[HN Gopher] You have a right to know why a health insurer denied...
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You have a right to know why a health insurer denied your claim
Author : srameshc
Score : 305 points
Date : 2023-11-09 17:19 UTC (5 hours ago)
(HTM) web link (www.propublica.org)
(TXT) w3m dump (www.propublica.org)
| convolvatron wrote:
| isn't that kind of pointless? they are denying your claim because
| its their goal to reduce costs. any justification is just going
| to point to some made up excuse or insanely complicated internal
| policy designed for obfuscation. you could demand they publish
| those policies, but how are you going to guarantee that they are
| finite and parsable by humans? look a the text of voting
| referendums for an example, or cell phone contracts.
| quadrifoliate wrote:
| > any justification is just going to point to some made up
| excuse or insanely complicated internal policy designed for
| obfuscation.
|
| I don't see how you can claim that without seeing all the
| records in question. Maybe it was deliberately obfuscated,
| _maybe someone just screwed up_. Guess what, human error is a
| thing. In fact, the article itself showcases a bunch of human
| errors -- those of people not knowing that their employer is
| required by law to provide claim files within 30 days.
| Zigurd wrote:
| There might also be a teakettle on the far side of the Moon.
| whoomp12341 wrote:
| you haven't fought a claim yet, have you.
|
| Its beyond infuriating, especially when you are on the hook
| for a large bill
| dboreham wrote:
| Beyond infuriating is when the Dr requests pre-approval
| then does the procedure and _then_ they deny it. And keep
| denying they approved it even after the hospital has
| revealed they record all calls with insurance companies,
| and they have the recording where the procedure was pre-
| approved.
| CocaKoala wrote:
| Eh, we're currently fighting to get some claims covered.
| Before a certain date, all the claims are denied; after a
| certain date, all the claims are approved. The claims are all
| for the same thing, related to the same procedure (physical
| therapy after a joint replacement).
|
| Could the claims have been rejected due to a simple human
| error? Sure, it's plausible. Was there another human error
| that caused the claims to be rejected after we appealed?
| Maybe, but probably not. Could a third human error cause the
| claims to be rejected again after our second appeal? Seems
| pretty unlikely.
| nerdjon wrote:
| ok great, so I should get to know why things get denied.
|
| Maybe... they just can't deny without a reasonable alternative
| that your doctor agrees with? Like fine deny name brand
| prescription for generic.
|
| The idea that your Doctor... who actually knows what is going on
| wants to do something and your Insurance can just say no is
| ridiculous.
|
| If we are so worried about Doctors doing unnecessary things to
| get money from Insurance than lets tackle that also.
| vondur wrote:
| My childhood doctor in the late 70's hated insurance companies
| over this. I'd hear him on the phone arguing with the insurance
| company reps asking if they had a MD Degree and would like
| explain the denial to him. Interesting to hear back in the day.
| nerdjon wrote:
| I have to imagine many do, it sucks since what the hell are
| their options. I would like to think that most doctors at
| least care somewhat. I can't imagine how they feel if they
| think someone truly needs something and insurance just says
| no.
|
| I know my sister at one point was having some critical
| medication for her denied so the doctor just kept giving her
| sample packs.
|
| I went through an issue with a medication for me and it was
| still never resolved.
| nradov wrote:
| In many cases that issue can be resolved through an appeals
| process. But this takes extra time for providers, and they
| don't get paid for that.
|
| Insurers may also require step therapy. Try a cheaper
| treatment first, then if the patient fails to respond they
| will authorize a more expensive option.
| nerdjon wrote:
| I call bullshit.
|
| I went through multiple appeal processes, my doctor tried
| to file multiple on my behalf, I called, and nothing.
|
| They don't care.
| RankingMember wrote:
| Sounds like you had a good doc. These days it seems like the
| insurance companies have won- every doctor I talk to has the
| most beaten-down expression when I ask them about coding and
| their relationship with insurance companies. For most I talk
| to, they got into medicine to help people, but find
| themselves spending a frustrating amount of their time
| fighting with insurance.
| LesZedCB wrote:
| the youtube channel dr glaucomflecken did a series on this
| that were pretty funny
|
| https://www.youtube.com/watch?v=Vp7u58R41N8&list=PLpMVXO0Tk
| G...
| vondur wrote:
| Yeah, he was a cantankerous one. Always telling my Mom to
| quit smoking while he himself would be smoking at the same
| time. The 70's were an interesting time to be a child.
| nradov wrote:
| Payer coverage rules typically do include that. This is known
| as step therapy. If a physician requests prior authorization
| for a branded medication then the insurer might deny it and
| recommend trying the generic alternative first.
|
| A lot of these issues arise because providers fail to review
| payer coverage rules before deciding on a treatment plan. And
| in fairness to providers, this takes extra time which they
| don't get paid for and the rules are inconsistent between
| payers. The new HL7 Da Vinci Project prior authorization burden
| reduction standards can help automate this to an extent by
| giving providers an API to check coverage rules in real time.
|
| https://www.hl7.org/fhir/us/davinci-crd/
|
| At a fundamental level, medical insurance has to involve some
| form of cost control and care rationing. Much of what insurers
| do is preventing waste, fraud, and abuse by verifying that
| treatments are medically necessary as per current best
| practices and balancing costs versus benefits. Unfortunately,
| patients sometimes get caught in the middle.
| bugglebeetle wrote:
| > Much of what insurers do is preventing waste, fraud, and
| abuse
|
| Medical insurers are the waste, fraud, and abuse.
| lotsofpulp wrote:
| US government employees would be doing the same things for
| Medicare and Medicaid and Tricare.
|
| Outsourcing that work to "insurers" helps keep the heat off
| the politicians.
| coredog64 wrote:
| Not true for Medicare. How it works is that Medicare
| splits the US up into regions (can't remember if it's
| currently 5 or 7). For each of these regions, a private
| medical insurance company handles all of the claims
| paperwork and the money for said claims comes from Uncle
| Sugar. This is also why it's disingenuous when folks trot
| out the "claim dollars per Federal employee" argument for
| Medicare.
|
| Note: I'm not talking about Medicare Advantage which is a
| separate program whereby Medicare pays the premiums for
| private health insurance plans.
| lotsofpulp wrote:
| It seems like we are in agreement.
| nradov wrote:
| I'm not sure what you mean there. Even Medicare in the US
| and single payer systems in other countries have strict
| rules to prevent waste, fraud, and abuse. They will refuse
| to pay claims that don't comply with coverage rules. In
| many cases those are even more strict than US private
| medical insurers.
| bugglebeetle wrote:
| What I mean is that what insurers do is try to screw
| people out of money and receiving necessary treatment to
| line their own pockets. Here's a fairly concrete example:
|
| https://www.propublica.org/article/unitedhealth-
| healthcare-i...
| nradov wrote:
| Insurers do deny some claims and authorization requests,
| but in most cases this doesn't line their own pockets.
| Rather the opposite. Most large employers are now self
| insured, and the medical "insurance" companies just
| administer claims. Due to the 85% minimum medical loss
| ratio imposed by the Affordable Care Act (Obamacare),
| insurers actually make _more_ profit when they approve
| more treatments.
|
| When claims or authorizations are denied it's generally
| because large employers have been pushing back to control
| their own costs. Unfortunately, many consumers don't
| understand this market dynamic and direct their blame in
| the wrong direction.
| bugglebeetle wrote:
| Apologies, but this is complete bullshit. They make money
| by denying expensive claims, regardless of whether or not
| people actually need the treatment, and optimize for this
| despicable behavior.
| nradov wrote:
| I have given you accurate information. If you choose to
| remain ignorant then that is your affair. The reality is
| that payers that offer health plans to self-insured
| employers don't make money by denying claims.
| bugglebeetle wrote:
| No, you've intentionally tried to deflect and deceive
| across this entire thread, as is obvious from all the
| downvotes and comments you've received. It's quite bold
| to lie and say insurance companies don't deny claims to
| make money, since there are only myriad news stories,
| court cases, books, films, etc about them doing so, but
| you do you.
| nerdjon wrote:
| > A lot of these issues arise because providers fail to
| review payer coverage rules before deciding on a treatment
| plan. And in fairness to providers, this takes extra time
| which they don't get paid for and the rules are inconsistent
| between payers. The new HL7 Da Vinci Project prior
| authorization burden reduction standards can help automate
| this to an extent by giving providers an API to check
| coverage rules in real time.
|
| I'm sorry but how with a straight face can you really write
| this paragraph. The Doctor, the person who is seeing you
| needs to check a system of what you they are authorized to do
| for you? That is dystopian.
|
| FFS we had an episode of this on Star Trek Voyager showing
| how bad this system is and yet that is exactly what we do.
|
| What you are describing id disgusting, end of story. There is
| no justification of any of this.
|
| Are there corrupt doctors? Sure. But insurance should not
| have a right to say what can and cannot be done if here is a
| good reason and it should be an actual discussion instead of
| Insurance having all of the power. ALL
| nradov wrote:
| You're arguing with the wrong person. I gave you accurate
| information about how the system works today, and a
| reference to technical information that hackers can use to
| mitigate certain problems. And I can do that with a
| straight face.
|
| Technically insurers don't say what treatments can and
| cannot be done. Their role is purely financial. Patients
| can always pay out of pocket, and some do. But in practice
| an insurance denial does sometimes leave low income
| patients without access to care.
|
| Ultimately though there does have to be some system for
| rationing care. Demand is effectively infinite and
| resources are finite. Even countries with single payer or
| socialized medicine restrict which treatments they make
| available, and often restrict patient access to expensive
| treatments by imposing queues.
|
| I didn't claim that the current system is a good one. I
| have no power to change it. Any real solution will have to
| be mainly political so complain to go take your proposals
| to Congress.
| standardUser wrote:
| "A lot of these issues arise because providers fail to review
| payer coverage rules before deciding on a treatment plan"
|
| A system wherein the trained professional with direct access
| to the patient has to defer to a board of anonymous
| bureaucrats to determine the course of treatment is absurd.
| These issues don't arise because "providers fail" they arise
| because the system is built to fail and the burden falls on
| everyone except the people making the rules (and the profit).
| bugglebeetle wrote:
| It's even worse than that: now they have a bunch of corrupt
| medical practitioners who they use to rubber stamp denials to
| make them more legally defensible. Most often, they're
| literally just clicking "CONFIRM" on some machine-generated
| auto-denial.
| FireBeyond wrote:
| Very much so. They'll get presented with several bullet
| points of reasons for denial based on their system, and be
| asked "do you see any need to disagree with this reasoning?"
| rather than any form of differential workup.
| ncallaway wrote:
| I've long believed that denials that come from an insurance
| company should be required to:
|
| - come from an individual doctor (not just be signed off, but
| the doctor originates the denial)
|
| - the doctor must be personally named and identified to the
| patient as the party responsible for the denial
|
| - that doctor is *personally* and *professionally* liable for
| harms that befall the patient from a wrongful denial
| ceejayoz wrote:
| I'd add a requirement that said doctor have practiced in the
| relevant specialty within the last decade.
| haneefmubarak wrote:
| This simply incentivizes a rapidly revolving door between
| practice and insurance, with a likely effect of making the
| actual practioners as a populace more friendly to the
| insurance companies in general (in expectation of quid pro
| quo).
| ceejayoz wrote:
| There's something deeply wrong when a gastroenterologist
| who hasn't seen a patient in person for decades can deny
| a neurosurgical procedure.
|
| Maybe you make it like jury duty; if you're a practicing
| doc, you periodically get randomly assigned some appeals
| in your speciality to review.
|
| The _current_ system already has a massive quid-pro-quo;
| if you aren 't willing to spend 1.2 seconds to deny tens
| of thousands of claims a month (not an exaggeration!
| https://www.propublica.org/article/cigna-pxdx-medical-
| health...), they'll find someone else. The docs and
| companies doing these "independent" reviews are
| completely captured by the industry already.
| JumpCrisscross wrote:
| > _Maybe you make it like jury duty; if you 're a
| practicing doc, you periodically get randomly assigned
| some appeals_
|
| Or send appeals to a committee of randomly-rotating
| reviewers. The state could administer the service to
| promote fairness and lessen the cost to the insurer.
| munk-a wrote:
| As someone close to the insurance industry I suspect this
| would just lead to a revolving door of Doctor Nicks that get
| cushy jobs for life and sip margaritas by the pool while
| their "reputation is ruined" - we need a better approach than
| this like (similar to Canada) having national guidelines for
| treatment that for the payer to act responsibly. You don't
| want to know just how many bodies UHC is willing to throw
| under a bus in order to make .5% more money.
| jjk166 wrote:
| Set it up so if you make a mistake, you're suspended from
| being able to issue any denials for a month. Make a second
| mistake, 2 months. 3 mistakes, 4 months. 4 mistakes, 8
| months... In a 40 year career each Doctor Nick would only
| get 9 mistakes. Maybe a month suspension for a first
| offense is too harsh; let's say a day instead, that's still
| only 14 mistakes in a career. Is the money saved from that
| handful of extra denials going to justify the cost of
| taking care of those doctors for life?
| vkou wrote:
| > The idea that your Doctor... who actually knows what is going
| on wants to do something and your Insurance can just say no is
| ridiculous.
|
| Death panels for a captive market, so it's all good.
| spondylosaurus wrote:
| One thing that's bit me in the ass repeatedly with insurance
| claims is that the people approving/denying claims aren't
| doctors, and the people you have to fight to appeal a denied
| claim are _definitely_ not doctors. So even if you know the
| grounds for denial, sometimes the reason is bullshit and flies in
| the face of the insurer 's own policies.
|
| I spent months fighting a claim for mesalamine DR tablets (and
| getting nowhere) only to discover that the insurance personnel
| were treating it as a different claim for mesalamine EC capsules
| --a totally distinct formulation. Any doctor or pharmacist could
| tell you that they're not equivalent. But they had different
| approval criteria in the insurance system, and even though I met
| the criteria for the former (the drug I wanted) they kept denying
| me for not meeting the criteria of the latter (the drug I did not
| want).
|
| But those are both oral forms. I think if they'd tried to run the
| claim as the suppository version, the error would've been more
| obvious.
| ceejayoz wrote:
| Even when they are a doctor, it doesn't matter.
| https://www.propublica.org/article/cigna-pxdx-medical-health...
|
| > Over a period of two months last year, Cigna doctors denied
| over 300,000 requests for payments using this method, spending
| an average of 1.2 seconds on each case, the documents show.
| spondylosaurus wrote:
| 1.2 seconds! Well they're sure putting that med school
| knowledge to use, huh.
| ceejayoz wrote:
| Yep. Don't worry, though; if they slip up and _do_ fund
| your expensive treatments, all of a sudden they have _lots_
| of time to focus on you.
|
| https://www.propublica.org/article/unitedhealth-
| healthcare-i...
|
| > At one point, court records show, United inaccurately
| reported to Penn State and the family that McNaughton's
| doctor had agreed to lower the doses of his medication.
| Another time, a doctor paid by United concluded that
| denying payments for McNaughton's treatment could put his
| health at risk, but the company buried his report and did
| not consider its findings. The insurer did, however,
| consider a report submitted by a company doctor who rubber-
| stamped the recommendation of a United nurse to reject
| paying for the treatment.
|
| > But the records reviewed by ProPublica show that United
| had another, equally urgent goal in dealing with
| McNaughton. In emails, officials calculated what McNaughton
| was costing them to keep his crippling disease at bay and
| how much they would save if they forced him to undergo a
| cheaper treatment that had already failed him. As the
| family pressed the company to back down, first through Penn
| State and then through a lawsuit, the United officials
| handling the case bristled.
| NickC25 wrote:
| Horrifying. Those "insurers" are absolute scumbags. Poor
| guy, I feel awful for him.
| JumpCrisscross wrote:
| > _Those "insurers" are absolute scumbags_
|
| It's complicated. On the other hand are fraudsters and
| private-equity owned hospitals maxing the bill button. If
| the insurer is lax with payouts, it depletes its capital
| and could be left insolvent. It's a scummy system more
| than a system of scumbags. (To be clear, there are
| scumbag insurers. But it's reductive to cite that
| generally, or designate it as the source of the system's
| troubles.)
| justinclift wrote:
| Taking 1.2 seconds to review claims means they are
| _without any question_ "doing something wrong".
|
| "Remaining solvent" doesn't seem to be the goal, rather
| "maximising quarterly bonuses regardless of lives
| destroyed" seems a more fit description.
| JumpCrisscross wrote:
| > _Taking 1.2 seconds to review claims means they are
| without any question "doing something wrong"_
|
| Nobody said they aren't. The point is, given the volume
| of claims, to do a proper analysis, we'd need a material
| fraction of doctors doing insurance reviews (instead of
| seeing patients). So we get a reliance on heuristics.
|
| If you're lenient, you get targeted by fraudsters. So we
| get a bias towards denial. (Nobody is getting a material
| quarterly bonus for denying a few more claims. That
| nonsense occurs at the level of PBMs and other scale
| operations.)
| justinclift wrote:
| > If you're lenient, you get targeted by fraudsters.
|
| So in this scenario, it sounds like the fraudsters are
| the medical insurance companies, and the group being
| lenient are the regulators.
|
| A place taking (on average) 1.2 seconds to review each
| claim shouldn't be in business.
| OfficialTurkey wrote:
| We have a system where doctors and nurses review
| medications and treatment options for patients. It's
| called _the medical system_. You know, the one where I
| can go see my doctor, talk to them about what's going on,
| and work with them to create a treatment plan that suits
| my problems and my goals.
|
| Why do we need to bolt on a secondary system that sucks
| up an untold wealth of time and money?
| lotsofpulp wrote:
| https://www.beckersspine.com/orthopedic/54193-fake-
| orthopedi...
|
| https://www.pbs.org/newshour/health/feds-break-
| up-1-2b-medic...
|
| https://www.fbi.gov/contact-us/field-
| offices/dallas/news/pre...
|
| https://www.cnn.com/2023/06/28/politics/doj-health-care-
| frau...
| ceejayoz wrote:
| Small potatoes.
|
| https://www.axios.com/2023/06/14/medicare-advantage-
| overpaym...
|
| > Overpayments to insurers administering Medicare
| Advantage plans now exceed $75 billion a year due to
| aggressive coding of patients' health conditions and
| easily-achieved bonus payments tied to quality,
| researchers with the USC Schaeffer Center for Health
| Policy & Economics found.
| lotsofpulp wrote:
| Insurers are not the ones coding, it is the healthcare
| providers. And the government is the one deciding to pay.
|
| If anything, that would mean more claims should be
| denied.
|
| Looking at the study, it seems like the government made
| some erroneous assumptions about who would be taking
| advantage of the policies the government created,
| resulting in the extra costs. (Third paragraph of "policy
| context" section).
|
| https://healthpolicy.usc.edu/research/ma-enrolls-lower-
| spend...
| ceejayoz wrote:
| Nope. https://www.nytimes.com/2022/10/08/upshot/medicare-
| advantage...
|
| > Anthem, a large insurer now called Elevance Health,
| paid more to doctors who said their patients were sicker.
| And executives at UnitedHealth Group, the country's
| largest insurer, told their workers to mine old medical
| records for more illnesses -- and when they couldn't find
| enough, sent them back to try again.
|
| > Each of the strategies -- which were described by the
| Justice Department in lawsuits against the companies --
| led to diagnoses of serious diseases that might have
| never existed. But the diagnoses had a lucrative side
| effect: They let the insurers collect more money from the
| federal government's Medicare Advantage program.
|
| > Eight of the 10 biggest Medicare Advantage insurers --
| representing more than two-thirds of the market -- have
| submitted inflated bills, according to the federal
| audits. And four of the five largest players --
| UnitedHealth, Humana, Elevance and Kaiser -- have faced
| federal lawsuits alleging that efforts to overdiagnose
| their customers crossed the line into fraud.
| lotsofpulp wrote:
| That is just clear fraud, and I don't understand how that
| is a lawsuit instead of felony charges for everyone
| involved.
| iamjackg wrote:
| If a business can't handle its own scale without
| negatively affecting its customers, it should probably
| stop growing. It's the same issue we see with Google
| accounts being seemingly randomly terminated.
|
| Since that probably won't happen, heuristic usage should
| at least come with penalties attached, otherwise the
| incentives are lopsided. If an airline's overbooking
| heuristics fail and get you bumped, you either get put on
| another flight and/or receive financial compensation. If
| an insurance company's "heuristics" fail and deny a
| legitimate claim, there should be a penalty. If Google
| terminates your account because of a mistake, they should
| pay a fine. They shouldn't be allowed to have their cake
| and eat it too.
| JumpCrisscross wrote:
| > _If a business can 't handle its own scale without
| negatively affecting its customers_
|
| The scale probably helps. The point is if every billable
| decision is medically reviewed for more than a few
| seconds, a material fraction of the healthcare workforce
| needs to be diverted from patients to review.
|
| There is simply no solution, given the current industrial
| structure, to avoid some combination of non-expert, high-
| speed review without making even stupider trade-offs.
| NoraCodes wrote:
| Sounds like we need to replace the structure, given that
| it's not fit for purpose.
| JumpCrisscross wrote:
| > _Sounds like we need to replace the structure, given
| that it 's not fit for purpose_
|
| We soundly agree. Health insurance, where risk is pooled,
| makes sense. Health "insurance," where payments are
| pooled with a bunch of needless intermediation, is
| unnecessary.
| sohex wrote:
| I think you could make fundamentally the same argument
| for a great number of the issues in the world today. It's
| a huge web of banal evils. That doesn't mean that it
| excuses the behavior of any given cog in that machine
| though. If we allow blame to be passed on indefinitely
| because everything is broken then nothing will ever be
| fixed.
| JumpCrisscross wrote:
| > _If we allow blame to be passed on indefinitely because
| everything is broken then nothing will ever be fixed_
|
| Or we can skip scapegoating and fix the system. This is a
| fundamental lesson from aviation crash analysis: the goal
| should be a better system, _not_ assigning blame.
| ceejayoz wrote:
| I suspect the Germanwings Flight 9525 crash investigation
| assigns _some_ blame to someone. There 's a difference
| between accidents and deliberate action by motivated
| actors.
| kurthr wrote:
| Remember, the insurance companies are HAPPY to pay higher
| prices (in fact they have forced many small ObGyn into
| more expensive hospital practice) as long as their
| competitors do too!
|
| Health Insurance companies grow their bottom line by
| growing the topline cost of healthcare since they're
| margins are limited.
| cycomanic wrote:
| United healthcare in 2022 had $324 billion revenue (up
| from $75 billion in 2007) and profits of $20 billion
| (both up >15% year on year). There is absolutely no risk
| that they become insolvent.
|
| https://www.statista.com/statistics/214504/total-revenue-
| of-...
|
| https://www.healthcaredive.com/news/unitedhealth-2022-ear
| nin...
| gustavus wrote:
| I'm assuming that the drs who end up as insruance claim
| evaluation drs are the Dr. Murphy's of the world who
| everyone decided it would be better if they weren't
| actually practicing medicine.
| ceejayoz wrote:
| Yes. Which makes it darkly ironic that the end result is
| them practicing medicine on tens of thousands of people a
| month each.
| yborg wrote:
| In many cases these doctors aren't practicing physicians,
| iirc the reviewer in the article hadn't practiced for 25
| years. They just need someone with an MD to sign off on the
| denials.
| carbocation wrote:
| My view is that these people and companies are practicing
| medicine and should start being held to the standard of
| care.
| MichaelZuo wrote:
| Since you have some experience in the field, How do you
| see your views becoming reality?
| gustavus wrote:
| Ya there is a Grisham novel about this exact thing. I hope
| the people involved in Cigna all have their spouses leave
| them, their children disown them, and then get their car
| towed.
| smnrchrds wrote:
| What's the name of the novel?
| ceejayoz wrote:
| https://en.wikipedia.org/wiki/The_Rainmaker_(novel)
| hotpotamus wrote:
| What if their spouses and children like having food and
| health insurance of their own?
| rqtwteye wrote:
| How are these guys allowed to stay in business? Hospitals and
| insurances make many "mistakes" in their favor and leave it
| up to the patient to navigate this kafkaeske bureaucracy. I
| understand making some honest mistakes but this stuff is just
| plain fraud.
| kurthr wrote:
| The combination of paying of pocket or face horrific
| medical consequences along with ERISA limiting legal claims
| makes it unlikely the insurance companies face any
| consequences to their actions.
|
| Unless you're a wealthy litigation attorney who has friends
| that will rack up enormous bills as insurance takes it to
| federal appeals court.
|
| https://www.propublica.org/article/blue-cross-proton-
| therapy...
| scythe wrote:
| One thing that's especially egregious about the situation
| in RadOnc is that there are plenty of situations where
| the doctors and physicists have already planned a
| treatment, billing $xxx per hour, and only then it is
| denied by insurance, so the hospital counts this as a
| loss and plans another inferior treatment, increasing the
| cost, in order to offer a "cheaper" procedure as demanded
| by the insurance company. The losses are of course
| amortized to drive up the cost of all treatments while
| the patients are given inferior care.
|
| It's absolutely infuriating. A friend who is a therapy
| physicist left the country and went back to work in
| Canada taking a 40% pay cut because he couldn't stand it
| anymore.
| autokad wrote:
| I think the solution to most problems is make the c-suite
| criminally responsible for errors. Things will resolve
| themselves
| spondylosaurus wrote:
| Enthusiastically agree, but considering how much political
| lobbying comes from health insurance giants I have no hope of
| it happening in my lifetime.
| NickC25 wrote:
| I think an even better solution is for our society to just
| admit that health insurance companies can't exist as for-
| profit entities that have to answer to Wall Street first and
| foremost.
|
| Think about it. A health care company collects money under
| the premise that "these premiums you're paying will cover you
| if something bad happens". If that something bad _does_
| happen (and for most people, it never will), that money
| should be available to pay for whatever happened. The
| insurer, now concerned about their margins and profits more
| than _providing you the service that you 've already paid
| them to do_, just gets to trot out some poorly paid rep with
| no medical knowledge to override the medical advice of a
| trained medical professional. Now, you're not only injured,
| you're paying out of pocket for a service that won't actually
| do what you've paid it to do. The only winner here is the
| insurer's C-Suite and stockholders who get to brag on
| quarterly earnings calls that they've denied tens of
| thousands of claims (and they even get fiscally rewarded for
| it!).
|
| In a more modern and honest society we would call for-profit
| insurers what they actually are: a racketeering organization
| operating under the guise of fraud.
| bugglebeetle wrote:
| I agree if you stop at "health insurance companies can't
| exist." Being a nonprofit doesn't stop you from being
| parasitic or malevolent.
| lotsofpulp wrote:
| That does not solve the root problem.
|
| The root problem is healthcare is an extremely complex
| field, requiring extremely specialized knowledge that takes
| extreme investment to get. And everyone wants it, the
| demand is infinite and the demand has no elasticity.
|
| So a buyer of healthcare has a problem. They have no idea
| what they are buying, and have no idea if the seller is
| scamming them or incompetent. So you need a second opinion.
| But as stated above, people who can provide this opinion
| are few and far between.
|
| It is not like paying $100 to get a second opinion on your
| car. It is more like paying $500 to $10,000 or who knows
| how much to get a second opinion.
|
| So the root problem is people simply cannot afford the
| level of healthcare they desire. Everything else is just
| papering over that intractable problem.
| burkaman wrote:
| > They have no idea what they are buying, and have no
| idea if the seller is scamming them or incompetent.
|
| It's worse than that, important healthcare decisions are
| often made while you are unconscious, and you just have
| to pay for whatever choice was made. Not only do you not
| know what you're buying, you don't even know a purchase
| is being made.
|
| I am convinced that it doesn't make sense to discuss
| healthcare as if it is a market. Patients are not
| "buyers". You pass out, some random person calls 911 and
| they send a private ambulance, you wake up at the
| hospital, and now you owe money to the ambulance company.
| In what sense have you "bought" anything? There has to be
| more to the definition than just "money is involved". We
| don't talk about the parking ticket market or the
| taxation market (just move to a different country if you
| aren't satisfied with your taxation provider!), and we
| shouldn't talk about the healthcare market.
| lotsofpulp wrote:
| That is a good point, but unless people work for free,
| someone is selling and someone is buying. While you might
| not have explicitly bought anything, your agent (whether
| it be family or the government) did buy something.
|
| More broadly, anytime you are dealing with limited
| resources (including time), you have to be buying and
| selling (i.e. there are opportunity costs to making a
| decision).
|
| > We don't talk about the parking ticket market
|
| You cannot buy a parking ticket, so this is not
| comparable. However, people do often calculate the cost
| of legally parking versus the probability * cost of
| potential fines.
|
| >or the taxation market (just move to a different country
| if you aren't satisfied with your taxation provider!)
|
| This happens all the time, but everyone may not have the
| means to do it. It was one of the factors for my
| relocation within the US.
|
| Even businesses use it to determine where to expand or
| close operations. Warren Buffett mentioned it in his
| annual letter some years ago.
| burkaman wrote:
| I agree that someone is buying and selling, what I mean
| is that it doesn't make sense to talk about healthcare
| recipients as participants in a market. Obviously
| firefighters purchase equipment and sell their labor to
| the government, but we don't refer to homeowners as
| buyers in a firefighting market. If we forced them to pay
| a fee after being saved from a fire, that wouldn't
| somehow constitute a market. The same is true for any
| other essential government service: we created socialized
| systems because they can't function as markets.
|
| > You cannot buy a parking ticket
|
| Exactly, just like you can't buy an unexpected medical
| bill. You still have to pay it though.
|
| The fact that rich people sometimes choose to accept a
| parking ticket or choose to purchase citizenship in a
| more favorable tax environment is not evidence of a
| market, in fact it's the opposite. If 99% of "buyers" are
| forced to participate but have 0 decision-making power,
| and a handful of rich people are able to (sometimes) shop
| around, you are not describing a market.
| lotsofpulp wrote:
| I think this conversation is going off track. For the
| purposes of determining prices for healthcare, there
| exists a market, even if the person receiving the
| healthcare is not paying.
| orangecat wrote:
| _important healthcare decisions are often made while you
| are unconscious, and you just have to pay for whatever
| choice was made_
|
| This is a problem, but it's not a major driver of health
| care expenses. Emergency care is around 5% of total
| spending: https://www.healthaffairs.org/doi/10.1377/hltha
| ff.2022.01287
| burkaman wrote:
| It looks like that figure doesn't include ambulance
| charges, which is the example I had in mind when I wrote
| that sentence. It also doesn't include decisions made
| during non-emergency surgery, which still might be
| necessary to stay alive even though you aren't in the
| emergency department. It of course doesn't include
| medication and followup care resulting from whatever
| unconscious decisions were made.
|
| Regardless, I don't believe determining an exact
| percentage is relevant to this discussion. I'm not an
| economist, but every definition of "market" I can find
| says something like "a system where two parties can
| engage in a transaction". If there's a significant chance
| that one of the parties is unconscious and/or about to
| die, they are not engaging in a transaction any more than
| a mugging victim is. 5% is the chance of rolling a 1 on a
| d20, that is certainly significant.
| MichaelZuo wrote:
| Can you link one such definition?
| ToucanLoucan wrote:
| > The root problem is healthcare is an extremely complex
| field, requiring extremely specialized knowledge that
| takes extreme investment to get. And everyone wants it,
| the demand is infinite and the demand has no elasticity.
|
| I'm sorry but this statement flies rather in the face of
| 22 other industrialized modern nations that have managed
| _some type_ of publicly funded healthcare. The United
| States being the _one that hasn 't,_ along with also
| being the richest nation in that group, along with
| already spending the most among that group per patient by
| a wide, wide margin and getting by far and away the
| shittiest service in return.
|
| We're also unique in that we're the only nation which
| hosts slap fights between hospitals and insurers that
| last months and leave patients wondering as they recover
| from whatever went wrong for them if they're going to owe
| $20 or $20,000.
|
| Now, do those other 22 nations have completely perfect
| healthcare systems? No, of course not. But to say "well
| it's just too complicated" and throw up your hands is
| just shit. You know what else those other nations don't
| have? They don't have people going bankrupt from being in
| a car accident _that wasn 't even their fault._
|
| And you know what is also unique among the United States?
| We're the only ones in that group who have several
| corporations with fully seated C-suites raking in
| billions of dollars off a service people literally cannot
| live without. So it seems to me, removing that part first
| is a solid first step.
| lotsofpulp wrote:
| The grandparent comments are discussing the approval or
| denial of claims, which also happens in countries with
| other systems of publicly funded healthcare. It might not
| be called a claim and done by an insurance company, but
| the government will have some type of system to evaluate
| appropriate/affordable expenses.
|
| The problem of insufficient resources exists in other
| countries too, but of course they may be managing it
| better.
| nradov wrote:
| That's not actually how the industry works in the general
| case. Health "insurance" companies no longer provide much
| insurance. Instead they mainly just create provider
| networks and administer claims on behalf of self-insured
| group buyers (mainly employers and unions). The remaining
| fully insured market is relatively small.
|
| Health insurers have low profit margins. You can read their
| audited financial statements for the publicly traded ones.
| Some are even non-profit. The Affordable Care Act
| (Obamacare) set a minimum 85% medical loss ratio. The
| insurers have to cover their operating costs and profit
| margins out of the remaining 15%. Even if we were to
| replace commercial insurers with some sort of "Medicare for
| all" system that would have only a marginal impact on costs
| to patients and availability of care.
|
| The real drivers here are the big employers. They are the
| ones ultimately paying most of the bills, and they insist
| that insurers ration care to control costs.
| FireBeyond wrote:
| > The Affordable Care Act (Obamacare) set a minimum 85%
| medical loss ratio. The insurers have to cover their
| operating costs and profit margins out of the remaining
| 15%.
|
| That's also a perverse incentive though. With capped
| "profit" windows, how is a company to make more money?
| Well if healthcare costs increase, then premiums need to.
| 15% of 1.3X is bigger than 15% of X, after all. And
| healthcare providers are unlikely to object to higher
| prices.
|
| And what if your insurer gets involved in vertical
| integration - perhaps Kaiser style, perhaps less formal?
| Now you get to reduce the actual cost to you (the
| insurer) by removing the middleman, and you get increased
| profit by keeping the price the same. It might show up on
| a different ledger on your books, but nonetheless...
| lotsofpulp wrote:
| > And what if your insurer gets involved in vertical
| integration - perhaps Kaiser style, perhaps less formal?
| Now you get to reduce the actual cost to you (the
| insurer) by removing the middleman, and you get increased
| profit by keeping the price the same. It might show up on
| a different ledger on your books, but nonetheless...
|
| Regulators are not this dumb or corrupt.
|
| This is not a big money making business, as evidenced by
| Buffett/Bezos/Dimon's foray failing:
|
| https://www.latimes.com/business/story/2021-01-04/buffett
| -be...
| peteradio wrote:
| UNH stock has doubled since 2020. Someones making big
| money.
| lotsofpulp wrote:
| Because the risk of removing ACA legislation is gone.
| It's a company with very reliable revenue that will keep
| up with inflation with relatively low liability.
| cycomanic wrote:
| And despite that Unitedhealthcare has grown from ~$70
| billion revenue in 2007 to $320 billion in 2022 and is
| making a $20 billion in profit (which I'd argue is a
| pretty healthy profit). So I guess the health insurers
| are just working around the system.
| nradov wrote:
| You're mixing up UnitedHealthcare with it's parent
| publicly traded company UnitedHealth Group. They sell
| other services and technology products unrelated to
| medical insurance, and those contribute a lot of the net
| profit. Medical insurance is a high volume, low profit
| margin business.
|
| https://www.sec.gov/ix?doc=/Archives/edgar/data/000073176
| 6/0...
|
| It is reasonable to criticize insurer profits but overall
| those are only a small part of much larger systemic
| problems in the US healthcare system. Even if profit
| margins were somehow cut to zero that would have only a
| marginal impact.
| JohnFen wrote:
| > A health care company collects money under the premise
| that "these premiums you're paying will cover you if
| something bad happens"
|
| That's not the premise of insurance, though. The premise of
| insurance is that a large group of people pools their money
| (through paying premiums), out of which the people in need
| of assistance get paid. It's not that you'll be "repaid"
| your premiums in services. It's pooled risk, not a kind of
| savings or investment.
|
| In order for it to work financially, most people have to
| never have claims in excess of what they paid in. The whole
| point is to be able to cover exceptional and rare
| disasters.
|
| I think one of the ways that health insurance (at least in
| the US) has gone horribly wrong is that it became a means
| to pay for routine medical things rather than just
| exceptional ones.
| lotsofpulp wrote:
| > I think one of the ways that health insurance (at least
| in the US) has gone horribly wrong is that it became a
| means to pay for routine medical things rather than just
| exceptional ones.
|
| This is solved by high deductible health plans.
|
| > In order for it to work financially, most people have
| to never have claims in excess of what they paid in. The
| whole point is to be able to cover exceptional and rare
| disasters.
|
| This is where the problem is. Humans will have health
| problems and will have claims, especially after age 50.
| Which means (assuming a stable population), the present
| value of premiums has to equal the present value of all
| the healthcare you will need (until you get to Medicare,
| age 65). Which is a large number, especially considering
| the obesity/hypertension/diabetes/heart disease rates.
|
| Which means premiums are effectively just another tax
| (except they are no longer mandated). A big wrinkle here
| is declining proportion of younger populations to pay for
| older populations, so the premiums young people pay for
| healthcare older people receive now, but when the young
| people are older, there will be fewer younger people to
| pay for them, so it is also a marginal "age" tax, where
| the younger people pay for more than what they will
| receive. Exactly the same as Medicare taxes.
| lesuorac wrote:
| > In order for it to work financially, most people have
| to never have claims in excess of what they paid in.
|
| I don't this needs to be true. If you say pay 10,000 and
| they invest that and it returns at 10,500 at the end of
| the year then if your claim is 10,300 they've technically
| made $200 still.
|
| Given that they're raking in billions in premiums I think
| they have access to better rate of returns than each of
| those individuals could've done on their own.
|
| > I think one of the ways that health insurance (at least
| in the US) has gone horribly wrong is that it became a
| means to pay for routine medical things rather than just
| exceptional ones.
|
| I really am surprised that most insurance networks don't
| become more vertically integrated. Like manufacture their
| own drugs, hire their own doctors, etc since a lot of
| their expenses are extremely predictable.
| lotsofpulp wrote:
| >Given that they're raking in billions in premiums I
| think they have access to better rate of returns than
| each of those individuals could've done on their own.
|
| Not really, as far as I know claims reserves have to be
| kept highly liquid (Treasuries or High Grade Corporate
| Bonds maybe?, especially for a health insurer which pay
| out almost all the premiums it collects every year.
|
| They are not going to be invested in VC/PE/REIT/etc.
| mrguyorama wrote:
| >I think one of the ways that health insurance (at least
| in the US) has gone horribly wrong is that it became a
| means to pay for routine medical things rather than just
| exceptional ones.
|
| Then why isn't this a problem in any country with
| socialized medicine or other required health "insurance"
| things? They have increasing costs but not nearly to the
| extent the US experiences.
|
| The cost of childbirth in the US is insane. It is
| literally cheaper to fly to another country, _pay out of
| pocket the purposely inflated "tourist medicine" price_,
| hang out in a nice hotel for a few days, and then fly
| back!
| zdragnar wrote:
| There's a number of reasons. -
| malpractice insurance - cost of living difference
| - government rationing of care in public systems
| - lower capital expenses for nice looking buildings and
| top-of-the-line equipment - unpaid bills turn
| into higher prices
|
| Medicare/Medicaid have their own distorting effects. One
| doctor told me that, for certain billing codes, he was
| effectively making less than minimum wage because the
| government rate was so low. To make up for it, other
| billing codes had to be overpriced, or he had to stop
| accepting any non-private payments.
|
| Countries with socialized medicine have their own
| problems. It can be great for average people with average
| problems, but outside those lines you run into things
| that would be trivial in a US healthcare setting.
|
| Obviously, it varies by country, and there are plenty of
| things I hate about how healthcare works in the US.
| JohnFen wrote:
| > It is literally cheaper to fly to another country, pay
| out of pocket the purposely inflated "tourist medicine"
| price, hang out in a nice hotel for a few days, and then
| fly back!
|
| I can top that...
|
| In my part of the US west coast, if you need to have two
| dental crowns done, it's cheaper to fly to Taiwan and
| have it done there than to have it done locally.
|
| As a bonus, the quality of care and materials will be
| much better and the dentist may even actually apologize
| for having to charge you at all.
| manuelabeledo wrote:
| > In my part of the US west coast, if you need to have
| two dental crowns done, it's cheaper to fly to Taiwan and
| have it done there than to have it done locally.
|
| This is exactly what I do.
|
| I would take the kids back to my home country, pay out of
| pocket for any treatment, and have a nice holiday in the
| process.
|
| Last time we went back, I was chatting with the dentist
| and casually told her about the treatment costs in the US
| - she was flabbergasted. Markup prices in the US seem to
| be 500%+ of those in many European countries.
| MandieD wrote:
| Cost of planned C-section as a private patient (a.k.a.,
| paying significantly more than public insurance) in
| Germany, including 3 day hospital stay (short because
| pre-vaccine, pre-quick test Covid): about 5000 EUR.
| coredog64 wrote:
| Please Google "medical loss ratio"
| ncallaway wrote:
| I think that, and making the doctor who denies the claim
| responsible personally and professionally as if they were
| providing care to a patient.
| beambot wrote:
| To play devil's advocate: Wouldn't that just result in
| healthcare systems being run by people too incompetent to
| realize the liability they're signing up for?
|
| That seems more likely (apriori) than healthcare systems
| magically becoming efficient, responsible, and ethical
| actors.
| amalcon wrote:
| I had an instance where the hospital had coded my spouse's eye
| issue as "routine" -- so it was not covered by medical
| insurance, because your vision insurance is supposed to cover
| that. Our vision insurance wouldn't cover it, because they only
| permit one visit per calendar year.
|
| The doctor that treated my spouse literally published a paper
| about the case, so uh... not routine. I got _super_ lucky with
| the insurance person, though -- she actually called the
| hospital for me and got them to re-code it.
| justinram11 wrote:
| Had literally the exact same issue with my spouse, but
| without the luck of finding an insurance person who cared. At
| the end of the day, it wasn't worth the $200 to continue
| fighting it (had already invested ~5 hours into phone calls
| back and forth between the clinic and insurance company).
|
| Infuriating to say the least.
| Natsu wrote:
| > I think if they'd tried to run the claim as the suppository
| version, the error would've been more obvious.
|
| Gotta tell the insurance company where to stick it? :)
| wnevets wrote:
| > So even if you know the grounds for denial, sometimes the
| reason is bullshit and flies in the face of the insurer's own
| policies.
|
| This is a feature health insurance companies, not a bug. Their
| entire purpose is to collect as much premiums as possible while
| paying out a little as possible.
| Obscurity4340 wrote:
| It'd be funny if they rubber-stamped all suppository claims.
| Like, we'll just cover it if it has anything to do with your
| ass.
| spondylosaurus wrote:
| Ironically I did want to try this steroid suppository foam in
| the throes of a bad IBD flare but my doctor said not to
| bother because insurance companies never cover it.
| eweise wrote:
| I recently sued my health insurance company in small claims
| court and won. They claimed my out of network costs were above
| the norm. The insurance company tried all kinds of tricks
| trying to get the case thrown and delaying. Took me four trips
| down to the courthouse but finally got them in front of a judge
| who knew they were full of shit and sided with me.
| sumtechguy wrote:
| Interesting one I heard once from my dad.
|
| 'your policy is denied you are not covered for this because
| only your spouse is' 'thats interesting that is not how I
| wrote my _OWN_ policy ' 'uhhh we will get back to you' They
| approved it. But not before denying it.
|
| He sold these policies for a living. He mostly quit exactly
| because of this sort of noise.
| Khelavaster wrote:
| The people who denied your insurance claims were literal
| criminal who need to be arrested and jailed. If their local
| municipalities don't prosecute on your own, you're [almost
| certainly] legally entitled to make a citzen's arrest with as
| much force as necessary to bring the criminal fraudsters
| denying your assets to justice..
| whoomp12341 wrote:
| It would be really nice to know IF my claim was denied. Health
| billing is so messed up.
| munk-a wrote:
| If it's an expensive procedure and you want to know what the
| cost will be you'll usually want to submit for prior
| authorization before the procedure. In an emergency this isn't
| an option but for any other treatment this can give you a lot
| of clarity about what your out of pocket will be - doctors (or
| their offices) should be able to handle this if you ask.
| eric_the_read wrote:
| I had a doctor once recommend a temporary treatment that
| would be provided by a third party. I called the third party
| and asked how much it would cost; they had no idea. I called
| my insurance company and asked how much it would cost; they
| had no idea. I called my doctor and asked how much it would
| cost; they had no idea.
|
| Literally nobody involved in the entire chain of providers
| had any idea how much it would cost. The best advice anybody
| could give me was to get the treatment, then look at the bill
| afterwards. (Oh, and nobody had any idea when I might get a
| bill either-- my wife is still receiving bills from the birth
| of our most recent child, 18 months ago.)
| evancordell wrote:
| > my wife is still receiving bills from the birth of our
| most recent child, 18 months ago
|
| I've been dealing with this as well, and the uncertainty
| has been the most frustrating thing.
|
| Medical bills from the same institution should be required
| to be high watermarks - i.e. if you give me a bill in
| March, you can't send me a bill in April that has charges
| from February that _weren't on the bill from March_. It
| feels like fraud (and maybe it is, but who has time to
| figure that out?)
| callalex wrote:
| Prior authorization does not come with any binding
| guarantees, insurance companies can and do reneg on their
| promises all the time.
| munk-a wrote:
| This is true - but they're _usually_ more predictable.
| Absolutely nothing in the US healthcare market is
| guaranteed. And, tbh, in healthcare there can always be
| complications - a simple surgery or treatment might turn
| into something much more extensive if things weren 't as
| they appeared initially or there's some abnormal response
| to treatment.
| NikolaNovak wrote:
| I know this is a low-quality comment, but this may be the #1
| thing Hacker News has taught me over the last decade: USA
| health/insurance system is an Orwelian nightmare multiplied by a
| hundred. No straight-up evil guy with a vision and mission
| statement could imagine and successfully implement something as
| brutal as apparently we've systemically created ourselves through
| a million small steps.
|
| I'm a bright guy but I don't know how I'd live with the
| _cognitive workload, stress and uncertainty_ over having to deal
| with all of this (the networks, the uncertainty over price and
| bills, the bills coming for weeks and months after care, the
| myriad involved parties, the rules and limits and interpretations
| and just... everything). More to the point, I don 't understand
| how anybody, on any party or political spectrum, can say "Yup...
| this is a reasonable system that helps people and needs no
| change".
| linuxftw wrote:
| Thankfully, the ACA made insurance mandatory for everyone. Not
| only do we have a garbage system, we're obliged to participate
| in it.
| vkou wrote:
| 1. You have always participated in it, regardless of whether
| or not you pay an insurer.
|
| 2. There are no penalties for not having insurance, that part
| of the ACA has been torpedoed.
|
| 3. The people who torpedoed it have no intentions of fixing a
| damn thing about this country's medical system.
| EvanAnderson wrote:
| This is sarcasm, right? The individual mandate was struck
| down.
|
| In my opinion, this was a brilliant strategic move by those
| opposed because it guarantees the eventual financial
| inviability of all of the ACA. Decreasing the size of the
| risk pool by allowing people to opt out will guarantee that
| it won't work long-term.
| TuringNYC wrote:
| >> More to the point, I don't understand how anybody, on any
| party or political spectrum, can say "Yup... this is a
| reasonable system that helps people and needs no change".
|
| 1. Many of the most painful core issues dont manifest until you
| have a real issue. So people assume it will work for them,
| until it does not.
|
| 2. There is so much money being made on the other side that
| there is a huge push for lobbying to keep the system in place.
| TuringNYC wrote:
| >> I'm a bright guy but I don't know how I'd live with the
| cognitive workload, stress and uncertainty over having to deal
| with all of this (the networks, the uncertainty over price and
| bills, the bills coming for weeks and months after care, the
| myriad involved parties, the rules and limits and
| interpretations and just... everything).
|
| When you have a real issue, it takes hundreds of hours to deal
| with it. Smart employers know that this eventually comes out of
| company time and productivity, esp since most of these calls
| need to take place during business hours.
|
| Smart employers will advertise "100% paid health plans, etc,
| etc."
|
| Penny-wise employers, even white-collar jobs/offices, will
| often provide the bare-minimum coverage, and pretend it has no
| effect. _Except it does._ You can see it when your cubicle-
| neighbor is on a 2hr call with insurance, etc. I 've had
| colleagues who will block a 4hr meeting on their calendar
| titled "calling insurance companies to figure out bills" as
| open protest. I've had people in the office just spend a day or
| two on the phone with doctors' offices, visible, both out of
| desperation and as a subtle form of protest for the
| organization's choices in health plans.
| kingTug wrote:
| Health insurance tied to employment is the second biggest
| scam in American history after Reaganomics. It forces people
| to stay in crappy jobs to maintain coverage and fucks with
| collective bargaining rights.
|
| We need universal, single payer healthcare.
| BeetleB wrote:
| > Health insurance tied to employment is the second biggest
| scam in American history after Reaganomics.
|
| And yet, sadly, even the "liberals" push for tying it to
| employment.
| orangecat wrote:
| Mostly the liberals. In 2008 Mitt Romney pushed for
| ending the favorable tax treatment of employer-based
| plans
| (https://www.commonwealthfund.org/publications/fund-
| reports/2...), which was instantly attacked by the left
| for "taking away your insurance". Then the ACA set up the
| marketplace for individual plans which was good, but also
| inexplicably added employer mandates.
| boc wrote:
| It started as a reaction to a market distortion
| during/after WWII. There was a government-imposed salary
| cap during the war (Stabilization Act of 1942), so private
| companies had to get creative to attract talent. One thing
| that stuck was offering additional health insurance to
| employees. The rest is history.
|
| Further reading:
| https://www.chicagotribune.com/opinion/commentary/ct-
| obamaca...
| dragonwriter wrote:
| > More to the point, I don't understand how anybody, on any
| party or political spectrum, can say "Yup... this is a
| reasonable system that helps people and needs no change".
|
| Nobody says that, and no one proposed the current system as is,
| either. Its not even a conscious, mutually unsatisfactory,
| compromise between competing visions, its simply the current
| state of an ongoing battle between multiple radically opposed
| views in a political system which is not good at resolving
| disputes of this kind, where some elements are successful
| attempts at implementing sabotage of broader components with
| the hope that the resulting failure will help politically
| support a conpletely different design.
| gosub100 wrote:
| > I don't understand how anybody, on any party or political
| spectrum, can say "Yup... this is a reasonable system that
| helps people and needs no change".
|
| The commonality between this and (including, but not limited
| to) homelessness is that the tragedy is laundered into
| political ammunition used against their opponents in the next
| election. I dislike the trite expression "Don't let a good
| tragedy go to waste", but I'll say it to preempt the reply. But
| it's true: if you can't use human suffering (denied medical
| coverage | no place to live) to attack your party's enemy, you
| are less powerful as a candidate.
|
| The other factor is lobbying. These companies (just like in
| many other industries) have US congress bought and paid for.
| The suffering aspect keeps people distracted and divided, so we
| never really hear about campaigns to end lobbying (because it
| would apply to both major political parties). Instead we joke
| about it and roll our eyes at how ridiculous it is (but still
| told to "get out and VOTE!" as if that somehow matters). My
| opinion is that it should go beyond financial contributions.
| Industry and trade groups should not have access to congress at
| all, it should be citizens only.
| oldandboring wrote:
| It's a low-quality comment but no worse than every other
| comment in this thread that similarly indicates zero
| understanding of how insurance actually works.
|
| Your claims are paid with the money collected from your, and
| other members', premiums. Everyone wants insurance that covers
| every single claim with few questions or limits, but that
| insurance company would quickly have to make the choice between
| dramatically increasing premiums or going out of business.
|
| Every time a government entity mandates that insurance plans
| cover additional services, the cost of care goes up and
| subsequently so do premiums. When premiums go up, people /
| businesses shart shopping around and leave the pool, meaning
| the risk is spread out among even fewer (likely sicker) people
| and the premiums go up even more.
|
| The alternative is just having everyone in one giant "single
| payer" pool so risk is minimized, with participation mandatory.
| Then, that entity (government probably) would just pay all the
| claims because in theory there would be less incentive to watch
| the bottom line. In reality, we've already tried this: Medicare
| is the largest single-payer health insurance system in the
| world, plus we have 50 Medicaid single-payer systems at the
| state level and additional single-payer systems at the federal
| level (Tri-Care and VA benefits). All of these systems face the
| same fiscal challenges and have been implementing every cost
| control measure they can think of for the past 2 decades.
| Medicare has been trying to move from Fee For Service (FFS) to
| outcome-based reimbursement for a long time now.
|
| Those of us who know, know: the problem is COST in the system.
| Healthcare is EXPENSIVE.
| warner25 wrote:
| I don't think that government-run health insurance (i.e.
| Medicare, Medicaids, Tricare) == "single-payer" healthcare
| system, especially in terms of the effects described by the
| parent comment.
|
| My perspective is being under Tricare. You can imagine it
| like a closed system in which Tricare beneficiaries just go
| to Military Treatment Facilities (Defense Health Agency and
| service-run hospitals and clinics) for everything, and
| everything done in those facilities is covered with no
| questions asked and no bills or money changing hands. But
| that isn't how it works in practice. A large amount of stuff,
| like most specialty care, gets referred to places "out in
| town" (at local, for-profit, civilian providers). Most ER and
| urgent care visits happen out in town. At times, my wife and
| kids have been on Tricare Select which works like a PPO and
| involves all the usual discussions about who does or doesn't
| take Tricare, in-network or out-of-network, whether something
| needs pre-authorization or not, why a claim has been denied
| and how to appeal it, whether we've reached our annual
| deductible or catastrophic cap, etc.
|
| So under Tricare, I think I feel more protected from profit-
| driven shenanigans and expensive mistakes than most
| Americans, but there's still a "cognitive workload, stress
| and uncertainty." I think a true single-payer system means
| that you don't have this (because it works like the closed
| system described above).
| dboreham wrote:
| If you study the history of how the system came to be, it turns
| out to be a combination of: Drs like money, and (like most
| things in the US) racism.
| Aurornis wrote:
| I worked with some coworkers who emigrated to the USA a few
| years back. They all shared similar fears about the US
| Healthcare system. Once we showed them how it worked, how to
| use our insurance company's website, and how to confirm that
| services were authorized they had no real problems.
|
| HN, Reddit, and the rest of the internet have become really
| good at sharing horror stories, but increasingly many of those
| horror stories are either misleading or based on old laws that
| no longer apply. A popular trick on Reddit is for people to
| post the part of their bill that goes from their provider to
| the insurance company and say "This is how much it costs to
| have a baby in the United States!". However, nobody actually
| pays the amount that gets billed to the insurance company. They
| pay an amount determined by their insurance deductible, co-pay,
| and out of pocket maximum. Once you go past the out of pocket
| maximum for a year, everything is covered 100% in network.
|
| We even recently had new laws against surprise billing, which
| plugs many of the holes that created those horror stories about
| going into a hospital and discovering you were out of network
| after the fact. Technically there are still holes where this
| can happen, but if you look carefully most of the horror
| stories online are from many years ago.
|
| Is the system perfect? Of course not. However, in practice
| people aren't going bankrupt every time they go to the doctor
| like you'd think from Reddit posts. When it comes to pre-
| authorizations, these tend to get negotiated between your
| doctor's office and the insurance company. Doctors offices know
| how to push pre-authorizations through if they want to put in
| the effort, but many some will shrug it off because it's not
| billable time for them.
| warner25 wrote:
| > However, nobody actually pays the amount that gets billed
| to the insurance company...
|
| While mostly true, the system always strikes me as insane
| when I see the amounts billed to my insurer alongside the
| amounts "allowed" or paid by my insurer (or paid by me until
| we hit the deductible). I'm talking about the negotiated
| rates, I guess, not even co-pays. I regularly see things like
| $8,889 billed and $149 "allowed."
| gnopgnip wrote:
| The reality for people with a well paid white collar job or a
| union or that work for the government or a non profit or in
| healthcare is that everything is fine. The employer pays for
| 100% of the premium. With insurance like Kaiser you pay your
| copay and that is all. Everyone at Kaiser in network, most
| directly employed, no surprise billing. Pre auths are easy when
| everything is in network. Your out of pocket max is as low as
| $2k.
| munk-a wrote:
| This problem is going to get even more fun as AI driven Prior
| Authorization denials get more prevalent.
| TuringNYC wrote:
| I had my FSA provider PayFlex deny a medical co-pay as "Not
| Medically necessary."
|
| Isnt it lovely when a Private Equity firm decides what is or
| isnt medically necessary? They were obviously using some
| automated system to try and deny claims, to hell with false
| positives.
|
| The best thing is to just repeatedly submit the legitimate
| claim until it goes thru. There seems to be some non-
| determinism in these systems and the same thing will sometimes
| be accepted and sometimes rejected. Bless my wife for taking
| care of this insanity.
| JJMcJ wrote:
| Not quite the same thing but many people report when a hospital
| bill seems high, and they ask for an itemized bill, magically the
| charges get reduced.
| coredog64 wrote:
| Potentially useful context: If you're not covered by a small
| employer, your claims are typically being self-insured by your
| employer. Your employer uses Cigna or BCBS for administrative
| functions, but they set the tone for the amount they're willing
| to pay. That's why you'll see differences in coverage even though
| you ostensibly have the same insurance provider in the same
| state.
| oldandboring wrote:
| And, importantly, these "ERISA" plans are exempt from state
| laws and regulations (although they do have to abide by federal
| laws and regulations).
| power wrote:
| A lesson learned from hard experience and unfortunately too late:
| get your own illness benefit insurance. If you have it through
| your employer you can't sue the insurance company since you're
| not a party to the contract. They don't even need to talk to you,
| only your employer.
| linsomniac wrote:
| I was preparing to possibly have to do this, but it looks like
| I've narrowly avoided it. My family has a procedure scheduled
| Dec 4, and my work insurance is changing plans Dec 1. Got pre-
| approved with previous plan, previous insurance company is
| exiting health insurance totally. New plan needs 15 business
| days to approve it, and can't start that until we get group
| numbers, and there's a holiday in here.
|
| But, the doctor has been able to get us in due to a
| cancellation, before the insurance expires.
| LocalH wrote:
| Insurance companies should not be able to override a patient's
| doctor in making a determination of what's not "medically
| necessary".
| mbauman wrote:
| In my experience, knowing why a health insurer denied a claim
| isn't useful; it just becomes a maze of medical billing codes and
| definitions that always ends at "insurer wins."
| dboreham wrote:
| Presumably this means "know their excuse". We already know the
| _reason_ : so they can make more profit.
| bawana wrote:
| As a physician, my patients are continually stymied by the
| preauthorization requirement for CT scans and procedures by some
| insurors. This ridiculous hurdle adds weeks of delay sometimes.
| And there is no real quality assurance or data assessment
| regarding the necessity of the procedure. I have to call, go
| through a phone tree, the delays are frustrating and unecessary.
| I didnt go to school and residency for 10 years to justify a job
| deemed necessary by some corporate second guesser. This is just a
| process added by an MBA that adds no value to the patient care.
| It is the result of trying to apply Adam Smith's precepts of a
| free market economy to a. market where the consumers have no
| choice. No one chooses the illness they have. A capitalist model
| serves this market poorly. And the whole idea of making a profit
| off of someone's illness to pay shareholders is wrong.
| iancmceachern wrote:
| I'm currently fighting this exact fight with Blue Shield
|
| I was getting nowhere until I started connecting with and then
| publicly shaming their executive leadership on LinkedIn. If you
| do that, you get transfered to their "executive relations team"
| who still are unable to get things done, but it's at least a
| different department you can file grievances that go nowhere
| with.
| InCityDreams wrote:
| Thanks for the heads up. Time to give my money to someone
| else...that is probably just as bad, but hey "I'm doing my
| part".
| jmyeet wrote:
| We are arranging deck chairs on the Titanic with the dystopian US
| health system. Like who here legitimiately believes this is a
| good system?
|
| The entire system is an exercise how capitalism fails where
| there's inelastic demand. Health insurance companies exist to
| extract wealth from consumers and governments by not providing
| health care to increase profits. It's that simple. There is a
| direct link between denying prior authorizations and increasing
| profits [1].
|
| Fun fact: Obamacare (ie the ACA) snuck in a ban on physician-
| owned hospitals [2] thanks to lobbying efforts. Just more
| artificial barriers and rent-seeking to increase profits.
|
| Health insurance companies continue to consolidate (eg requiring
| prescriptions are filled by their PBM-approved pharmacists,
| buying up medical providers).
|
| It is utterly insane to me that anyone can defend this system who
| isn't a major shareholder in United healthcare. Yet ordinary
| people do, which usually comes down to "I don't want to lose my
| insurance", which is so insanely short-sighted and selfish, it
| blows my mind.
|
| [1]: https://www.healthleadersmedia.com/revenue-cycle/cost-
| denial...
|
| [2]: https://www.fiercehealthcare.com/providers/hospital-
| groups-a...
| nikanj wrote:
| Why? Because fuck you, that's why. Sue us, see whose legal budget
| runs out first -Every insurance company
| Khelavaster wrote:
| Surprised disabled people don't do citizens' arrests on insurance
| company account administrators and executives, using heavy
| assault weapons when necessary to leverage force with their
| disabilities..
| ongytenes wrote:
| Back in 2005 I was working for Dupont and had a mandatory hearing
| test. I asked for the results and was told that was the property
| of the company and I couldn't have access to it. I felt at the
| time it unethical to withhold information regarding my health.
| Now I'm wondering if it was illegal too.
| jackallis wrote:
| you might be interested in whole series
|
| https://www.propublica.org/series/uncovered
| amatecha wrote:
| I wish articles like this would clearly indicate what country's
| laws they are referring to. This article appears to only be
| directly relevant to the United States.
| dimgl wrote:
| Is this not an American site?
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