|
| Had it not been for their constant denials of a drug I had been
| on for over two years prior, I might still be taking that
| medication instead of having developed antibodies for the 6
| months they denied.
|
| My doctors office gave me free samples as long as they were
| able, but in 2022 they were wiped out as _all_ patients that
| were on that drug were being denied coverage.
|
| Worse still, insurance recommended "use drug X, which is
| similar"... but I couldn't because I was on drug X--until I had
| anaphylaxis from it!
| magila wrote:
| I also have Crohn's and am going through this right now.
| Months of delays and denials for a new drug lead to two
| hospitalizations. I'm currently on TPN (IV nutrition) while I
| taper my Prednisone dose as low as possible prior to surgery.
|
| The funny/sad thing is: between my hospitalizations, TPN and
| related home health care, and surgery, this is all going to
| cost my insurance far more than the drug they were denying
| would have. One would hope this provides them with motivation
| to better judge the necessity of treatments, but I'm not
| holding my breath.
| Centigonal wrote:
| Situations like this are infuriating to me. Our healthcare
| system needs to have some kind of provision for "this patient
| needs to be on treatment X probably for life. They are
| authorized for this treatment and subsequent claims will be
| approved unless there is a qualifying event (e.g. a recall,
| condition changes, patient and their doctor switch treatment,
| etc)."
|
| I have UC that's well-controlled with mesalamine, and I've
| had a few scares (my insurance rolls out a new prior auth
| every year, and I have to call my provider to have them sign
| it for some reason, or the new insurance only covers the name
| brand (not generics) because of PBM antics). The thought of
| having to come off of mesalamine for even a week is
| terrifying. I really feel for you because your condition
| seems much more severe/hard to control.
|
| Why do I need a new prior auth every year? My medication
| hasn't changed, and neither has my condition. It's a
| bureaucratic hoop, and if I don't jump through it I get to
| spend my whole day on top of a toilet. That's a terrible way
| to treat a human being.
|
| Even from a purely amoral capitalist perspective, I know the
| cost of my medication is a small fraction of the dollar value
| that doesn't get generated if I can't take it. I don't
| benefit and society doesn't benefit if I'm sick - the only
| group who benefits is the insurance company who gets to
| pocket my premiums and avoid paying out. It makes me furious.
| nine_zeros wrote:
| Here's a simple solution. Insurance HAS to pay if a doctor
| recommends it. This is what premiums are for. If insurance
| cannot pay, they can go out of business.
| ridgeguy wrote:
| "For every complex problem there is an answer that is
| clear, simple, and wrong." - H. L. Mencken
|
| Even a moment's thought about the power disparity between
| an insurer and an individual facing medical problems
| leads me to conclude your "simple solution" has little to
| recommend it.
| hayst4ck wrote:
| I don't love insurance companies and I don't love the
| profit incentive they have.
|
| If a patient breaks a leg and a doctor recommends not
| experiencing gravity for a while, do we fly them to
| space?
|
| I am using hyperbole to demonstrate a point: there are
| meaningful economic limits that must be created by some
| entity and enforced.
|
| What is the value of a human life? The GDP of a nation is
| a hard upper limit. The total money a particular person
| in question has access to is the lower limit.
|
| If you run an insurance company (or you run government
| run healthcare) you can't avoid answering that question
| with an actual real dollar amount.
|
| At some point spending money on a person with a
| particular condition _does_ mean that someone else with a
| different condition can 't have money spent on them.
| kurthr wrote:
| Wife is a nurse. Required surgery for lifesaving/severe
| disability (inherited congenital, killed her father). Insurance
| was Aetna and Hospital Self Insured. Surgery recommended by
| world class surgeon she worked with.
|
| Finally pre-approved on 3rd appeal after 8 months and 150pages
| of documentation of every piece of every single communication
| (who, when, response, expected next contact) only weeks before
| surgery scheduled >6 months before. First rejection was
| automatic, second was revealed to be a dermatologist, third was
| a gynecologist. (They really hated that we figured out who the
| person was, their specialty, the state they worked in, and
| pending disciplinary actions).
|
| Standard answer is we can't tell you why you were rejected
| (code only) because the criteria are from a third party and
| their review document is proprietary. When you find an online
| leaked document with the same code it says "unnecessary
| cosmetic surgery". Wrong contact numbers are provided, people
| go on vacation and do not respond for weeks, "that person
| doesn't work here".
|
| If you're not a professional in the field with time on your
| hands and a detail oriented A-hole, you will be denied anything
| expensive that isn't considered immediately lifesaving at a
| trauma ICU recommended by the attending.
|
| After pre-approved surgery with excessive blood loss and an
| extra 12 hours in recovery... Overcharge/All-claims-denied.
| Multiple appeals until involving Hospital CFO who agrees to
| split the extra (self-insured) cost of the insurer and get the
| final insurance reimbursement check... it is $3k less than
| promised (hospital paid the correct amount). Surgeon was going
| to start charging late fees and interest or send it to
| collection after 4 months.
|
| Is it worth fighting any more? No.
| theGnuMe wrote:
| >Insurance was Aetna and Hospital Self Insured
|
| Does this mean that the hospital self-insured and provided
| the surgery? As in why have Aetna involved at all then?
| anonuser123456 wrote:
| The sneaky thing to do is have your attorney send a letter to
| the insurance carrier's liability insurance provider,
| detailing everything you uncover and that they will be on the
| hook for the malpractice claim. That will get you an highly
| aggressive advocate with teeth.
| TedDoesntTalk wrote:
| What is a liability insurance provider? Are you saying
| Cigna and other medical insurance companies have insurance
| themselves?
| anonuser123456 wrote:
| Every business has insurance, including insurance
| companies. This is because they specialize in their own
| business and outsource non-core business.
|
| An insurance provider for a specific industry has teams
| of skilled attorneys that are expert in that specific
| domain. Cigna might self insure if they consider medical
| malpractice a core part of their business. In that case,
| your attorney sends the letter to their corporate
| counsel.
|
| Often times, day to day business people just ignore
| liability risks because it's not in their core mandate.
| But the corporate counsel is in charge of managing legal
| risk, and they will see such a situation as unacceptable.
| Corporate counsels also hold a lot of sway within a
| businesses structure.
| css wrote:
| Yes, it's called reinsurance:
| https://en.wikipedia.org/wiki/Reinsurance
| stochastastic wrote:
| Yes, they typically will buy insurance to deal with risks
| outside their core business (like the health insurer
| having liability coverage).
| ridgeguy wrote:
| This is excellent advice, and isn't restricted to the
| medical arena.
|
| Corporate counsel for insurance companies comprise one of
| the very few spots on the brontosaurus with low-latency
| innervation from the brain. Poke it, you'll usually get a
| response that will arrive faster than the usual appeals
| processes.
| djbusby wrote:
| Lawyers, the best way to get reasonable healthcare in USA.
|
| What can be done?
| davidw wrote:
| Elect people, starting at the local level, who want to
| change the system?
|
| That change doesn't have to be 100% or perfect. The ACA
| ensured that a lot more people got covered, even if it
| was not perfect.
| dahfizz wrote:
| The ACA just gave more power and money to these same
| scummy insurance companies.
| davidw wrote:
| So, no, definitely not perfect. Also, some people are
| alive today because of it, and many are healthier. I'll
| take that over a better reform that doesn't get passed,
| and keep working to elect the people necessary for better
| reforms in the future. This stuff just doesn't happen
| overnight, sadly.
| explaininjs wrote:
| Like Bernie Sanders? Who was then placed in a debate in
| an "insurance town" where every audience question was
| some insurance leech complaint that his plan would
| destroy their jobs? Yeah dude. That's the pint, your job
| is bullshit and you shouldn't be doing it.
|
| The media also loved to bring on people who "adored their
| current insurance plan and would hate to lose it". I've
| never met someone like that in real life, but the MSM
| would have you believing you were the only one in all of
| America who had any ill thoughts about their insurance
| company.
|
| If voting could change anything it'd be illegal.
| AnIdiotOnTheNet wrote:
| I mean, I don't want to say "start shooting them until
| they get the message that we won't put up with their
| bullshit", but I honestly can't think of a better plan
| given that people will find all sorts of excuses to keep
| voting for the kinds of assholes who prefer it this way.
|
| I'd really like to hear one, cause the violence option
| isn't really very appealing.
| anigbrowl wrote:
| _Standard answer is we can 't tell you why you were rejected_
|
| How did you find out about the automatic rejection/identity
| of the reviewers?
| kurthr wrote:
| That is a good question. The first appeal was "free" so we
| didn't have to justify it with anything other than, "no
| really the surgery is necessary". They only gave us a
| rejection number on the second and third rejections and we
| had to request the written forms by mail, which took weeks.
| The written form didn't have much more, mostly boiler
| plate, but it did have the number (and maybe a
| chapter/paragraph number citation?) and on the second one
| it had a signature by the reviewing doctor along with his
| typed name, which was luckily relatively uncommon. We had
| to provide statements from our doctors and surgeon (who
| also didn't get a reason for the refusal) justifying the
| surgery's need and effectiveness.
|
| From the doctor's name and the Midwest area code for review
| center we were able to filter down the doctor's name to a
| single individual and then do a search in the state medical
| board system (I'm not sure if this is readily available to
| non-medical personnel). That popped up his med school,
| residency, work history (ended more than a year before) and
| some pending issues with his performance. When we replied
| by registered mail we made an obvious CC to a local lawyer.
|
| Speaking to the surgeon we were also able to makes some
| guesses as to the rough name/title of a justification
| document they would use and that along with the citation
| number in a google search popped up a downloadable pdf
| which was 5-6 years old, but seemed about right. And when
| we looked up the paragraph and rejection it was pretty
| clearly related to roughly the right kind of surgery. That
| let us make a more focused/documented appeal to the
| rejection. When they finally approved we got a bit more
| documentation about the prior rejections and who reviewed
| them. I assume ass covering.
|
| In the end the thing that really pissed me off is that they
| didn't even pay what they promised to and we knew it would
| another 100hrs of work to get it.
|
| Edit: we paid ~10% out of pocket on a $60k surgery + their
| shortchange. good news is 15y later totally successful and
| healthy! P.s. this is by memory but somewhere we've still
| got that notebook and all the paperwork filed that I'd
| rather forget.
| anigbrowl wrote:
| Good grief. I'm sorry you had to go through that, the
| bureaucratic trauma involved in health billing/insurance
| increasingly seems as bad as or worse than the medical
| issue itself.
| kurthr wrote:
| It was definitely a learning experience. If you're in the
| hospital under a doctor's care it's a lot easier, but if
| you have major (expensive) preventative care, then the
| insurers want to discourage or delay that as long as
| possible.
| Jcowell wrote:
| How on earth can some one read this and think that the
| American Health System isn't fucked up?
|
| Can someone explain to me why the model we choose to pay
| for the health for the populous of this country is
| through insurance and not straight up taxes??
| ridgeguy wrote:
| "We" don't choose.
|
| America's health care system is shaped and maintained by
| those who benefit economically from its configuration.
| Configuration maintenance tools include lobbying,
| gerrymandering, targeted tax favors, and wide
| dissemination of misinformation.
|
| It's a very small fraction of "we" that maintains this
| status quo.
| tstrimple wrote:
| Because it works well enough for them now, and they seem
| to have no capacity to either understand or care that
| others are suffering under the same system. For some, the
| demand for maintaining the status quo is far more cruel.
|
| https://www.bostonreview.net/articles/jonathan-m-metzl-
| dying...
|
| > Even on death's doorstep, Trevor was not angry. In
| fact, he staunchly supported the stance promoted by his
| elected officials. "Ain't no way I would ever support
| Obamacare or sign up for it," he told me. "I would rather
| die." When I asked him why he felt this way even as he
| faced severe illness, he explained: "We don't need any
| more government in our lives. And in any case, no way I
| want my tax dollars paying for Mexicans or welfare
| queens."
| anakaine wrote:
| If that isn't the best summary of what I feel the
| conservative American psyche is at large, then I don't
| know what is.
| ClumsyPilot wrote:
| > Standard answer is we can't tell you why you were rejected
| (code only) because the criteria are from a third party and
| their review document is proprietary
|
| So you paid for a service, and you don't get the service you
| paid for, and you will not be told why?
|
| If I did this in my line of work, I would be in prison for
| fraud.
| prh8 wrote:
| This is literally how it works in the US, this is not the
| exception
| Eric_WVGG wrote:
| Here's an example of something that happened to my sister
| that isn't exactly the same, but is the same sort of
| philosophy in action.
|
| My sister was the manager of a coffee franchise named after
| a certain character from classic literature. Her location
| was doing extremely well, she was a competent type-A who
| commanded a great deal of respect in her entire district,
| and was generally assumed to on the fast-track for
| promotion.
|
| One day, $200 was missing from her daily cash. She was
| fired the next day. Not for the missing money; they came
| showed her a list of very minor issue (clerical errors, an
| unwashed countertop on a random inspection, a couple
| unhappy customer feedbacks) that had come up in her eight-
| year career, and said she was fired for general
| incompetence.
|
| Two weeks later, one of her ex-employees called up, crying;
| she was doing her laundry, and found $200 in one of her
| pockets. She had gone to the safe to make change for the
| register and screwed up.
|
| The point here is: corporations understand that you can't
| fire someone or deny coverage based on reasons that can be
| contested. It's not fraud if you fire them for some other
| reason. It's not fraud if you don't even know why you
| denied coverage. You're only in trouble if you play fair.
|
| We're Americans and we love this sht and it's no wonder the
| CEO of that coffee company thought he deserved to be
| President.
| ClumsyPilot wrote:
| I understand that, but how is it legal to refuse to
| fullfil your insurance obligations without revealing the
| reasons?
|
| Like in US insurance is at will, okay, fine.
|
| But insurance is surely under a legal obligation to
| fullfill their end if the bargain?
| loa_in_ wrote:
| I don't think you understand. They only have to make case
| for "their end" to not apply to the specific case, and
| it's okay. Same as firing someone for incompetence
| because you suspect them of theft. Realize, an employer
| has this option always. Why bother "playing the game".
|
| > [...]you can't fire someone or deny coverage based on
| reasons that can be contested. It's not fraud if you fire
| them for some other reason. It's not fraud if you don't
| even know why you denied coverage.
| indymike wrote:
| When someone in my family does not get pre-approved for care, I
| write a letter and and ask my physician to sign, and ask the
| other doctors at his practice to sign a letter that goes like
| this:
|
| "I beleive this procedure _____________ is medically necessary
| for __________. Time is of the essence, and this procedure
| should be performed as close to immediately as possible."
|
| In the signature block, I include the degree, specialty and
| medical school of the doctor. I then fax the letter in, and
| within 30-40 minutes, I have a phone call apologizing for
| rejecting and giving me pre-approval for the care. I learned
| about this when my (at the time) 15 year old was rejected for a
| cardiac procedure and the billing person pulled out a pre-
| printed deck of letters that was pre-signed by every department
| head at the hospital. The one thing the insurance people fear
| most is risk.
| firstlink wrote:
| This must have been before insurers adopted the mantra "we
| aren't denying care, only paying for the care!" With that
| legal magic wand, there is no risk to the insurer.
| indymike wrote:
| That was in full effect at the time. They would like for
| this to be the case, but reality is very different.
| ridgeguy wrote:
| Noted and saved for future use. Thanks for this.
| stouset wrote:
| Counterpoint.
|
| I have an Aetna PPO and experienced a stroke last year.
| $100,000+ hospital stay and insurance just... covered it. I
| paid $1,100 out of pocket.
|
| I had a $100,000+ surgery a few weeks ago to repair a heart
| issue that may have led to it. They just covered it. No fuss,
| no hassle. I paid $3,300, which was the remainder of my total
| annual out-of-pocket, and now I will pay $0 for healthcare for
| the rest of the year.
|
| For the surgery, I called in advance to double check that it
| was covered and after five minutes on the phone with a
| concierge they confirmed that it would be covered.
|
| Obviously I am only a single data point and I can't speak
| towards other conditions or procedures. But Aetna has done
| right by me, at least from within the perspective of our insane
| for-profit healthcare system.
| alpaca128 wrote:
| > I paid $3,300, which was the remainder of my total annual
| out-of-pocket
|
| So with insurance you paid more than a European without
| insurance would, and you call that a counterpoint?
| whatthesmack wrote:
| Sure, if GP is in the US and the European is paying 2-3x
| the income tax rate & earning half the salary.
| Centigonal wrote:
| I'm glad you had such a good experience. Not a counterpoint,
| though.
|
| Healthcare is like running water, bridges, or banking systems
| - a high-volume system with extremely high stakes. We need
| many nines of consistency as protection against preventable
| harm.
|
| There are around ~35M hospital admissions in the US every
| year. Even if 9/10 patient experiences are like yours, that
| means more than 3.5 million people had a sub-par experience
| that year - that's the entire population of LA. We need to
| strive for a much higher bar of quality and consistency.
| stouset wrote:
| I'm not defending the current system _at all_.
|
| I was simply trying to say that, within the confines of the
| current system, this particular actor has not gone out of
| their way to fuck me over in the same way that I hear about
| so many other actors.
|
| I have no idea if my experience with Aetna is common or an
| outlier. My hope was that by posting this, it would provide
| a data point for people forced to choose a private health
| insurance provider in the future. I also hoped to hear from
| others who had experiences either mirroring or opposite my
| own.
|
| If I could, I would dismantle our current system in a
| heartbeat and replace it with some form of single-payer. I
| can't, so I tried to provide information about one player
| within the incredibly fucked up system Americans are forced
| to operate within.
| pcurve wrote:
| I've been working in the industry for 20 years. All companies do
| this. I don't think this is even the worst example of rule driven
| coverage review
| electrondood wrote:
| For anyone who is against government regulation... this is
| another perfect example of the kind of perverse financial
| incentives unregulated capitalism results in.
|
| Blanket denial without consideration lowers your costs as an
| insurance provider, because it acts like a filter on people who
| care enough to appeal repeatedly.
| whatthesmack wrote:
| This is not unregulated capitalism. This is crony capitalism or
| corruption. It is government regulation that allows a monopoly
| of large corporations to remain the powerful health insurance
| companies they are, and ObamaCare gave them even more power.
|
| If this was a free, unregulated market, healthcare in the US
| would be cheaper.
| elromulous wrote:
| I interpreted "saves millions" as "saves millions of lives". I
| couldn't have been more wrong.
| diebeforei485 wrote:
| Obama gave the insurers (who are big donors/lobbyists) way too
| much power.
| daviddever23box wrote:
| There is a curious irony regarding retirement funds that invest
| in health insurance companies: if one is healthy and pays into
| the system, the insurers will reap ample profits, and one's
| retirement plan will reap the benefits. Get sick, and one may
| never make it to retirement....
| stathibus wrote:
| This reminds me of the US patent approval system. There are too
| many claims to properly vet them all, so just "click and submit"
| and only put effort into the ones that come back to complain.
| (Except the PTO is biased toward approval and not rejection, of
| course.)
| AnthonyMouse wrote:
| Not exactly. The US PTO rejects a large proportion of patent
| claims. It can be quite expensive / time consuming to get a US
| patent as an individual inventor. But you can appeal the
| rejections, and large corporations and patent trolls have staff
| attorneys who do that all day long, so then tons of garbage
| patents get approved too.
| switch007 wrote:
| > "Put yourself in the shoes of the insurer," Howrigon said. "Why
| not just deny them all and see which ones come back on appeal?
| From a cost perspective, it makes sense."
|
| This is more or less how the UK government handles benefits
| (welfare) applications.
|
| It's cruel and demeaning and damaging to health in many many
| cases.
| smsm42 wrote:
| Imagine spending years studying medicine and ending up doing
| this.
| duxup wrote:
| I was on a jury on a civil case that involved medical claims.
|
| The insurance company doctor seemed like a doctor who sort of
| plodded his way through jobs and eventually just found a place
| where he could be a doctor and just reject insurance claims.
|
| Dude didn't seem to actually know all the medical claims involved
| in the case, seemed confused about what kind of care was done ...
| just not at all on the ball.
|
| When we deliberated and reviewed the evidence absolutely nobody
| on the jury had any faith in the insurance company's doctor and
| we disregarded his testimony entirely.
|
| I honestly felt like there should be some consequences for
| someone acting as a "doctor" testifying in a court case and
| having very little clue what was going on, but choosing to
| testify.
| kwhitefoot wrote:
| > there should be some consequences for someone acting as a
| "doctor" testifying in a court case and having very little clue
| what was going on, but choosing to testify.
|
| It will make no difference. It is the people higher up and the
| investors in the company who are responsible. The doctors in
| question don't behave as they do just because they want to,
| they do it because that is what the company that employs them
| demands.
| duxup wrote:
| I'd like to see the doctor be at least at risk of losing his
| license. It's a serious profession and should be held to
| standards.
| nine_zeros wrote:
| I'd like to see the doctor's license suspended and all exec
| pay to be held until investigation of malpractice is
| complete.
| hayst4ck wrote:
| If you reached out to the medical licensing board and
| communicated that situation it's not implausible that there
| would be consequences.
|
| Here is what it is for California:
|
| https://www.mbc.ca.gov/Consumers/File-a-
| Complaint/complaint-...
|
| https://www.mbc.ca.gov/FAQs/?cat=Complaint&topic=Complaint:
| %... What kinds of complaints warrant a
| formal investigation? In general, any complaint
| that would warrant disciplinary action if
| substantiated (e.g., sexual misconduct, gross negligence
| and/or incompetence, etc.) is referred for
| investigation. Other kinds of complaints may also
| require a formal investigation. These include physician
| impairment, unprofessional conduct and unlicensed practice
| issues.
| jc_811 wrote:
| Wow. This is almost the exact plot of The Rainmaker by John
| Grisham[1] that came out in 1995:
|
| "Rudy uncovers a scheme by Great Benefit to deny every insurance
| claim submitted, regardless of validity. Great Benefit was
| playing the odds that the insured would not consult an attorney.
| A former employee of Great Benefit testifies that the scheme
| generated an extra $40 million in revenue for the company."
|
| [1] https://en.m.wikipedia.org/wiki/The_Rainmaker_(novel)
| dafelst wrote:
| Privatized health care as a person's sole option for care is an
| absolute dystopian nightmare. Any system that requires balancing
| human suffering against profitability is inevitably going to
| optimize for profitability.
|
| The fact that this is even a thing is mind boggling.
| casenmgreen wrote:
| I may be completely wrong, but I understand in the US normally
| people have health care through their employer? so they are not
| themselves paying the insurer, and cannot change insurer.
|
| If this is the case, then it is no wonder the insurer has no
| particular care for them. It is the power of the consumer to
| change provider which gives them influence over the provider.
| dboreham wrote:
| Even if not employer provided, there's usually little choice
| in carriers due to anticompetitive practices and regulatory
| capture.
| lumb63 wrote:
| This is the case, and is, IMO, the central problem with
| American healthcare. Folks in both political parties argue
| for or against socialized healthcare, and ignore that a huge
| amount of the problems could be solved by having an actual
| free market.
|
| My opinion is that providing healthcare as a benefit should
| be banned. Employees who have healthcare today should be
| provided the amount the employer would have spent on health
| care in wages/salary. The fine details are hard to work out,
| but I think it is a good starting point.
| Someone1234 wrote:
| I agree, an important component though is that insurance
| premiums are pretax, so you'd need to expand HSAs to be
| large enough to pay insurance premiums.
| paulddraper wrote:
| I knew I was going to see this comment.
|
| As if Medicare didn't reject millions of claims too.
|
| A number of physicians just don't accept Medicare because it's
| subpar.
| slackfan wrote:
| I see you've never had to do a major procedure in a "public"
| system.
|
| Heh.
| winrid wrote:
| I have literally spent years trying to get an MRI for my knee
| after an accident. Both Kaiser and Anthem won't cover it.
| t344344 wrote:
| I had MRI in EU, it was 160 euro for scan, and another 50
| euro for specialist consultation. Public insurance would not
| cover it, so I paid it myself.
|
| Not sure what is holding you back, but health should be a
| priority!
| winrid wrote:
| Yeah, that's an idea. It's like 10k here.
|
| The trip to the EU, a vacation, and the MRI itself would be
| cheaper...
|
| I was actually planning on getting it done on my next trip
| to China, which is about the same cost wise, and the
| doctors are good as they see so many people lol
| hirsin wrote:
| I get a screening in India when I visit some family
| there. Full blood work, you call in the morning, they
| come by the house and draw it, results in the next
| morning. It's faster and cheaper to do that, including
| the flights, than to try and get this done through my
| doctor in the US.
|
| So, yeah, go for it.
| mdorazio wrote:
| Not sure what you mean here. Services like Personalabs or
| just scheduling straight through Quest Diagnostics cost a
| couple hundred bucks for blood & urine tests on most
| things, there's probably a facility near you, and you get
| your results in a few days. I do it every few years with
| zero issues.
| avgDev wrote:
| Because in US MRI is $1000 to $8000.
|
| It is a joke.
| thallium205 wrote:
| $550 for an MRI.
|
| https://tellicaimaging.com/
| winrid wrote:
| 600 miles away. But yeah I can probably find one nearby
| for a couple grand. Still, that's insane.
| nrb wrote:
| An MRI in the US without insurance coverage can reach up to
| several thousand dollars.
|
| Heck, WITH insurance you can expect it to cost up to around
| $1000 depending on coverage.
| eric-hu wrote:
| Do you know if an American could go to where you are and
| pay for an MRI and doctors visit out of pocket?
| Scoundreller wrote:
| Pretty much, the answer is yes.
|
| Though sometimes the price the consumer pays isn't
| reflective of the true cost.
|
| Sometimes the public health system does buy/subsidize the
| machine for the provider and a private client isn't
| charged some chunk of the amortized cost of the machine
| because the public system (rightly) assumes that 99% of
| the work is going to be for their residents. The clinic
| can profitably just charge for their professional/office
| use.
|
| Here's a Bucharest Romania MRI clinic with tariffs:
|
| https://rmntineretului.ro/tarife/
|
| It's about 3 Lei to a USD, or US$200-US$500 for an MRI.
| yborg wrote:
| That MRI would probably bill out at >US$ 1000 in most urban
| areas in the US. I've been billed $300 for a simple
| shoulder X-ray.
|
| The real kicker is that you generally can't even find out
| this price until you have the procedure and receive the
| bill. It's become almost akin to a legal mafia cartel. In
| my area, a majority of the urologists have become part of a
| medical group that now dictates pricing for related
| procedures. Most of the major insurance carriers don't want
| to pay this pricing so this group is not a covered
| provider, so finding a urologist that is covered entails
| sometimes waits of months for an appointment.
|
| It's the worst parts of socialized and for-profit health
| care assembled into one system.
| CogitoCogito wrote:
| > The real kicker is that you generally can't even find
| out this price until you have the procedure and receive
| the bill. It's become almost akin to a legal mafia
| cartel. In my area, a majority of the urologists have
| become part of a medical group that now dictates pricing
| for related procedures. Most of the major insurance
| carriers don't want to pay this pricing so this group is
| not a covered provider, so finding a urologist that is
| covered entails sometimes waits of months for an
| appointment.
|
| I find the American healthcare system pretty atrocious,
| but I've never had issues getting upfront costs when
| scheduling non-emergency procedures using cash. Then
| again it's probably been a good 8+ years since I've done
| that in the US.
| slaw wrote:
| MRI accessibility is regulated at the state level, which
| determines the number of MRI machines available to the
| public. I was able to obtain an MRI while on vacation in
| Europe without any appointment or referral from a physician.
| The process was straightforward; I explained my needs to the
| receptionist, and a technician conducted the MRI. The cost
| was 180 euros.
| matwood wrote:
| I know it's still not cheap, but I needed an MRI a few years
| ago and it was $350. Talk to your doctor and let them know
| you want to pay cash. Mine suggested a place.
|
| Don't get one in the hospital if you can help it. They charge
| 1-2k because they have a full set of people who can't go
| anywhere else.
| winrid wrote:
| idk where you are but the hospital here wants 10k to do it
| and the private clinics are around $2k last I checked.
| rsyring wrote:
| My family has received multiple radiology procedures
| including x-ray, MRI, and ultrasound from private radiology
| businesses (I.e. not the hospital). They are typically 10x
| give or take less expensive. Last MRI was $600.
|
| Doesn't help if you are stuck in the hospital. But, it's an
| option otherwise.
| rr808 wrote:
| > Privatized health care as a person's sole option for care is
| an absolute dystopian nightmare.
|
| Dont exaggerate. I've lived in 3 European countries and
| Australia. My American healthcare is easily better than those.
| Sure I'm lucky to have a good job that pays for it, but you
| can't say its terrible without looking at how those public
| systems are really struggling right now.
| mavelikara wrote:
| > Sure I'm lucky to have a good job that pays for it,
|
| That is not where you are lucky.
|
| You are lucky to be healthy enough that you can hold on to
| that job. Once your health takes a bad turn, and you are
| unable to work, when you really need your healthcare, that's
| when you are better positioned to judge the quality of
| healthcare.
| rr808 wrote:
| Yes that is true.
| CogitoCogito wrote:
| My personal healthcare in Sweden has been higher quality
| (considering both personal cost and state cost) than my
| healthcare in US. I have heard complaints the other way of
| course.
|
| Regardless of our personal experiences, the US spends so an
| enormous amount on healthcare and gets very little in return
| by basically all international measurements. Americans who
| think American healthcare seem to me too insecure to accept
| that their system is just plain bad. But yes Americans with a
| lot of money have access to better healthcare than average
| Americans. That said, this is essentially true in all
| countries so it's not that relevant really.
| ugh123 wrote:
| > a good job that pays for it
|
| If that's whats necessary to get decent health care in this
| country, then something isn't right.
| lotsofpulp wrote:
| Technically, you just need money to pay for it. However,
| buying the employer's choice lets you pay for premiums with
| pre tax funds, and the employer usually subsidizes 70% of
| the premiums.
|
| So for an individual, it is roughly a $10k per year benefit
| to get it via employer and for a family of 4, $40k per year
| benefit.
| menage wrote:
| That's not true. As I discovered when my COBRA ran out
| recently, finding individual plans that match the
| coverage of employer plans is very hard or impossible,
| regardless of how much you're willing to pay.
| moate wrote:
| You're telling me a mega-corp buying coverage for 10000+
| employees might have an advantage in negotiating price
| that a single "rugged individual" doesn't?! But that sort
| of thinking could burst the whole "pull yourself up by
| your bootstraps" thinking that fuels the American dream!
| Clearly all individuals (both single citizens and
| corporate entities)are the same other the law!
| lotsofpulp wrote:
| I've always been able to find the same or similar BCBS
| plan my employers offer on healthcare.gov. If it has the
| same metal level (platinum/gold/silver/bronze), it should
| be the same actuarial value.
|
| Only thing that Carrie's
| mertd wrote:
| We need to realize that publicized healthcare is the only
| option. Then we can focus on how to make it more efficient.
| nobodyandproud wrote:
| Unions on the left and most of the right are deadset
| against this.
|
| It's astonishing how much market _inefficiency_ we're
| willing to tolerate.
| globalise83 wrote:
| The important question is: have you ever made a large claim
| for a serious long-term illness? If not, you aren't yet in a
| position to judge the two systems.
| hayst4ck wrote:
| Do you think your health care experience represents the
| median healthcare experience in all 5 countries?
|
| If we divide up people into percentiles based on wealth, 25,
| 50, 75, 95, how do you think people fare in the different
| countries? How do you think they the median experience is in
| America?
| rr808 wrote:
| Totally if you're poor in the USA the healthcare medicaid
| is OK not great. If you have a little bit of money so dont
| get medicare its an expensive disgrace.
| walls wrote:
| Oh, well as long as you personally have not yet had a
| problem.
|
| Everything is fine everyone, no need to worry.
| [deleted]
| interstice wrote:
| An ironic use of the phrase survivorship bias springs to mind
| jfengel wrote:
| The article suggests that your health care isn't as good as
| you think it is. You never know if you'll be one of those
| cases where they make you fight for every bit of care you
| get.
|
| Some Americans do get excellent care with a minimum of grief.
| Others think their insurance is fine while they're healthy
| and only discover later that it doesn't really cover what
| they imagine it does. And the difference is entirely
| arbitrary.
|
| The fundamental problem of health insurance is that you
| cannot know what you will need, and there is no way to make
| an informed consumer choice, but your need when you have it
| is absolute. It's pathologically pessimal as a free market.
| And you usually don't know until it's too late.
| lumb63 wrote:
| You cannot know what you will need, but to leap from that
| and say that you cannot make an informed consumer choice is
| a huge and incorrect leap.
|
| Actuaries know, in aggregate, what specific demographics
| will need. Insurance companies use those statistics to make
| profit. The view that consumers cannot make informed
| choices on healthcare needs is incompatible with the fact
| that risks are not perfectly and uniformly random. Unless,
| by "informed choice", you mean one that is correct in
| hindsight, in which case, I agree.
| b59831 wrote:
| > The article suggests...
|
| Maybe because it's a politicized topic? How can you smugly
| dismiss their point like that?
| stonogo wrote:
| > How can you smugly dismiss their point like that?
|
| Because "it's fine if you're rich" is a shitty place to
| terminate the matter. It's not a useful counterargument
| in any sense. Of course it's fine if you're rich, that's
| why people want to be rich. What about, you know, the
| rest of the planet?
| cscurmudgeon wrote:
| ProPublica has been known to twist facts. They are not the
| final word in this.
| [deleted]
| ryanSrich wrote:
| Yeah this is a very common sentiment. I feel like most people
| in the US haven't actually talked to someone that has
| experience with socialized healthcare at scale. I had a
| German professor that was very clear about just how much
| better healthcare is in the US.
| TylerE wrote:
| US is great if you're either basically helpful or
| incredibly sick.
|
| It's not so great for those in the middle.
| Dobbs wrote:
| As someone who has lived in the US, UK, and NL. I'll
| happily take the UK (pre-running it at such a budget that
| it fell apart) or NL systems over the US anyday.
|
| There is no fun surprises like finding out that while your
| surgeon and hopsital were in-network your anaesthetist was
| out of network.
| thallium205 wrote:
| "There is no fun surprises like finding out that while
| your surgeon and hopsital were in-network your
| anaesthetist was out of network."
|
| This practice has been outlawed this year.
| ratg13 wrote:
| Healthcare in the US can be higher quality, but you never
| know what you're going to pay for it.
|
| When I was starting my career, I had to go to an ER that
| was out of network, I checked with my insurance and they
| said they would cover it. They decided after all not to
| honor their word and charged me 10's of thousands of
| dollars.
|
| Being young and independent, this was devastating, despite
| having a good job, good insurance, etc.
|
| I largely credit this with my push to move to Europe, and
| have never looked back.
|
| Sometimes knowing you can get any healthcare you need
| without it potentially a bankrupting you is it's own
| reward.
| rqtwteye wrote:
| I am from Germany and agree that US healthcare is very
| shiny. But once you get sick it's very easy to get stuck in
| an extremely expensive bureaucratic nightmare between
| hospitals and insurances. I prefer the German system where
| I can go to a doctor or ride an ambulance without the fear
| of having to pay tons of money.
| karmelapple wrote:
| The German healthcare system was surprising to me. It was
| affordable, it was fairly honest, and our anecdotal
| experience was not as good as most experienced we've had
| in the USA.
|
| A few examples for those wondering: * the total cost for
| over a week stay was a couple hundred dollars - very
| affordable! * certain painkillers banned in the USA were
| the first line of defense there * getting very strong
| pain killers was next to impossible - I think we probably
| only got it because we were family members of the
| anesthesiologist, and he knew we needed it. And it took
| nearly 24 hours of agonized pain before we could finally
| get them * nurses are not trained to put in IVs - we
| needed an MD for that. And the MD had a lot of things to
| do and we had to wait quite awhile even though there were
| many nurses around. In the USA, I think most people with
| the title of nurse can do that
| kwhitefoot wrote:
| > nurses are not trained to put in IVs - we needed an MD
| for that
|
| That's very odd. Nurses do that all the time in Norway.
| kube-system wrote:
| In the US people with the title of nurse can be someone
| who is highly skilled and is playing an important hands-
| on role in major and complicated surgeries.
|
| I think some other places around the world use the title
| nurse for what may be a medical assistant in the US. (No
| clue about Germany though)
| A4ET8a8uTh0 wrote:
| Eh. I did in Poland, but, admittedly, it is a poster child
| of how to do it so badly that people opt for now existing
| separate private care. It is, however, definitely a
| negative example of socialized health care.
| EnglishRobin96 wrote:
| Having lived the opposite, I have to strongly disagree. I
| lived the nightmare of US healthcare, where my provider
| decided to stop working in my state, which meant that I no
| longer had access to any doctors under health insurance
| despite it being paid for by my company.
|
| The UK was amazing - no questions asked care for my health
| was a massive improvement over what I had in the US. Free
| access to a doctor at any time is more life changing that you
| can think - every health issue I had I could talk to a
| medical professional and get guidance. Even free mental
| health care.
|
| Moved to Ireland last year, with a mixed public/private
| system, and my health is now slipping a bit. Going to a GP,
| trying to file for reimbursements, and knowing that every
| time I have a health concern, it will cost me money, is a
| powerful suppressing force. I miss the NHS.
| [deleted]
| ClumsyPilot wrote:
| Can anyone name any usefull innovation that has come from
| private health INSURANCE in the past 100 years?
|
| Not private hospitals/drug manufacturers - those are arguable -
| just insurance. What do they contribute?
|
| They got bailed out in Covid, they take money out of the system
| in good times, they deny you care in the bad times.
|
| Best I can tell they serve no usefull function
| thallium205 wrote:
| So then what are your thoughts on those who get denied on a
| Medicaid plan?
| xwdv wrote:
| Public health care can be similarly dystopian in other ways:
| Very long wait times due to limited resources, subpar medical
| care, limited prescription options and drugs, beauracracy.
|
| No matter what society you live, the advice is the same: try
| not to get sick.
| PicassoCTs wrote:
| Ah, yes, have a privatized public sector, use the gained
| funds to lobby in other countries, pushing a ideology that
| destroys public sector/services, use the result of ones own
| actions to push the conversion to more privatized public
| sector. The ultimate glider gun ideology.
| weaksauce wrote:
| > Very long wait times due to limited resources, subpar
| medical care, limited prescription options and drugs,
| beauracracy.
|
| those are all there because the people that created the
| system did not think paying for it was good enough. it
| doesn't have to be that way. and even with wait times being
| long you still eventually get it. in the privatized system if
| you are poor and have bad health care you don't get it at
| all.
| nathan_compton wrote:
| This might be true, but as someone who has lived in the U.S.
| and Europe I can say utterly unequivocally that I preferred
| Health Care in Europe. I wasn't even in one of the European
| countries with a great reputation for Health Care.
|
| Health Care in the U.S. isn't just bad, its outright fucking
| brutal. An elderly friend of mine recently fell and went to
| an urgent care where they couldn't get him into the x-ray
| machine. They told him to go to an emergency room where he
| waited for _13_ fucking hours with a broken pelvis. I'm
| basically 100% sure that such emergency room bullshit
| literally kills people from stress or exposing them to other
| sick people. You can't even wait in your damn car and just
| have them text you - they just force you to sit in this
| horrible room with a ton of sick people for hours on end.
|
| The U.S. Health Care system absolutely fucking blows.
| ChrisMarshallNY wrote:
| As someone who has dealt with many folks suffering from
| AIDS, I can say that it may even rise to the level of
| crimes against humanity.
|
| It's a well-known trope (probably proven, but I don't know
| the studies) that insurance companies routinely delay
| healthcare to AIDS and other patients with terminal
| diseases, in the direct hope that the patient dies.
|
| With AIDS patients, there's a big moral component to the
| diagnoses, and companies can "get away with it," because
| there's such stigma to the disease, but I have also heard
| of the same thing happening to cancer patients. In fact, it
| can sometimes be a matter of life and death. If a treatment
| is delayed enough, it can change the outcome.
|
| I have been told (but don't know it for a fact) that this
| is actually the point of the delays, and that the delays
| are triggered by the diagnosis.
|
| In many cases, delaying payment, also delays treatment.
| Most patients don't have an extra 500K, floating around,
| that they can pay the hospital for a procedure, in the hope
| they get reimbursed. No promise of payment, no treatment.
|
| So that means that refusal to pay _is_ the same as
| withholding treatment, and these companies know it.
|
| I think that AI is likely to make this worse, as they will
| probably give these decisions to an AI, thus removing any
| hope that there may be a caring human in the process that
| could possibly feel shame.
| xwdv wrote:
| I'm fully insured and have always been well taken care of
| in the United States health care system. Never wait more
| than 30 minutes if I were in an emergency room, and usually
| I'm attended to within 10-15. Doctors appointments are easy
| to get, never paid much for prescriptions.
|
| If I was in a public system, I'd fear I'd be fighting for
| attention alongside the general public, so I'm not
| convinced it would be better.
| KyleJune wrote:
| Where is the wait only 30 minutes? Every time I've been
| to the emergency room the wait has been 6+ hours. I think
| the only way it would be that fast at the hospitals I've
| been to is if you'd die waiting longer, otherwise it's a
| long wait.
| Scoundreller wrote:
| Everywhere and nowhere it can be 30 minutes. Every
| competent ER on the planet triages patients. Come in with
| crushing chest pains and it should be 30 minutes
| everywhere 99% of the time. Broken arm? You might wait
| hours if people keep coming in with crushing chest pains.
|
| "Wait" can be defined very differently. Wait time to get
| triaged by a nurse? An ECG for chest pains? Initial
| physician assessment? Entry-to-exit? Lab results? Time to
| X-Ray if needed?
|
| Lots of directives may be in place too. In an efficient
| system, the nurse is empowered to "order" many procedures
| that screen out serious things that require immediate
| physician intervention. Or just to save time like
| ordering an X-Ray first instead of waiting to see a
| doctor to order it and then waiting again for it to come
| back to review.
| xwdv wrote:
| Post COVID hospital in Ohio, limped in with severe ankle
| sprain, got doctor in less than 15 minutes and out within
| an hour with splint and crutches. Even got X-Ray.
| mdorazio wrote:
| What city? Most of us in this thread live in larger
| cities. When I lived in LA and had to go to the ER, the
| wait was 5 hours and they literally rolled a cart over
| and made me prepay my insurance deductible (several
| hundred dollars) before a doctor even saw me. Helped a
| friend get to the ER in Phoenix and it was about 3 hours.
| glenstein wrote:
| I am also fully insured and I have never once heard of
| emergency rooms with an average wait time of 30 minutes
| in the United States.
| oogali wrote:
| I've waited hours in NYC.
|
| I've waited less than an hour in New Jersey and
| Connecticut.
|
| When I still lived in NYC, I resolved that if I needed a
| hospital but I wasn't in extremely bad shape, I would
| drive an hour into an adjacent state's ER rather than
| wait in NYC.
| nobodyandproud wrote:
| Call 911 and get an ambulance.
| cmiles74 wrote:
| ProPublica has a tool that will provide the average wait
| time for hospitals in your area.
|
| https://projects.propublica.org/emergency/
|
| Where I live, all in driving distance have an average
| wait time more than 2.5 hours.
| Timon3 wrote:
| Don't you think it's a worthy goal to strive for this for
| all people in your country? Would you really try to block
| progress towards that goal due to your fear of being
| treated as they are right now, instead of putting your
| energy towards nobody being treated that way?
|
| Sincerely, if anyone can explain to me - how can we as a
| species both have figured out game theory, AND consider
| this as a position that is in any way acceptable?
| fnimick wrote:
| Game theory explains it perfectly.
|
| The current situation is that the parent poster has
| preferential healthcare access, and other people that
| they do not care about do not. The alternative is equal
| treatment which might mean the same access, or worse
| access as they are forced to "fight for attention
| alongside the general public" as they so blithely put it.
|
| Given the option between the status quo, or a change
| which can only ever be the same or worse for you
| personally (regardless of the broader impact), of course
| someone self-centered would choose the former.
| Amezarak wrote:
| The best insurance I've seen in the US is Medicaid.
|
| It's people in the middle who are getting squeezed by
| HDHPs, mostly not the poor, who have access to Medicaid
| (exact qualifications vary by state) or Medicare
| (everyone 65+).
| cmiles74 wrote:
| I am fully insured in the United States. An appointment
| with my primary for something urgent is typically a week
| out, if I can't wait a week I am advised to go to an
| emergency room. An appointment with a specialist, if I
| can get one, is typically six months out. An average
| emergency room visit is typically a three hour wait to be
| triaged, additional multiple hours to talk to someone
| about my condition.
|
| I live in Massachusetts. I would take a public system
| over what we have now, no questions asked.
| CogitoCogito wrote:
| > If I was in a public system, I'd fear I'd be fighting
| for attention alongside the general public, so I'm not
| convinced it would be better.
|
| Are you basing this fear on any sort of facts or are you
| just afraid out of ignorance?
| specialist wrote:
| Your experience (in the USA) is not the norm. Especially
| since COVID-19.
| illiarian wrote:
| > If I was in a public system, I'd fear I'd be fighting
| for attention alongside the general public
|
| Ah yes, how dare the plebs interfere with the path of the
| chosen ones.
| zamadatix wrote:
| Only ~8% of people are uninsured so I wouldn't be so
| quick to distance yourself from being "the general
| public". Besides, you don't need insurance to be
| stabilized in an ER that only comes into play after (or
| if you enter with a non-emergency). 30 minutes is pretty
| good though, especially if it's the latter type of visit,
| it'd be about 3x better than the best state average
| https://www.beckershospitalreview.com/rankings-and-
| ratings/e.... Specific location and severity have more to
| do with ER wait times than your insurance. Travel can
| often be a "spin the wheel" type situation. I'm lucky to
| have short wait times near where I live but on some work
| trips I haven't been so lucky.
| WarOnPrivacy wrote:
| Regarding the CPS ASEC ~8% number, census.gov seems to
| track insured Americans similar to how the FCC tracks
| broadband availability[1].
|
| This ~92% insured in 2020 includes:
|
| - People subscribed to unusable ACA and private plans
| (eg: $9100 deductibles)
|
| - People considered eligible for Medicaid by CMCS,
| including those who are denied coverage by state
| administration agencies
|
| - Millions of people who were directly granted temporary
| Covid Medicaid coverage by CMCS (bypassing state
| agencies) - which expires in days
|
| [1] FCC broadband maps consider an entire census tract
| served, as long as an ISP alleges just one house there
| can be served.
| nathan_compton wrote:
| I'm fully insured and have a kid and have been to the
| emergency room quite a few times and most of the time its
| been a few hours.
|
| Contrast this with Europe, where I could get a doctor to
| make a house call at 3am for a reasonable fee.
| avgDev wrote:
| I have been to an ER in a top US hospital. Waited 6
| hours.
|
| This anecdotal evidence is garbage.
| stemlord wrote:
| I'm fully insured and healthy but still just paid almost
| $3000 in deductubles for a single upper endoscopy (common
| procedure for 40+ folks). Cigna. In Italy last summer I
| received a dental xray and diagnosis as a walk-in, for
| FREE.
| eecc wrote:
| Just adding that in Lombardy, the region around Milan who
| have a bad case of parochial wanna-be NYC, local (right
| wing) government is pushing towards private health care
| with lavish subsidies for privates and a grossly
| underfunded public health system. To get an MRI via
| public you can wait 1k days, invia private is a next-day
| appointment although you must be ready to pay thousands
| EUR. frankly it's obviously deliberate
| stemlord wrote:
| That's disappointing to hear. My experience was in
| Brescia. I'm from NYC so I can say that if they're
| charging thousands of euro for a scan they're right on
| the money.
| arrosenberg wrote:
| I find it hard to believe you have never waited more than
| 30 minutes in an emergency room. I can't ever remember
| waiting less and I've always had pretty good insurance.
| Scoundreller wrote:
| ERs, even in US, will triage patients by need, not
| quality/quantity of insurance. If they're seeing insured
| ankle sprains before uninsured strokes/heart attacks,
| they're going to get sued to dust.
| dwater wrote:
| How old are you and what are your insurance premiums and
| deductibles? Generally the US healthcare system works
| better the more money you have and the less risk you
| have.
| JeremyBanks wrote:
| [dead]
| yowzadave wrote:
| > I'd fear I'd be fighting for attention alongside the
| general public
|
| Are you not a part of the "general public"? If it is true
| that there is a class of people who don't have your
| advantages and therefore have worse medical care, is that
| a situation that you see as acceptable?
|
| It always seems strange to me when people argue this
| about this issue from a hypothetical perspective, when we
| have a wealth of actual data that we can use to compare
| health outcomes. We can just look at the results and see
| what works better!
|
| https://www.pgpf.org/blog/2022/07/how-does-the-us-
| healthcare...
|
| (TLDR: the US spends much more per capita on healthcare,
| especially in administrative costs, and has worse health
| outcomes than most wealthy countries).
| earthling8118 wrote:
| To me this is similar to being "stuck in traffic" as if
| it is something that you are experiencing. No, you ARE
| the traffic. The congestion didn't come to ruin your day.
| You contributed to it too.
| fnimick wrote:
| > If it is true that there is a class of people who don't
| have your advantages and therefore have worse medical
| care, is that a situation that you see as acceptable?
|
| The answer is obviously yes, given that they don't want
| the "general public" to have the same level of access and
| make them potentially have to endure any longer waits.
| Their convenience is more important than the health of
| others.
| kevviiinn wrote:
| People love feeling like they're better than someone
| else, that's an ideal that's been floating around the US
| for quite some time. Ingroup outgroup stuff, great way
| for capital owners to keep the workers fighting amongst
| themselves and keep the attention where they want it
| harshalizee wrote:
| I moved from a third world country with both socialized and
| private healthcare, to the United States. I pay vastly more
| for worse healthcare than anywhere I've lived. The fact that
| you, your doctor can agree that a certain procedure is
| required, only to be denied by a third party with no medical
| qualification is absolutely dystopian.
| alphanullmeric wrote:
| Sounds like you should have stayed then.
| drowsspa wrote:
| Is American healthcare a patriotic issue or something,
| that's why criticizing it warrants a "don't come here"?
| Where the hell does your comment come from?
| CogitoCogito wrote:
| Americans who are unable to listen to critiques of their
| system are frankly an embarrassment for the country.
| Their insecurity is kind of pathetic. They hold us back
| in development as a nation.
| alphanullmeric wrote:
| Nothing to do with patriotism, I just question why
| supporters of collectivism constantly flee to capitalist
| countries.
| nobodyandproud wrote:
| Sounds like misplaced patriotism to me.
|
| Not everyone came to this nation due to capitalism. My
| parents partially came here to be free to say whatever
| they wanted and not disappear, for instance.
|
| It doesn't mean healthcare is done right; just as using
| TP to wipe one's ass is 100 years backward.
|
| I sometimes wish they stayed back, because my own life
| and theirs would've probably been much better in the long
| run.
| alphanullmeric wrote:
| You're always free to go back. Unlike many collectivist
| countries, we won't stop you from leaving, or try to
| force you to do things in general. So it's not
| unsurprising that your attempts at forcing others to pay
| for your things is met with hostility when you and others
| that share your views don't even want to face those
| policies themselves.
| Mizoguchi wrote:
| I also came to the US from a country with a good hybrid
| public/private system and my experience in the US had been
| different.
|
| So I guess it depends on where (city/state) you live and
| also what type of insurance you have.
|
| Where I live I have access to a SOTA network of hospitals
| with great technology and some practices amount the best in
| the world (people come here from other states and even
| countries for treatment) and I use their own insurance, so
| it's been great so far, never dealt with any issues having
| medical care rejected.
|
| I pay $350/month (self employed) and I have a very
| reasonable deductible, $60 copay to see specialists and
| many preventive procedures such as cancer and heart disease
| screenings (which I use), blood work and some PT sessions
| completely free.
|
| I even get discounts on fitness centers and health tracking
| apps which helps offset part of the premium.
|
| My shoulder was actually spared from a very invasive
| surgery thanks to a doctor top of his field (he sees
| olympic teams) who was able to treat me with only PT.
|
| I don't think I paid more than $1000 out of pocket for
| everything including several MRIs and multiple visits to
| his practice, plus several sessions of PT and medications.
|
| It could have been free back in my country, I guess, but I
| could have also been screwed for life due to an unnecessary
| surgery.
| wahnfrieden wrote:
| Sounds like death panels made up of unqualified bureaucrats
| Scoundreller wrote:
| Both public and private systems have "death panels".
| Though cited article suggests even death panels run by
| doctors are no guarantee of effectiveness.
| wahnfrieden wrote:
| The article is not about death panels run by doctors,
| they are run by insurance companies. The doctors in this
| scenario are workers given bounded instructions on how to
| operate by the ones running it, without autonomy on how
| to organize the death panel decisionmaking. It's in the
| title - the "having" shows who is in control. These are
| not worker owned cooperatives. Nor are most state owned
| death panels.
| Scoundreller wrote:
| > doctors
|
| > without autonomy
|
| This is an incredibly poor way to act given that doctors
| usually have unlimited personal liability, even if they
| are employees
| ipaddr wrote:
| Now you are talking about insurance which is the heart of
| the problem
| illiarian wrote:
| > Very long wait times due to limited resources, subpar
| medical care, limited prescription options and drugs,
|
| You realize we're discussing the US which has _all this_?
|
| > beauracracy.
|
| It's funny you mention this, because the US spends vastly
| more on bureaucracy in its health systems than other
| developed nations.
| pithon wrote:
| [flagged]
| xenospn wrote:
| As someone who grew up in israel, I can confirm your
| statement is factually incorrect.
| cmurf wrote:
| Sounds exactly like my private for profit health care
| provider.
| cscurmudgeon wrote:
| We have non privatized health care too. There is a reason why a
| communist head of state from India who routinely praises Xi and
| thrashes US/capitalism travelled to the US on Indian taxpayer
| money to receive treatment.
|
| https://www.dailypioneer.com/2022/india/kerala-cm-goes-to-us...
|
| The US is a favorite spot for Communist leaders in India of
| states that have extensive public health care. Why? Why did
| their "great" public health systems fail them?
| resoluteteeth wrote:
| That just shows that the us has good medical treatment for
| people with essentially infinite money who don't have to
| worry about cost or insurance coverage so they can bypass the
| kind of issue the article is talking about entirely.
|
| For normal Americans who actually have to worry about these
| things, healthcare in the us is a nightmare.
|
| You can't just ignore insurance and judge the us healthcare
| system based on the best hospitals and doctors when most
| Americans aren't going to have access to that.
| firstlink wrote:
| All claims being reviewed by big health insurance conglomerates
| is the antithesis of privatized healthcare. It incorporates the
| worst part of public healthcare and destroys the best potential
| benefit of privatized healthcare.
| gentoo wrote:
| it's funny how whenever a big company does something bad
| that's actually an example of how socialism is bad
| kevviiinn wrote:
| Mental gymnastics to avoid acknowledging that they've been
| brainwashed by capitalism
| johngladtj wrote:
| A key component of the free market is the ability to say
| "no thanks" to an offer to do business.
|
| Can you explain to me how the government telling you "you
| must do business with one of these insurers or else" is in
| any way a free market?
| AlexandrB wrote:
| > A key component of the free market is the ability to
| say "no thanks" to an offer to do business.
|
| So a free market in health care is _not possible_ because
| you can 't consider your options and say "no thanks" when
| you need emergency treatment. Whatever the government
| does or does not do, you can't really get around the fact
| that at a moment of crisis health care providers have you
| in a coercive situation and could charge life changing
| amounts for care if they were permitted to.
| emodendroket wrote:
| How is that so? The health insurance conglomerates are in
| private hands.
| dboreham wrote:
| Parent probably means that those companies are part of a
| government sponsored cleptocracy.
| glenstein wrote:
| What part of public healthcare is incorporated into health
| insurance conglomerates? And what potential benefits of
| privatized healthcare are we missing out on?
| thallium205 wrote:
| Who do you think run all state level Medicaid programs?
| Government employee health plans? Private conglomerates.
|
| That's one of many many examples.
| specialist wrote:
| What are some real world examples of beneficial privatized
| healthcare?
| pantulis wrote:
| IMHO in privatized healthcare you are not the patient, you
| are the customer. As such, you should be having a better
| "customer journey" than in public healthcare: more
| immediate test/diagnostics, better experience in the
| hospital (like a room for yourself). And that's it. As a
| counterpart, it's not clear you are receiving the best
| medical attention. And of course you (through your
| employer) are paying for something that can be denied.
|
| Note: I happen to have private healthcare with Cigna in a
| country with a reasonably good public health system (Spain,
| though it varies between different autonomous communities),
| happy to pay the taxes and will defend that public health
| systems are a staple of any modern country.
| LocalH wrote:
| "Being the customer" doesn't matter one bit to most
| modern megacorps, because people are fungible to them. We
| _constantly_ hear about big money screwing over little
| money.
|
| Small-time capitalism is quite good. Make a few millions,
| sure. I have no problem with that. But when the amounts
| concerned are in the billions? There needs to be
| _massive_ oversight and regulation, regardless of the
| relevant field.
| harvey9 wrote:
| The best potential benefit of privatised healthcare comes to
| those wealthy enough to just pay cash for what they need.
| cmurf wrote:
| This is not properly referred to as health insurance. It is a
| sickness, aging, and death payment plan. There's no such
| thing as major medical anymore.
|
| It was private healthcare that backed public law forcing
| minimum coverage. Why? Because their pool was shrinking. They
| were getting sick people who needed care, but with premiums
| skyrocketing, what benefit is there for healthy people to buy
| in?
|
| But I agree that the private for profit health care system is
| an abomination only made much worse by making it public law
| requiring we buy into it. Instead of Medicare for all.
| binarymax wrote:
| The fictional story "The Rainmaker" is about a fictional
| insurance company with a secret internal policy to deny all
| claims on first submission, and only fulfill some claims on
| appeal.
|
| It was meant to be fiction, but I suppose it's not. This whole
| company should go down for fraud.
| theGnuMe wrote:
| Yeah that's basically a true story, also before the ACA there
| were plans that would deny your insurance claiming that you
| lied during the underwriting process if you used the insurance.
| It was big news at the time and lots of state action against
| those plans.
|
| I think Cigna needs to be sued class action style for denials.
| I think it would probably work in the case where Cigna is
| operating as the claims administrator which is where your
| company self-insures (so they pay the claims) but Cigna just
| deals with the paperwork. I would not be surprised if Cigna
| advertises its services to large companies as "cost effective"
| etc...
| d1str0 wrote:
| I'm not familiar with class-actions, but I assume they would
| not work well for a class pool that has an extremely wide
| ranging list of claim value, and background
| evidence/ailments.
| Osiris wrote:
| My insurance is denying mental health care for my teenager who
| has Autism. They also rejected prescriptions given by my doctor
| for reasons that the doctor would already have taken into
| account.
|
| Both rejections came with a note to "not stop getting care".
|
| In my opinion, insurance companies should not be able to override
| a doctor.
| hestefisk wrote:
| This is the reason we need universal public healthcare.
| luckylion wrote:
| That won't help you there. Germany's public healthcare system
| denies plenty of things too, and will only pay for treatment
| when you sue (or know someone who works there). Germany's
| private healthcare system on the other hand is usually better
| (I'm sure there are exceptions and some insurance company that
| sucks).
| hestefisk wrote:
| You can have good public healthcare without the need of the
| notion of 'claims'. The Scandinavian healthcare system is a
| good example
| (https://en.wikipedia.org/wiki/Healthcare_in_Denmark).
| firstlink wrote:
| > The central government plays a relatively limited role in
| health care in Denmark.
|
| So the exact opposite of what people usually mean when they
| say they want public healthcare.
|
| Words mean something.
| theossuary wrote:
| Public healthcare means health care paid for via public
| funds, nothing more.
|
| Many public health care systems aren't entirely
| centralized, even though they use public funds. For
| example even the UK's NHS has regions with allocated
| budgets they manage based on the number of patients they
| see, which they then spend as they see fit.
|
| You're trying to attach your biases and assumptions onto
| an amorphous phrase, and then pretend others are using it
| wrong because they don't have the same expectations. That
| isn't reasonable.
| marginalia_nu wrote:
| Eh, my experience with health care in Sweden last couple of
| years is that almost no matter what your issue is, they'll
| ask what meds you are on, take your blood pressure, and
| some token blood samples and send you home. This costs $20.
|
| This process obviously does nothing to alleviate any
| medical issue, so you come back a few weeks later. You pay
| your $20. New doctor this time, who asks what meds you are
| on, takes your blood pressure and orders the same tests.
|
| Obviously testing the same thing a second time didn't
| further the investigation. So you go back. You pay your
| $20. Yet another doctor this time, who asks what meds you
| are on, takes your blood pressure and orders the same
| goddamn tests.
|
| Rinse and repeat. I've had like five of these contacts the
| last few years. Starting to look like a heroin junkie from
| all the blood samples. I've never learned of any test
| results. Just keep taking the same tests over and over.
| There is just zero continuity.
| colinmorelli wrote:
| This anecdote may be true, but Sweden has significantly
| more favorable health outcomes across most dimensions
| compared to the US. Infant mortality, in-hospital
| mortality, etc.
|
| In fact, most developed nations do. But part of what
| makes it so difficult to have a productive conversation
| about healthcare is that _everyone_ has experience with
| the system in every single country, and bad experiences
| get passed around. So we say X country is doing better,
| and someone chimes in explaining how that country has its
| flaws.
|
| They all have their flaws. But the US health system is
| measurably worse than most other developed nations across
| most axes that we care about. Though there are
| interesting questions about how much worse per-capita
| healthcare spend actually is given the comparatively
| higher R&D investment in the US.
| kwhitefoot wrote:
| > you come back a few weeks later. You pay your $20. New
| doctor this time,
|
| That's odd. Here in Norway I can always see the doctor
| with whom I am registered. Very occasionally I'll accept
| seeing a different doctor in the same practice because
| that can mean getting an appointment sooner.
|
| I think you should complain to someone because you are
| clearly getting substandard care.
| speedgoose wrote:
| The Norwegian public healthcare is great. The default
| recommendation to most health issue is to do more sport.
| Being very physically active usually helps, so it's not a
| bad recommendation.
|
| You may experience more pain compared to some other
| healthcare systems. Like France from my experience and
| probably USA from what I read.
|
| I had some unforgettable experiences in Norway, such as a
| colonoscopy without sedation or anaesthesia in case I can
| tolerate the pain. I didn't after a while.
|
| Or some little operation that according to the English
| Wikipedia is done under general anaesthesia in USA. The
| doctor in my local small emergency room simply told me that
| the needle for a local anesthesia would be as painful as
| the operation so it's unnecessary. She then asked a large
| nurse to hold me and I was given instructions about how to
| breathe. I think the doctor may have lied about the pain.
|
| But I pay between $20 and $40 per visit and I don't have to
| pay if it accumulates more than $300 per year. It's also
| not connected to my work, I can be fired and still have the
| same healthcare benefits, forever.
| kwhitefoot wrote:
| > I had some unforgettable experiences in Norway, such as
| a colonoscopy without sedation or anaesthesia in case I
| can tolerate the pain.
|
| What pain? I have had a colonoscopy without any sedation,
| also in Norway. It was uncomfortable, occasionally very,
| but I wouldn't have called it painful. I think you must
| have encountered an incompetent doctor.
|
| Can't imagine why you would want general anaesthesia
| unless it was strictly necessary as it gives an
| additional risk of dying.
| p_l wrote:
| Having worked tangentially on AI that approved payments for
| outpatient ops for one of the companies involved in handling
| German health system...
|
| The very basic design goal was that the AI system could only
| approve, not reject. The goal was that obvious cases should
| be auto-approved, and anything where the AI returned below a
| certain confidence value was booted back to human to make a
| decision (same as pre-AI).
|
| So at least you get that.
| ourmandave wrote:
| [flagged]
| SkeuomorphicBee wrote:
| The USA medical insurance system is missing a "stick" for such
| bogus rejections. Unduly denying a claim should result in a fine
| big enough to be felt in the company balance sheet, that is the
| only way to change companies' behaviours.
|
| , missing some kind of harsh
| avidiax wrote:
| What if we just don't have a stick. The government or a company
| they hire is the party that reviews claims. The insurance
| contacts must have standardized terms and conditions.
|
| This probably wouldn't even really hurt the insurance
| companies. They would not need to compete with each other by
| denying claims on the backend to provide lower prices on the
| frontend.
|
| The current system is a race to the bottom.
| thallium205 wrote:
| The terms and conditions (usual and customary) are already
| there. People just don't know what they are.
| vfclists wrote:
| There a few points to be made here:
|
| 1. The doctors who signed of on those batches should be sued for
| medical malpractice and negligence. Where is the AMA on this
| issue?
|
| 2. Why are the tests so expensive? All it requires is to add some
| chemicals to the blood sample or whatever and see if it changes
| color or something? $1000 of dollars?
|
| 3. Isn't there a trust relationship between Cigna and the doctors
| who authorize the tests? Does Cigna believe that some of its
| doctors have a relationship with the testing companies where they
| receive kickbacks for authorizing the tests?
|
| 4. The patients whose tests were signed of in batches must file a
| class action lawsuits against each doctor separately and Sigma.
| The doctors and Cigna are colluding in medical fraud. Even if
| subsequent indepth evaluations indicate that declining a tests
| was justified they should still be sued as they signed off the
| tests without actually doing the tests for real.
|
| 5. I think American doctors, their healthcare institutions and
| their medical schools have a serious problem with the medical
| ethics if so many doctors are that criminally minded.
| moogly wrote:
| The title is missing "of Dollars". Right now one might mistakenly
| think it implies "of People".
| 32kfjh23 wrote:
| vD is stored in the bones? Author needs to get facts straight as
| that's the first thing you read. Is ProPublica quality going
| down?
| lotsofpulp wrote:
| And still Cigna's profit margins are low single digit
| percentages.
|
| https://www.macrotrends.net/stocks/charts/CI/cigna-group/pro...
|
| Wonder what premiums and out of pocket maximums would have to be
| if there were fewer denials.
| OrvalWintermute wrote:
| If they are paying out huge sums to their c-suite, giving them
| stock left and right, and enriching the company through stock
| schemes or dividend payouts, unjustly, perhaps their
| compensation shouldn't be so rich?
|
| https://www.statnews.com/2022/05/12/health-insurance-ceos-ra...
| lotsofpulp wrote:
| Is their pay out of line with executives in any other similar
| sized businesses?
|
| As far as I can tell from the financial reports, profit
| margins are so low simply because expenses are that high, and
| its across at least 7 publicly listed health insurers.
|
| The main cause of low profit margins that I can tell is high
| healthcare expenses (and lots of competition and state
| regulation so they cannot increase premiums more).
| candiddevmike wrote:
| C-suite, board members, a bunch of "foundations", probably
| some for-profit contracting services for IT and accounting
| (also managed by the c-suite, probably). Unraveling health
| insurance admin costs is probably similar to Panama Papers
| level of financial engineering, especially after the ACA
| capped profit margins, the companies just turned to malicious
| compliance.
| lotsofpulp wrote:
| If you look at the 10-K for any of the 7 publicly listed
| health insurers, administrative cost increases are
| minuscule compared to healthcare expenditures.
|
| You can get rid of half the employees and cut everyone's
| pay by half, and it won't make much difference.
|
| I think the US's biggest problem in healthcare is
| liability. Every entity is spending so many resources on
| making sure that they do not get blamed in the event there
| is a lawsuit, because the damages are huge.
|
| In countries with taxpayer funded healthcare, this
| liability issue is much less because you are dealing with
| the government only and suddenly liability and damage
| amounts are reduced.
| vkou wrote:
| I think we can just go a step further and kill their entire
| toxic business model. After decades of observing how it
| behaves, it should be pretty clear that it's always going to
| devolve down to privately-ran death panels.
| GiorgioG wrote:
| 15 years ago I worked for a "non-profit" health insurance
| company that was a Blue Cross Blue Shield affiliate/franchise.
| The CEO made $2.1m/year while the other VPs were raking in >
| $1m. The IT organization was as backward as they come - 200+
| full time employees. I got in trouble for trying to introduce
| using source control to their developers. Beyond that, they
| used Excel spreadsheets as the source of truth for their
| healthcare plans...and the spreadsheets fed the claims
| processing system. There were 20 dedicated employees to
| managing Excel spreadsheets.
| [deleted]
| eapressoandcats wrote:
| For all the crappy stuff insurance does, their medical loss
| ratio for group insurance is pretty good. The actual problem is
| that healthcare costs way more in the US than most other
| countries. Health insurance just ends up getting the blame for
| that.
| missedthecue wrote:
| I tend to agree. People love to blame insurers for the
| difference in price between US and (other country) healthcare
| prices, without any mention of facts like US nurses earning 4
| to 8 times as much as an average NHS nurse, or that half a
| trillion dollars goes to end of life care in the US every
| year, i.e. spending $70,000 to extend an 85 year life 3 more
| months.
|
| Income = expenditure. They are one and the same. Every dollar
| spent on healthcare in the US is someone else's income and
| looking at the profit margins, 'someone else' doesn't seem to
| be the insurers.
| cmiles74 wrote:
| IMHO, the push-and-pull between insurance companies and
| hospitals is a big problem here. They seem to be in a co-
| dependent battle to consistently raise the costs of
| everything. I don't think any solution to managing cost will
| succeed unless we're altering the incentives for both
| insurance companies and hospitals.
| netmonk wrote:
| [dead]
| Logans_Run wrote:
| Free Market, Self-Regulation, Share-Holder Value.
|
| My Friends, The Revolution is near. There comes a time when the
| common man can no longer stand idly by and watch as their
| brothers and sisters (and themselves) continue to be screwed
| over.
|
| There are many amongst you that fear speaking out in the vain
| hope that some day that they will get their share of 'the Good
| Life'. I regret to inform you that if it was going to happen, it
| would have happened to you by now.
|
| Don't remain silent nor inactive in fear of rocking the boat, the
| 'they' are mocking you and holding out a carrot on a stick while
| you blindly plod on in the hope of 'some day'.
|
| Do what you can, when you can. Even the smallest ant can overcome
| an elephant.
|
| Do not be discouraged nor disheartened if you feel there is
| nothing you can do. That is what the 'they' count on.
|
| Enough of this Shit!
| whatthesmack wrote:
| There's no free market for healthcare in the US. What you mean
| is crony capitalism and corruption. If there was a free market
| for healthcare and health insurance in the US, it wouldn't be
| so expensive.
| woohoo7676 wrote:
| This has been happening to me for the past several months.
|
| 1. Cigna will not tell you for any reason, why the claim is
| denied
|
| 2. Reps will not help at all other than "Oh I see the issue, will
| reprocess" which often just results in another denial
|
| 3. The issue that a helpful rep finally disclosed: Cigna's own
| claim form for providers has a box that is overloaded for
| procedure code and equipment code; apparently the CPT code for
| therapy is the same as the equipment code for injections.
|
| So one claim processor decided that the claim was for injections
| and denied it. Then every subsequent claim has been denied under
| the same reason.
|
| 4. At this point the only option for me is for my provider to
| appeal every single claim (which takes months), as this is the
| only way to get someone to actually read the claim and make an
| intelligent decision.
|
| An absolute nightmare :(
| kurikuri wrote:
| I always wonder if small claims court could be somewhat viable.
| In the instances where I've fought and gotten approval, I've
| spent my own time, my own money, and had my health deteriorate.
| Ideally, I'd like to be compensated for the time I've spent
| defending myself to this company, and I'd like some form of
| remuneration (somewhat for retribution, somewhat as a negative
| incentive to the company) for my now diminished health...
| firstlink wrote:
| If you have health insurance from your employer, it's
| probably covered under ERISA. This is federal, so no help
| from your state insurance agency and no small claims, and I
| have found that there are few lawyers who will touch it even
| in a large city.
| Kye wrote:
| There needs to be something like the CFPB for health care. I
| couldn't get an actual human to acknowledge me when dealing
| with PNC when they ate up my bank, but one CFPB complaint got
| them to do exactly what I asked. That way you never get to
| the point of burning time, money, and health because they're
| afraid of action from the agency.
| lotsofpulp wrote:
| It would be the state's insurance regulator, although do
| not know if they are as effective as CFPB. Financial issues
| tend to be much less complicated than health issues, and
| usually just a result of understaffing and underinvesting
| in customer service.
| woohoo7676 wrote:
| Great idea - agreed we need an agency to go to that has
| some teeth, as the insurance co's will never be afraid of
| individuals.
| indymike wrote:
| > 1. Cigna will not tell you for any reason, why the claim is
| denied
|
| Of course not. Fight fire with fire. Get care providers to sign
| a letter to Cigna saying the procedure is medically necessary
| Going through the process will not work and will go slow. But
| putting them on notice by having licensed, local care providers
| say something is medically necessary and urgent will work
| almost 100% of the time.
| bombcar wrote:
| And blatantly copy your state's insurance regulatory
| department. Insurers LOVE that.
| hughw wrote:
| Where are the professional bodies for physicians in all this?
| These doctors seem to be using their medical credentials to get
| paid for fake work.
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