[HN Gopher] Using AI to fight insurance claim denials
___________________________________________________________________
Using AI to fight insurance claim denials
Author : jpmattia
Score : 173 points
Date : 2024-08-26 15:31 UTC (7 hours ago)
(HTM) web link (sfstandard.com)
(TXT) w3m dump (sfstandard.com)
| jpmattia wrote:
| The subheading of the article is "Using AI to fight insurance
| claim denials", and her site is here:
| https://fighthealthinsurance.com/
| dang wrote:
| Ok, we'll use that for the title above. Thanks!
| rqtwteye wrote:
| Single payer or not but I think everybody should agree that
| dealing with health insurance needs to be easier and more
| predictable. When I read the stories of how people won against
| them, it's always mind boggling to see the giant effort they had
| to put into it.
|
| Hospitals and insurances should be fined if they have a high
| ratio of claims that get rejected first and reversed after
| appeal. Patients simply shouldn't have to go through this. The
| whole system is set up to profit from wearing down patients by
| attrition.
| WaxProlix wrote:
| > Hospitals and insurances should be fined if they have a high
| ratio of claims that get rejected first and reversed after
| appeal
|
| They'd just invest more in not having to reverse on appeal.
| Handling these kinds of incentives with rules and strictures
| gets messy fast.
| ryandrake wrote:
| Well, write the law to address that, too.
|
| Too often, we throw our hands up and declare legislation
| impossible "because companies will just get around it in
| ways, X, Y, and Z". The solution is to write better laws that
| also remove X, Y, and Z as options. And also X0, X1, Y0, Y1,
| Y2, Z0, Z1, Z2, Z3, and Z4. The world is complex and
| regulation can be complex, too. You'll never fix things by
| giving up and saying "We can't write the perfect law--oh
| well, let's just let companies do whatever they want!"
| dylan604 wrote:
| The concept of spirit of the law vs letter of the law
| infuriates me to no end.
|
| I think the letter of the law should stipulate the spirit
| of the law (almost a TL;DR right at the beginning) so that
| jurists can later take that into account when deciding if
| the law was broken.
| 1-more wrote:
| US Tax law is the only place where I can think of that
| the spirit is the most important part of the law. There
| isn't much of a hard and fast definition of a home based
| business, but if the vibe is "this is a hobby and I'm
| using the business only to claim deductions, not turn a
| profit someday" you can be in violation.
| kredd wrote:
| I agree in some sense, but spirit of the law also creates
| very uneven playground and leaves a lot of questions. The
| way I see the problem, it takes way too long for us to
| legislate anything. By the time something passes
| different levels of approval, whoever has any skin in the
| game might figure out a way around it.
|
| That happens a lot with finding loopholes in housing
| related legislations. If there is a proposal that would
| hurt investors, they lobby against it for a while, buying
| time to figure out an alternative method, and by the time
| it passes, they don't really care because they've
| circumvented it anyways.
|
| I see why it would also suck if we fast tracked most of
| the legislations though.
| piva00 wrote:
| > I agree in some sense, but spirit of the law also
| creates very uneven playground and leaves a lot of
| questions.
|
| That happens anyway though, as much of law in Common Law
| systems is only settled by precedents, jurisprudence,
| etc. Even the US's Constitution interpretation is up to
| the courts when questions arise, that's the courts' job
| anyhow.
|
| At least working with the spirit of the law allows ways
| to prevent loopholes in a way that the letter of the law
| process only allows if new legislation is passed to cover
| those loopholes.
| vundercind wrote:
| > Even the US's Constitution interpretation is up to the
| courts when questions arise, that's the courts' job
| anyhow.
|
| Judicial review of the constitutionality of laws is
| _itself_ an invention of the courts, in fact. (And
| probably a good idea, but it's something the courts had
| to decide they had, not a role or power plain in the
| law). So that specific thing being their job is...
| something they decided was their job, which is kinda
| funny.
| xn7 wrote:
| I agree that it's very frustrating, but law is a language
| game between opposing parties. There is always going to
| be willful misinterpretation, because, well, sometimes
| people want incompatible things. If you add a spirit of
| the law TLDR, you'll need a spirit of the spirit of the
| law, and so on.
| cataphract wrote:
| The US obsession with literality in recent times is very
| sui generis (and even then you have a lot of people
| criticizing it for not taking further, e.g. the fish is a
| tangible asset SCOTUS case). In Portugal, the law
| specifies how it should be interpreted (1966 civil code,
| art. 9)
|
| 1. Interpretation should not be limited to the letter of
| the law but should reconstruct the legislative intent
| from the texts, taking into account the unity of the
| legal system, the circumstances in which the law was
| drafted, and the specific conditions of the time when it
| is applied.
|
| 2. However, the interpreter cannot consider a legislative
| intent that does not have at least a minimal verbal
| correspondence in the letter of the law, even if it is
| imperfectly expressed.
|
| 3. In determining the meaning and scope of the law, the
| interpreter will presume that the legislator has adopted
| the most appropriate solutions and has expressed their
| intent in suitable terms.
|
| It doesn't help make the meaning of the text more
| determinate, but it may shift where the battle is fought.
| giantg2 wrote:
| This is pretty similar to _most_ US case law and
| judiciary rules on how the law should be interpreted.
| giantg2 wrote:
| Most laws have preambles and records of the debates to
| help with their intent.
|
| The theory of strict construction is a _protection_ in
| our legal system. Otherwise you 'll end up with a system
| similar to the insurance you're complaining about -
| generalized rules, you won't know the outcome going into
| it, and they can find ways to make the rules for the
| desired outcome. (This stuff happens in the legal system
| today, it would just get immensely worse)
| adolph wrote:
| If the letter doesn't follow the spirit then fix the
| letter, don't add on more crust.
|
| https://xkcd.com/927/
| silverquiet wrote:
| As I've gotten older, I've found that I've lost a lot of
| belief in the law at all. Despite being rather clever, we
| are still primates who live in primate societies. Some of
| us are greedy psychopaths and some of us are generous
| empaths. If you put the greedy psychopaths in power, it
| will have deleterious effects on society regardless of
| whatever scribbles you have on paper.
| willcipriano wrote:
| Most of the time the "we oughta do" ideas are so simple
| that they wouldn't work as a law "it should be illegal to
| charge too high prices!" so it's sort of a non-solution as
| it factually wouldn't work in the real world.
|
| Real talk, the US spends more on socialized medicine per
| capita than all of Europe, nobody should get reelected, no
| foreign aid rendered nor bombs dropped until we receive
| what has been long paid for.
|
| They want you to focus on the former sort of "solution"
| than the one I provide and that's why you probably are
| first hearing of mine now.
| vundercind wrote:
| > it should be illegal to charge too high prices!
|
| Funnily enough, as far as I have been able to figure,
| this is basically _the_ unifying element of all
| developed-country healthcare systems outside the US,
| which have a lot of variety but all seem to do this, one
| way or another.
|
| Some do it with comprehensive direct price controls that
| are pretty much exactly "it's illegal to charge too-high
| prices" (Japan), some through state monopsony (Great
| Britain), some through limited price controls but the
| very-credible threat of adding more if providers get too
| greedy (Singapore), and many through some combo of the
| above, but the effect always boils down to price
| controls.
| willcipriano wrote:
| You misunderstand. In nations with socialized medicine
| (and this includes the US) there is really only one
| primary buyer of healthcare products and services.
|
| If that buyer decides your price is too high, you sell
| around 0 units.
|
| You can often receive these treatments if you wish to pay
| privately. Only the very wealthy do this, a small market.
|
| Drug companies in the US prefer to sell units at the
| prices that the buyers in those nations are allowing them
| VS not selling them at all. That's why they do it. Then
| turn around and say they can't do the same in the US as
| it would bankrupt them.
|
| The difference is in the US, Medicaid is quite happy to
| pay prices that are multiples of what other nations are
| paying. They sort of pretend this is all some sort of
| accident or due to some complexity that you wouldn't
| understand but it's just theft.
| vundercind wrote:
| If your point is that the US government is
| _tantalizingly_ close to being able to throw its weight
| around and drop healthcare prices a bunch with only
| minimal changes in policy and law, due in large part to
| its very-high spending on healthcare, but is just
| choosing not to, I agree.
|
| [edit] apologies if I've misunderstood, though--the above
| is not intended as one of those "rephrase your point into
| something you definitely weren't saying" sarcastic things
| people do sometimes, I'm really trying to follow along.
| willcipriano wrote:
| If you look at the investment portfolios of politicians
| you'll quickly understand why there is no interest in
| using Medicare to reduce prices. Watch a single
| commercial break during the nightly news to understand
| why they will never cover it, drug companies are half
| their advertisers (more worrying a quarter of them sell
| bombs)
|
| Reimports of drugs produced in the United States back
| from Canada are prohibited for safety reasons. You know
| because those Canadians are famous for tampering with
| drugs for unclear reason and benefit. It's all a farce.
| rqtwteye wrote:
| " They'd just invest more in not having to reverse on appeal"
|
| That would be the goal. Get it right first time around.
| WaxProlix wrote:
| "Invest" here doesn't necessarily mean monetary investment,
| they could for instance choose to degrade their arbitration
| and appeals process further, understaff it, or push
| regulatory boundaries in that direction. And that would
| possibly save them money, at least in the short term.
|
| And to the extent that costs _do_ go up for appeals
| processes, there 's no guarantee that the resulting setup
| has margins that incentivize doing right by customers at
| all.
| rqtwteye wrote:
| That could be solved by proper regulation. As far as I
| can tell they are already making the process as miserable
| as possible. I don't think it would get worse.
| aidenn0 wrote:
| Most of the time it's not too bad to appeal a claim for smaller
| amounts. People go through the hoops for the larger denials
| because they are so motivated.
|
| I got a $150k bill for emergency care for my daughter once; it
| wasn't too bad because they denied it as "uncovered elective
| procedure" which was trivial to show it wasn't, but it was
| still a tense month for me waiting. The punchline, of course,
| is that the insurance company and the provider agreed upon
| $30k.
|
| Doctors' offices can't tell you what a procedure will cost
| ahead of time, and the amount they bill you afterwards is
| completely fictitious (because if you don't have health
| insurance you probably can't pay 5x what the insurance
| companies pay, so will be bankrupted anyways).
| rqtwteye wrote:
| " because if you don't have health insurance you probably
| can't pay 5x what the insurance companies pay, so will be
| bankrupted anyways"
|
| Or it could go the other way depending on arbitrary factors.
| Nobody knows.
| dimal wrote:
| "Most of the time" in my case, it has been bad. Because it
| wasn't one big bill. It was dozens of bills for $200-500.
| Each submission could fail in unpredictable ways. "Lost"
| claims forms, database "errors", "incomplete information",
| etc. And trying to deal with this burden while being sick,
| was too much for me. I scraped back a few dollars, but had to
| give up and move forward with my life.
| barryrandall wrote:
| This is cool, it's just unfortunate that it's necessary.
|
| It would be nice to see more research into the role of "payor
| harm" in patient outcomes.
| nostrademons wrote:
| There are a large number of other industries where SOP is to make
| life difficult for customers in hopes that they give up on
| asserting their legal rights. Among other ones I can think of:
| insurance, debt collection, customer service disputes, privacy
| opt-outs, warranty work, property management, labor law.
|
| It seems like these industries are ripe for AI-based startups
| whose job is basically to be an asshole to corporations on behalf
| of customers, the same way that corporations are assholes back.
| If anything, at least consumers will be able to say "Have your
| AIs talk to my AI."
| rwmj wrote:
| You correctly identify a problem then suggest a complicated
| technical solution. The simple solution is to make these
| practices _illegal_ by passing laws.
| ttymck wrote:
| > passing laws.
|
| As if that's any less of a complicated technical solution.
| mrguyorama wrote:
| The law passing solution has been implemented in tens of
| states, so apparently it's not that difficult.
|
| Meanwhile, how often has a company in the US been reigned
| in by another company?
| sirspacey wrote:
| Often
|
| Disruptive services dramatically impact companies at
| scale
|
| The Credit Dispute industry radically lowered the
| aggressive dark patterns of credit score companies like
| Experian, as an example.
| salawat wrote:
| Because money laundering, wage theft, tax evasion, and labor
| violations _never_ happen, right?
|
| Law being on the books does not resolve the central asymmetry
| here. Again, their full time job is bleeding you. You getting
| your rights asserted comes at the expense of your time.
|
| Hell, when was the last time you got to negotiate a EULA with
| $BigCorp's legal group? Odds are, never.
| nequo wrote:
| > labor violations
|
| The NLRB will work to represent your interests. They are
| doing their job. Go to them if you have a dispute to
| resolve.
| jrockway wrote:
| It's difficult to simply make the legal system do this. You
| have to back it up with investigatory teeth, and the victim
| still has to file an understandable complaint to start the
| wheels turning. The legal system also has to be sufficiently
| "documented" so that people will file the right complaints.
| The net result is the same as the current system, basically.
|
| As an example, insurance covering trans care is required by
| state law in my state. Is it any easier to be trans in New
| York than other states? Yes. But you still get very familiar
| with your insurance claims process and the documentation
| hurdles. ("We need a letter from your therapist, not your
| doctor." This exists nowhere in WPATH8, but it does delay the
| money going out of their bank account while a therapist copy-
| pastes the form letter. One week to wait for your
| appointment. One week for them to turn it around. 2 weeks of
| interest earned by the insurance company. And that's the best
| case for the patient that already has the necessary support
| network.)
| rwmj wrote:
| > _You have to back it up with investigatory teeth, and the
| victim still has to file an understandable complaint to
| start the wheels turning. The legal system also has to be
| sufficiently "documented" so that people will file the
| right complaints._
|
| Correct, this is how it works in many other countries.
|
| > _[Some stuff about health insurance documentation being
| complicated]_
|
| Almost every developed country except the US has settled on
| some model of a single-payer system with universal
| coverage. This whole thing with private insurance companies
| and documentation requirements doesn't have to be a thing.
| jrockway wrote:
| Honestly, those systems don't look too good for trans
| people. The NHS requires you to wait years to go on
| $40/month hormone replacement therapy. The government
| passed a law banning prescription of puberty blockers for
| kids that are undecided on which gender they'd like to be
| as adults, forcing them to go through the wrong puberty
| or work around the system. Saw a post on Reddit yesterday
| that was "I support my daughter but we can't keep her on
| GnRH analogues anymore because it's illegal here." The
| consensus was to fly to Spain once a month and pay cash
| for the injection, or skip puberty blockers and start
| estrogen early.
|
| This is not amazing. The single-payer model is
| unfortunately too political, and somehow being trans is a
| hot button political issue right now. It really, really
| sucks for these kids.
|
| Meanwhile in the US, there is a lot of hate, but a lot of
| insurance companies do cover the necessary care. They
| even pay for flights/hotels in other states when care
| isn't available in your state because of political
| issues. We all like to hate insurance, but seeing those
| things commonly available in private insurance policies
| is ... refreshing. You are still going to have to file
| appeals, but it's better than "the government doesn't
| believe in trans people so fuck you".
| rwmj wrote:
| It's important to note that nationalised healthcare
| doesn't preclude you from paying for services privately.
| Unlike with insurance-based systems, you just find out
| the prices up front, and if you like the price and can
| afford it, then you pay it. Plenty of people in the UK
| pay for cosmetic surgery and the like.
|
| _> The government passed a law banning prescription of
| puberty blockers for kids_
|
| This is completely independent of how health care is paid
| for. It might happen that a similar law is passed in the
| US, and the same would apply over there, private health
| insurance or not.
| sssissk wrote:
| Good to hear that the UK's ban on this abusive
| pharmaceutical intervention is working as intended.
|
| Those parents should be investigated by social services
| for this abuse. Violating a crucial stage in your child's
| developmental process to adulthood is awful, deleterious,
| terrible parenting which shouldn't be enabled by anyone
| and needs to be urgently prevented.
| LorenPechtel wrote:
| Which defines a line they will toe up to, probably making
| things worse.
| nostrademons wrote:
| They're _already_ illegal.
|
| The point is that laws are useless without enforcement.
| There's a wide body of civil law that depends upon the
| plaintiff to assert their rights. The government isn't going
| to go monitoring every private transaction to ensure it
| conforms to every applicable law. We don't _want_ them to do
| that - in general the government should stay out of private
| transactions, that 's what makes them private. And the law
| usually requires multiple attempts and back-and-forths to
| ensure that everyone has had a chance to rectify the
| situation before it goes to the court system. Again, this is
| a _good thing_.
|
| But one side of the transaction is much more able to put up
| with convoluted processes and paper trails than the other. A
| corporation can amortize the cost of the paper trail across
| many customer interactions and build systems to handle it
| automatically. It can hire employees to do nothing but sit on
| the phone, and build delays into business processes that will
| make most customers give up.
|
| These sort of LLM startups just give the same economies of
| scale to customers seeking redress. Yes, it'd be easier if
| the whole process didn't exist - there's an old joke about
| LLMs generating e-mails to sound longer and more impressive
| than they need to be, and then another LLM summarizing the
| e-mail back into one sentence that isn't really what the
| original person meant. But the problem is that _each
| incentive along the way_ makes the company better off if they
| get the customer to go away, while _each incentive_ for the
| customer makes them better off if they don 't go away, and so
| you get an arms race between them.
| HarryHirsch wrote:
| The other problem is that the government is in on the joke.
| OSHA in my liberal state is about two people. Civil right
| claims are capped at 300 kUSD for a large employer. The
| existing laws are plainly insufficient to claim the rights
| that the citizens supposedly have. The present state of
| affairs really undermines government legitimacy.
| danaris wrote:
| I think it can be dangerous to view "government" as a
| monolithic entity in cases like this.
|
| So many of our consumer-protection laws are written by a
| tremendously adversarial system: one side does its level
| best to get solid, genuinely-effective protections in
| place, and the other side won't let them happen _at all_
| until they 're hamstrung almost beyond their ability to
| function.
| HarryHirsch wrote:
| The study about the influence of the ultra-rich on policy
| in the US is 10 years old, and matters haven't gotten
| better since:
| https://www.cambridge.org/core/journals/perspectives-on-
| poli...
|
| It'd not wrong to view "the government" as something that
| is run by a small group whose interests are not congruent
| with the majority of the population, and experience shows
| this.
| mrgoldenbrown wrote:
| Already illegal yes but in a way that favors the insurance
| company. For example, if the insurance co claims your
| appeal needs a peer to peer (your dr talks to their Dr)
| they currently get to decide on when the talk happens. If
| your dr can't meet at the exact time slot they want, you
| lose by default. We could rewrite the law to make the
| patients actual doctor win by default rather than the
| insurance doctor who rejects literally thousands of claims
| per week and hasn't even read the patients history.
| Suppafly wrote:
| >You correctly identify a problem then suggest a complicated
| technical solution.
|
| That's one of the hardest things for STEM types to learn, not
| everything can or needs to be solved with a complicated
| technical solution. You see it with HR and interpersonal type
| things all the time, where some minor communicator could
| solve the issue, but people start suggesting overly involved
| technical processes instead.
| bojangleslover wrote:
| The problem with fighting claims is that it's an asymmetric game.
| You, the patient, must MAKE time outside of your regular life, to
| argue on the phone with someone who is currently AT his full time
| job, and who feeds his family with YOUR premiums. It's a dirty
| game.
|
| Disputing charges, small claims court or simply never paying
| bills is the better option because the good faith channels are
| rigged.
| toomuchtodo wrote:
| I help folks in r/sterilization who have obtained permanent
| birth control navigate and appeal their insurance. ACA
| compliant plans require this be covered at 100% as preventive
| care, so it's building a workflow to check the boxes in the
| Rube Goldberg system to get to the outcome (full coverage per
| statue) insurance is constantly trying to avoid.
|
| This project is helpful and is going into the case management
| workflow right away. Fight slop with well crafted, guardrailed
| slop.
| pyuser583 wrote:
| Why the interest in sterilization? Because ACA makes it a
| very simple use case?
|
| Out of curiosity, does ACA require coverage if the doctor
| refuses?
| toomuchtodo wrote:
| Because it is the most aggressive way at almost no cost to
| empower someone's reproductive rights in an adversarial
| socioeconomic system, while each avoided unwanted child is
| a net positive. Cost benefit ratio is enormous. ~40% of
| annual pregnancies (both US and international) are
| unintended, $330k cost 0-18 (2023 dollars), limited to no
| support for parents, etc.
|
| ACA coverage is for the procedure, doctors who won't refuse
| can be found at https://childfreefriendlydoctors.com/
|
| If you want kids, Godspeed. If you don't, I am building
| systems to radically empower that outcome. "Build something
| people want." or something like that. Essentially a
| suffering reduction flywheel.
| Suppafly wrote:
| > ~40% of annual pregnancies (both US and international)
| are unintended
|
| how many are unwanted though? unintended doesn't
| necessarily have the negative connotation that
| /r/childfree folks make it out to be.
| pinkmuffinere wrote:
| To be fair, even if 5% are unwanted I would think this is
| a good investment of effort. I have no data though
| Suppafly wrote:
| Sure, honestly I have no problem with people wanting to
| sterilize themselves, although I do somewhat support the
| idea that what you want at a younger age isn't
| necessarily what you want at a later point in your life,
| so sterilization should be handled at least somewhat
| seriously.
|
| That said, I do take umbrage with people using suspicious
| statistics in unusual ways to push an agenda. If your
| cause is just, there is no need to use misleading
| statistics to inflate its importance. I argue this for
| causes I support as well as those I don't support.
| jb1991 wrote:
| Not if you call them from work.
| antisthenes wrote:
| Don't waste your employer's time.
|
| The morally correct choice is to just not pay.
| snakeyjake wrote:
| Since the vast majority of Americans are on health
| insurance plans provided to them by their employers as part
| of their compensation, fighting insurance claim denials is
| morally equivalent to fixing payroll or expense report
| errors.
| lenerdenator wrote:
| That then gets sent to collections and then you get to deal
| with that and the ramifications for your finances.
| aketchum wrote:
| cant show up on your credit report though - so why does
| this matter?
| recursive wrote:
| Why can't it?
| lenerdenator wrote:
| There's currently a _proposal_ that medical debt not be
| taken into account on credit reports. [1]
|
| Personally, I just don't trust companies to not put that
| sort of thing in a credit report. Do we actually audit
| for that sort of thing? And what if they do? Assuming
| anyone finds out, they get to drag the punishment out
| over the span of years, and if they do get punished, it's
| probably only a fraction of the money that they earned by
| reducing risk.
|
| [1]https://www.consumerfinance.gov/about-
| us/newsroom/cfpb-propo...
| snakeyjake wrote:
| The impact on your credit report is irrelevant.
|
| Debt holders can (and will) sue to collect, win, and take
| the money by court order. Depending on the state they
| will take the debt, then take the amount it cost to
| collect the debt.
|
| Do people live in some kind of alternate reality USA
| where poor people who can't pay extortionate medical
| bills don't have their checking and savings accounts
| wiped out by private equity firms pretending to be
| healthcare providers?
|
| In my state over the past ten years 14,000 civil suits
| have been filed to collect medical debt. Up until last
| year it was legal for debt holders to place liens on
| debtor's houses, often their only remaining asset after
| being wiped out by an illness. It was only made illegal
| after a particularly aggressive private equity-backed
| firm cosplaying as a healthcare provider started
| relentlessly pursuing their debts, putting liens on
| elderly people's homes, and then aggressively pursuing
| judgements on the liens, and-- get this-- SNIPING THE
| HOME DURING THE LIEN SALES.
|
| A person cancer would not show up to court due to being a
| person with cancer, the private equity firm pretending to
| be a healthcare provider would get a default judgement,
| and then immediately start hammering on the courts to get
| dispositions and final judgements in order to add the
| person with cancer's house to their real estate
| portfolio.
|
| The state legislature made it illegal to garnish the
| wages of someone living below the poverty level at the
| same time because medical debt collectors were
| specifically targeting patients who could barely pay
| their mortgage due to not working due to being sick by
| garnishing what wages they were able to earn, if any, to
| the point that the debtor went into foreclosure (in order
| to facilitate the confiscation of their home).
|
| Please try, for just a few hundred milliseconds, to
| imagine losing your paid-off (or almost paid off) house,
| a scant few years before retirement age, because you got
| cancer.
| antisthenes wrote:
| So you'd rather pay tens of thousands of dollars and keep
| feeding the beast, rather than take a few points ding on
| your credit score?
|
| Your choice, but don't act like you have some kind of
| moral high ground here.
| jrockway wrote:
| A lot of insurance plans are employer-paid, meaning that
| the money comes out of their bank account, not the
| insurance company's bank account. The insurance company
| just takes a fee to administer the claims and keep as few
| bills from hitting your employer's bank account.
|
| I remember Google denying coverage after a surgical
| procedure that they approved during the prior authorization
| period, and then running out the clock on my appeal. That's
| on them, no evil insurance company to blame, just my
| employer. And, the market decided... I don't work there
| anymore.
| sweetjuly wrote:
| Does Google actually administer the insurance plan?
| Usually the way it works is that they hire some
| traditional insurance company to administer is and then
| they just payout. Administering the plan themselves is
| very risky and has tons of compliance burden (because
| then Google would be a health insurance company). This
| means that the company doesn't have any direct control
| over claims, though they have substantial control over
| the general policy itself.
| jrockway wrote:
| No, they had an administrator. I filed the appeal through
| HR, though, which was the recommended process at the
| time. Probably not the right process in retrospect,
| especially because I accepted the appeal denial at face
| value and just paid out of my own pocket.
| vundercind wrote:
| _Massive_ untracked cost of our healthcare system, too. We're
| already more expensive per-capita than anywhere else, by a long
| shot, _plus_ we impose huge costs on patients and their
| families in time & stress spent fighting the system. Any good-
| faith accounting of that would put our costs way in to "WTF is
| wrong with us that we're not rushing to fix this immediately by
| any means necessary?!" territory.
|
| There are other hidden costs, too, like government employees
| who have to deal with private insurance issues for purposes of
| sorting out benefits and child support and all kinds of things,
| but aren't primarily involved with healthcare so I'm sure those
| hours aren't counted among costs of our healthcare system. Not
| sure about the hours (and hours, and hours) HR at entities
| public and private lose to dicking around with insurers and
| brokers and HSA providers and such. Doubt that's counted, but
| it's real and significant. Healthcare providers waste lots of
| money on similar things from their side, but I expect those
| figures make it in to even fairly naive system cost estimates.
| gamblor956 wrote:
| _Disputing charges, small claims court or simply never paying
| bills is the better option because the good faith channels are
| rigged._
|
| Yes to the first two, but the latter is a good way to get your
| credit score destroyed for a few years, and plenty of insurance
| companies are willing to send unpaid bills to collections
| agencies which are very aggressive about collecting.
| JohnMakin wrote:
| > Yes to the first two, but the latter is a good way to get
| your credit score destroyed for a few years
|
| Not necessarily or at all - in California there are a bunch
| of laws about what healthcare debt can even be reported on
| your credit score. I routinely let things fall into
| collections and maintain a very high credit score because I
| ironically gain more negotiation power occasionally with the
| debt collector than whatever service I was charged for -
| often this happens as a result of over-billing. Dispute it
| enough times and they can just disappear. The credit hit
| is/should be minor. They use "credit" as an intimidation tool
| to coerce people into paying bills they don't actually owe.
|
| Classic example - I get a procedure. Doctor submits a claim
| that is pre-authorized (I don't know the exact term). You
| receive procedure, insurer later denies claim. The doctor
| then passes the bill to you. Later, the doctor and insurer
| may come to an agreement, and the doctor is paid - but
| sometimes/often this is never communicated back to the
| patient, effectively "double billing." In these cases the
| only sane way to navigate it is by simply allowing it to fall
| to collections.
| ericmcer wrote:
| This is the dynamic that every corporation and government
| entity leverages. I feel like a frog noticing the water is
| starting to get hot as I see everything: water, power, trash,
| internet, groceries, registration fees, etc. getting more and
| more expensive and I just for sanity have to pay each one and
| forget it.
|
| Just this morning I was thinking how every single streaming
| service pushed out a version with ads and a more expensive ad-
| free version recently. It just comes to ~$20/mo to upgrade them
| all, but how much more can they pile on before people just have
| nothing left?
| mindslight wrote:
| I haven't noticed Kodi or nfs-ganesha pushing out a version
| with ads? There are many markets that have been captured by
| duopolies and turned into inescapable extraction gauntlets,
| but when you've got some actual market power you've got to
| exercise it!
| metadaemon wrote:
| I think about this a lot. It's certainly not sustainable for
| streaming companies to consistently increase end-user
| pricing. I understand why they are doing it, but there will
| only be an increasing number of individuals unwilling to
| watch X amount of ads or pay X amount a month.
| mmcconnell1618 wrote:
| Large companies consolidate industries and have the
| asymmetric advantage of more resources than individuals. They
| can leverage AI and other economic models to extract more and
| more from individuals. As we saw recently with Justice
| Department case against RealPage, the large companies can
| collude without officially colluding through better
| information access.
|
| The end result is that there is less slack in the economic
| system. There are fewer and fewer opportunities for
| individuals to leverage inefficiencies. It means there is
| less room to be human. Less room to make mistakes.
| danaris wrote:
| This is enshittification[0], and while it's not a completely
| new phenomenon, it has expanded enormously since the end of
| zero interest rates.
|
| It is just the latest way of transferring wealth from the
| many to the few.
|
| [0] https://en.wikipedia.org/wiki/Enshittification
| sensanaty wrote:
| I'm back to just pirating everything, except for (many) games
|
| It's like Gaben said, piracy is a service problem, not
| entirely a cost problem. The same 20 euro subscription
| would've gotten be 100x more movies and shows a few years
| ago, whereas now it's split to a million random services.
| Sometimes one season of a show is on 1 service, while the
| next one is on a different one. You also can't get 4K
| anywhere, every service has shit quality.
|
| So why bother paying, when radarr lets me get 4k content of
| anything I'd ever want to watch, completely for free?
| sharpshadow wrote:
| Absolutely I was shocked to see almost all movies on that
| Amazon streaming service are 4EUR to watch onces. Why pay
| for the service when most movies are not included and need
| additional purchases.
|
| I would like to see some data actually about each streaming
| service content availability in a chart by country with
| over time changes.
| Suppafly wrote:
| I really feel like amazon does themselves a disservice by
| mixing paid for content in with the 'free with prime'
| content. By not clearly differentiating which is which,
| I'm sure they make money from people just happy to have
| the content and willing to pay for it, but it pushes a
| lot of other people away from the service altogether,
| although maybe they are ok with that, since those people
| will still pay for prime for the free shipping.
| jacobsenscott wrote:
| Yes, the asymmetry is how it is designed, but generative AI can
| turn the tables there. You should be able to sic an AI on the
| company and go back to watching your (AI generated) shows on
| netflix.
| DamnYuppie wrote:
| How does this make sense? The insurance company has an
| overwhelming asymmetric advantage in regards to the data that
| is used to make such claim decisions and would be used to
| train such AI agents. Unless of course you are referring to
| legal proceedings specifically and not the data that would be
| used in the case.
| jacobsenscott wrote:
| You overestimate the ability of an insurance company to
| make use of AI - it will take them years of meetings,
| internal political maneuvering, technical failures, etc.
| Individuals can basically start using chatgpt today.
| mrgoldenbrown wrote:
| They already can reject your appeal based on BS like you
| didn't fax a form correctly (or more likely, you did but
| they claim they didn't get it), or they require a peer
| consult with your doctor and chose a time he wasn't
| available (on purpose). And don't forget they already use
| tech to speed up denials - Cigna had one doctor "review"
| and sign off on 60,000 a month via automation. That's
| under a minute a case, assuming he worked 24/7. It takes
| longer than that just to fax in your form. So you submit
| an appeal via AI, they spend 20 seconds rejecting it,
| with their tech stack from a few years ago. If they
| invest in AI it's only getting worse for individuals
| unless there are new regulations that put the burden of
| proof on the corps instead of on patients and doctors.
| Suppafly wrote:
| >You overestimate the ability of an insurance company to
| make use of AI
|
| They already do, and it's pretty obvious.
| floatrock wrote:
| I have a queasy feeling that's not going to be how this
| actually pans out.
|
| It's clear the people adopting the AI systems are the big
| co's -- we've been battling half-assed phone navigation
| agents for a decade now, and more recently chatbots (often
| with humorous results -- see the "No Backsies" car dealership
| chatbot). AI always favors the one with more resources.
|
| When you have AI's battling AI's, rather than making
| progress, I suspect it'll actually result in confusion, more
| delays as tighter roadblocks pop up, and probably some
| humorous events like the infamous Dominos-vs-Papa-Johns prank
| call https://www.youtube.com/watch?v=ALnPVybD9X8 but darker
| because it'll be about cancer treatments instead of pizza
| prices.
|
| The only winners will be data center operators, and the
| losers will be everyone without access to the AI tools. In an
| arms race, everyone loses in the long view.
| mrmuagi wrote:
| I feel like AI would and has been an edge companies would
| field better than the average citizen. Even now calling a
| companies phone line seems to be this weird rigmarole of
| infuriatingly trying to tell a virtual agent your purpose.
| Terr_ wrote:
| Nah, at that point big companies will use their position to
| impose a "must be communication from a real customer" policy,
| and they'll implement a terrible "bot detector"... where a
| high false-positive rate will be a _feature_ to them, not a
| bug.
|
| In other words "suspicious bot activity detected, start over"
| and "account suspended for security reasons" will become new
| crappy barriers to claims and appeals.
| datavirtue wrote:
| My AI has power of attorney.
| Terr_ wrote:
| Evil-genie wish granted: Your AI is now a person that can
| hold power of attorney... _Buuuut_ you 're going to jail
| for child-slavery.
| datavirtue wrote:
| I'm conflicted now.
| mrgoldenbrown wrote:
| But the asymmetry still exists. Which means your AI has to
| fight a much better trained AI that the company developed
| because it would rather spend 10 billion on AI than pay out
| 11 billion in claims, and now you're still screwed.
| karmakaze wrote:
| The idea is to automate the tasks for the filing process.
|
| > She began helping friends file appeals, too, then asked
| herself a question that's typical for engineers: Could she
| figure out a way to automate the process?
|
| > After a year of tinkering, she just launched her answer:
| Fight Health Insurance[0], an open-source platform that takes
| advantage of large language models to help users generate
| health insurance appeals with AI.
|
| [0] https://fighthealthinsurance.com/
| ToucanLoucan wrote:
| And then health insurance companies downsize their legal
| departments, replacing them with AI too.
|
| Next thing you know the entire system is just a bunch of
| large language models shooting email at one another and it
| becomes even more unwieldy and irritating to engage with.
| datavirtue wrote:
| That sounds more efficient.
| blargey wrote:
| The equilibrium would still converge on the letter of the
| policies and law, which is the goal of the endeavor.
|
| What will happen to insurance companies (and policies) once
| they can no longer rely on flippant violations to pad their
| profits depends on other factors.
| ToucanLoucan wrote:
| I think it's a very generous assumption on your part that
| increased infiltration of AI into this process will
| benefit consumers more than the corporations. It would
| make AI fundamentally different from... I mean, every
| previous technological innovation in the history of
| corporate structures, and previous to them, the robber-
| baron empires?
|
| And I mean, it _could be,_ the history has yet to be
| written for AI in terms of it 's long-term effects on
| industries, but I think as I said it's very generous on
| your part to preemptively assume that it will benefit the
| customers.
| doctorpangloss wrote:
| If some people stop paying bills, will healthcare prices go up,
| or down?
|
| Prices is a purposeful word choice. I don't mean costs, or
| _your_ costs. I mean agnostic to who is paying - whether it's a
| compulsory non tax payment via insurance and hence the price
| the insurer sees, or the price you pay for insurance, or the
| price that CMS pays for an appointment, whatever.
| pj_mukh wrote:
| The application form is a site to behold:
|
| https://fighthealthinsurance.com/scan
|
| Specifically laying out what and how everything is stored. Hahah.
| Probably overwhelming to a non-dev, but Kudos either way!
| secabeen wrote:
| The insurance companies are already using AI to generate denials,
| might as well use it to appeal them too.
| OptionOfT wrote:
| Health insurance is such a weird thing. It shouldn't exist. You
| insure yourself against exceptional things. Yet we use insurance
| for our yearly flu-shot, hardly exceptional.
|
| And insurance doesn't want to pay out, that is their business,
| which actually goes against the whole idea of healthcare. You
| need to spend money now to prevent higher cost later.
|
| (on the other hand, car insurance weirdly doesn't penalize you
| for buying cheap tires, even though the difference between 4
| cheap tires and 4 Michelin tires is less than the cost of a
| deductible for you when miss out on those 10 ft of breaking
| distance).
|
| I'm about to switch healthcare plans and I'm already mentally
| preparing (i.e. stressing out) to file appeals for some
| medications I need that they will deny-by-default.
| josefresco wrote:
| I get your point but Michelin is a global company, that
| manufacturers in over 60 countries. Maybe leave the "Chinese"
| part out and go with just "cheap tires".
| schmookeeg wrote:
| I think those two are colloquially synonymous to most people.
| Particularly those with Amazon Prime accounts :)
| dotancohen wrote:
| I used to work at the Vehicle Engineering Lab at the Technion
| in Israel. China is the only place where large volume of
| tires are manufactured and distributed to worldwide
| retailers, which documents their tires using the DOT standard
| yet consistently fails all DOT tests when tested. As the DOT
| requires tires to be tested only after a certain number of
| failures, the DOT standard is meaningless when the factory
| can change owners and name on a whim. That consistently
| happens only in China.
| hervature wrote:
| > You insure yourself against exceptional things.
|
| This isn't strictly true. We insure against the unexceptional
| as well. With regards to your specific example, I think
| refunding the flu shot is perfectly reasonable and an elegant
| solution to solving the social problem of getting people to be
| healthy. We all pay higher premiums but only those that
| actually do the preventative stuff get any benefit. Put another
| way, if health care plans were $1/month cheaper and the cost of
| the flu vaccine was $12, I'm pretty sure we'd see our already
| lackluster yearly vaccination rate plummet.
| GolDDranks wrote:
| You are correct but not taking it far enough. Vaccines are
| (often) cheap and preventative for diseases that are not
| cheap to treat. I bet there are many cases where taking the
| vaccine should not just be refundable, but actually discount
| your rate.
| MajimasEyepatch wrote:
| On the other hand, imagine if you had to go through your car
| insurance every time you had your oil changed or your tires
| rotated (going for an annual wellness check). Or worse, every
| time you had to fill up your gas tank (picking up a regular
| prescription).
|
| Ideally this sort of routine "maintenance" work would be
| affordable and accessible to anyone, but we have layers of
| middlemen in the way because the entire healthcare industry
| in this country is designed to run everything through
| insurance.
| HarryHirsch wrote:
| And then you have phenomena like a restaurant being closed
| for deep cleaning because an outbreak of Hepatitis A was
| traced back to it - a sick employee dragged himself to work
| instead of being at home curing their disease.
|
| So you go and take personal responsibility for your liver
| and take the Hep A shot yourself. One wishes the government
| supported life, liberty and happiness of its people and
| offered labour protection, sick leave and healthcare to its
| weakest citizens.
|
| Vaccinations are a few hundred per shot, and the part-time
| worker hasn't got insurance or the spare cash.
| Buttons840 wrote:
| > Health insurance is such a weird thing. It shouldn't exist.
| You insure yourself against exceptional things. Yet we use
| insurance for our yearly flu-shot, hardly exceptional.
|
| I knew this in theory, but never really thought much about it.
|
| I need a flu shot, so the company that makes the flu shot needs
| to be compensated (paid), and the nurse that knows how to
| inject it into my arm needs to be compensated, and that's it.
| The manufacturer and nurses provided a sufficient
| infrastructure to administer flu shots.
|
| But in America, I also have to pay a bunch of insurance
| companies. I used to make 6 figures as a programmer in the
| insurance industry. I knew my salary ultimately came from the
| high medical bills everyone pays, and while I didn't blame
| myself personally for a nation wide problem, I would have been
| happy to see my job and my company rendered obsolete and all of
| us move onto more useful jobs.
|
| I want to see a political cartoon where someone gets a flu shot
| and then does their patriotic duty, opens their wallet, and
| starts handing out money to half the nation. In the end,
| there's even a few bucks left for the nurse.
|
| I exaggerate a bit. In truth I think about 20% of US workers
| are involved with the healthcare industry and the surrounding
| insurance and other supporting industries (if I remember
| correctly). I really do have to pay all those people every time
| I have a medical bill.
|
| Fixing healthcare costs will require a lot of people losing
| their job, and that wont be popular.
| mgkimsal wrote:
| > Fixing healthcare costs will require a lot of people losing
| their job, and that wont be popular.
|
| And going to a 'single payer' model would also reduce jobs.
| And the whole "they want to get rid of your insurance and
| raise your taxes!".
|
| Well, the taxes would be raised, but almost certainly to a
| smaller extent than the price of the insurance policy you pay
| for. A middle of the road health insurance policy for me
| right now is around $1k/month. Whether _I_ pay for it, or an
| employer offsets some of it - it 's beside the point. That's
| $12k/year that is effectively a 'health tax', it's just not
| called a 'tax'. Somehow, weirdly, we use the term 'benefit',
| without with I may more easily and quickly die or languish in
| pain. Some benefit ;)
|
| But yes... if my taxes go up by $10k year, but I don't have
| to pay for a health insurance policy... I'm still ahead. If I
| pay for it all, and the employer is out of the loop, it'll
| feel 'wrong' to many employed folks, but the employer will
| have more money - they should either pay people more, or hire
| more people (who used to work in private insurance
| companies).
| throwway120385 wrote:
| It's a "health tax" that's administered entirely by a
| private entity that you can't get rid of except by quitting
| your job or by spending thousands of dollars extra per
| month out of pocket.
|
| I think if it's politically untenable to go single-payer
| then every employer must instead be required to give you a
| stipend every month to buy your own insurance. Then make it
| illegal for a company to offer insurance for their own
| employees. If everyone saw what it really cost and what
| they were really getting there would be a lot more impetus
| for changes.
| kaibee wrote:
| Honestly at this point I'd be happy if employers would
| include on the paystub, the amount the company is
| actually paying for health insurance for the employee. So
| many people go around saying oh they have a job with
| great health insurance that's only $100/month.
| lostlogin wrote:
| > That's $12k/year
|
| You dont need to pay that much. You can halve that.
|
| https://en.m.wikipedia.org/wiki/List_of_countries_by_total_
| h...
| eadmund wrote:
| > Somehow, weirdly, we use the term 'benefit', without with
| I may more easily and quickly die or languish in pain. Some
| benefit ;)
|
| Not dying or languishing in pain sounds like a pretty
| awesome benefit. And indeed, that's the problem with health
| care: when one needs it, one will pay almost anything to
| the provider.
|
| Prices are a communication: they signal customers how to
| ration goods, and producers how to produce them. The higher
| the price, the fewer the customers but the more the
| producers; the lower the prices, the more the customers but
| the fewer the producers. In a free economy, it is possible
| to say that the work output of one FAANG engineer is
| economically worth that of 5 New York City garbagemen or 10
| Podunk, Idaho janitors or 35 burger-flippers.
|
| How many rolls of toilet paper is one vial of insulin
| worth? Infinitely more, to someone who doesn't need
| insulin. Some fraction, for someone who does. Some really
| small fraction, for someone who needs it _right now_. It
| doesn't make any sense for all three of those people to pay
| the same price, for either the toilet paper or the insulin.
|
| In a single-payer system, how much does the single payer
| pay? How much do the producers of health care (e.g.,
| physicians, surgeons, nurses, medical researchers,
| pharmaceutical factories) get paid? It ends up being based
| on the whims of the people setting those prices (a wage is
| just a labour price), not on any fundamental voice of the
| market -- and thus it is either too high, or too low, and
| there is no feedback mechanism to constrain it. And that
| means society will produce either too little or too much
| health care, which means it will produce too much or too
| little of _other_ things.
| mapt wrote:
| To participate in an American healthcare treatment you need
| to interact with a private for-profit company which will shut
| down if it doesn't on average attain significant
| profitability; Let's say 30% goes to shareholders, taxes,
| receptionists, keeping the lights on.
|
| But they don't deal with everything. They have to interact
| with upstream providers! And they have to pay somebody to
| negotiate with them. So another 30%, and add 5% just to pay
| somebody to bargain the price with the Flu Shot Distributor.
|
| But the flu shot distributor has to interact with yet more
| upstream providers - the flu shot packager, who interacts
| with the flu shot pharmaceutical company, and the syringe
| company. Everybody adds their overhead and then their
| premium; "Price signals" become exponentially complex and
| more a matter of the mood of the negotiation than anything
| else.
|
| This is all an externality of a non-vertically-integrated
| capitalist system, which is somehow, somewhy, supposed to be
| regulated by your desire to get a flu shot relative to your
| ability to pay; It is not at all optimal in the market system
| for everybody to get a flu shot, that defeats the fundamental
| mechanism of the supply-demand curve.
|
| https://siderea.dreamwidth.org/1179450.html this essay series
| offers some of the better hypotheses on cost disease that I'm
| familiar with.
| polygotdomain wrote:
| > Fixing healthcare costs will require a lot of people losing
| their job, and that wont be popular.
|
| Agreed, but I also don't think it _has_ to be this way. First
| and foremost, a switch to single payer would mean that a lot
| of the infrastructure that's currently in medical insurance
| industry would need to shift towards being government
| employees. While there'd be massive administrative savings
| with single payer, there wouldn't be zero administration at
| all.
|
| I'd also posture that the US would never go full single
| payer, and that there'd be supplemental plans similar to the
| German model (and Medicare, to be fair), so while private
| insurers would still exist, the administrative burden would
| significantly lower.
|
| In the end, you'd still end up with a lot of people losing
| their job, but it wouldn't be a complete wipe out of the
| industry. Certain areas would get hit harder than others with
| the insurance brokers likely getting cut out big time.
|
| > In truth I think about 20% of US workers are involved with
| the healthcare industry and the surrounding insurance and
| other supporting industries
|
| That seems pretty high to me. I wonder what made you come up
| with those numbers.
| jrockway wrote:
| I really think that health insurance is this. Your premiums
| cover the yearly risk of getting cancer plus a constant amount
| for preventative care; a couple vaccines (get your HPV vaccine
| if you haven't!) and a physical exam.
|
| I'm looking at my EOBs for this year, and all insurance has
| done by their own documentation is negotiate discounts for care
| I've received. I think they have paid $0 of their own money.
| Meanwhile, I'm still paying premiums, but I don't know for
| what!
| PaulDavisThe1st wrote:
| The problem with this analysis is (at least) two fold:
|
| 1. health care is a mixture of the predictable and the utterly
| unpredictable. It is vaccines, regular exams, and minor trauma
| care. But it is also cancer, severe trauma, rare diseases.
|
| 2. insurance in its purest form is not a business but a way of
| pooling resources and distributing risk. Even in some countries
| with socialized health insurance, it is still called
| "insurance" for that very reason. We could get rid of every
| for-profit health insurance company in the USA tomorrow, and
| we'd still want something that is in every way just like
| "insurance" and would likely still be called that.
| Terr_ wrote:
| > Even in some countries with socialized health insurance, it
| is still called "insurance"
|
| To add another data-point: In the US, the real name for the
| law behind "Social Security" is "Old-Age, Survivors, and
| Disability Insurance".
|
| That said, it is frequently mis-characterized in our
| political discourse, with people making apples-to-oranges
| comparisons to investment accounts. I blame that on bank
| lobbyists' attempts to take the money for themselves. Anyway,
| if one views it as "old and unable to support yourself"
| insurance, many of its "weird quirks" make perfect sense.
| throwaway-blaze wrote:
| The weirdest thing about health insurance in the US is how tied
| it is to employment, Obamacare helped a little with this. The
| second weirdest thing is that insurance companies can't offer
| more tightly defined plans for, say, young people who never go
| to the doctor except for critical/emergency care vs me who goes
| a couple times a year for various things. Obamacare did not
| help with this, at all.
| Retric wrote:
| Age impacts health insurance costs, but health insurance is
| specifically excluded for considering existing conditions
| because people can't get long term coverage.
|
| If someone gets a chronic condition while covered the company
| isn't paying out a lifetime benefit, so they soon need to
| renegotiate rates while sick even though they had insurance
| while they got sick.
| ceejayoz wrote:
| > The second weirdest thing is that insurance companies can't
| offer more tightly defined plans for, say, young people who
| never go to the doctor except for critical/emergency care vs
| me who goes a couple times a year for various things.
|
| That's not weird; it's essential for the system to work,
| because you can rapidly move from "never go to the doctor"
| into "seven figures of healthcare spend" without much
| warning.
|
| We used to have "high risk pools"; it was horrific.
| https://www.kff.org/affordable-care-act/issue-brief/high-
| ris...
| SkyPuncher wrote:
| One the second point, they essentially offer this with high
| deductible plans. Essentially, these plans really only make
| sense if you only expect to have emergency care (like young
| people).
| HarryHirsch wrote:
| These things don't make sense even for young people because
| at a young age people tend not to have savings, and a
| medical emergency can totally wipe out your finances.
| Remember what they told you about burial insurance: it's a
| scam, except for young people who don't have savings
| mindslight wrote:
| Well the entire public policy point of insurance is to have
| the people who pay in but don't really use it subsidize the
| people who end up needing it. This dynamic is why the ACA had
| an individual mandate, which addressed the incentive of young
| healthy people to not want to pay in.
|
| It would be sensible if we were talking about one society-
| wide pool (ie single payer), since those younger people would
| end up being subsidized as they developed health conditions.
| But as it stands having many pools run by independent
| companies is fraught with perverse incentives, since an
| "insurance" company is quite happy to have you as a customer
| when you're paying in, but much less happy when they're
| paying out.
| jabroni_salad wrote:
| There is actually a decent way to do that.
|
| You get a high deductible catastrophe plan, and bolt on a
| Direct Primary Care provider for simple things. The DPC is a
| doctor who you pay a small retainer (My guy is $70/mo) and
| the main reason that the cost is so low is that he does not
| need to staff a billing department due to simply not
| integrating with insurance at all. I keep $10K in an HSA to
| cover my deductible if I need to.
|
| DPC doctors also keep a much smaller patient roster so it is
| pretty easy to book time with him and he isn't being
| pressured by some middle manager to keep every interaction at
| 10 minutes or less. Once you see how this all works it's easy
| to become singlepayer-pilled because wow the whole medical
| scene could pay providers better, offer higher quality
| services, and have competitive pricing if we could just get
| around to deleting the billing department and insurance
| company.
| abecedarius wrote:
| Unfortunately the high-deductible catastrophic care plans
| are a lot less attractive ever since Obamacare. I agree
| about your advice as the least bad choice (afaik) when you
| don't have coverage you like through work.
| matwood wrote:
| If you're making income you should max your HSA. It's
| triple tax advantaged.
|
| https://www.investopedia.com/articles/personal-
| finance/12071...
| snarf21 wrote:
| This was a consequence of WW II labor shortages and the
| government froze wages. So companies used benefits like
| health care instead. It should have been outlawed after the
| war. It is very anti-worker and many people won't change jobs
| for no reason other than healthcare. It has also created an
| issue where the health "insurance" companies don't have to
| compete like they do in car insurance, etc.
| Brian_K_White wrote:
| It is entirely correct that the young have to pay for the
| old. It's not robbing from the young who "don't need" it.
| It's the young paying for their own selves who absolutely
| will need it.
|
| Setting aside the reality of the system which will happily
| collect premiums for 40 years and then use any slightest
| technicality to avoid paying in the end, ie like changing
| jobs or providers and it's like you were born on the day of
| that switch and haven't been paying in your whole life. That
| is a seperate issue from the simple concept that the young
| somehow "don't need" to be contributing to the health care
| pool because they "don't need" to dip from it.
|
| In this, there are no individuals and it's not some elective
| luxury like how much you want to blow on toys.
|
| Merely in the US, we have been treating it like it was,
| except even worse, because when I buy a fancy over the top
| steak, I know the price ahead of time and get no surprises
| after the fact either. I don't just get hit with $500 steak
| bills with no warning or choice or recourse and thank god my
| boss takes $12k out of my salary so that I only have to pay a
| $50 deductible and fill out 3 forms correctly for that $500
| steak I didn't ask for...
| golergka wrote:
| > Health insurance is such a weird thing. It shouldn't exist.
| You insure yourself against exceptional things. Yet we use
| insurance for our yearly flu-shot, hardly exceptional.
|
| I treat it more like a subscription. I pay a little over $100 a
| month for health insurance. A doctor visit would cost around
| $10-20 out of pocket, so it wouldn't be worth it. However, the
| insurance also costs with 50% discount on medicine, which ends
| up right about $80 a month (in discount), so it pays itself
| back more or less.
| kaibee wrote:
| > I pay a little over $100 a month for health insurance.
|
| Sorry friend, your total comp likely something like
| $800~$1400 lighter per month due to health insurance. The
| fact is that your company is paying the vast majority of your
| actual premium and you just never see that money as coming
| out of your paycheck.
|
| https://www.completepayrollsolutions.com/blog/how-much-
| does-...
| golergka wrote:
| I work as a contractor. My company is one country, my legal
| entity that receives SWIFT transfers, invoiced every week,
| is in a second country, and I live and pay medical
| insurance in a third country.
| amarshall wrote:
| Health Insurance pays for vaccines and other preventative care
| in part because they believe that doing so will cost them less
| money in the long run.
|
| Somewhat similarly, car insurance will often give discounts for
| completing defensive driving classes, and home insurance for
| having an alarm system.
| alphazard wrote:
| Insurance isn't weird. We have been trading risk for thousands
| of years, and modern insurance companies have existed for
| hundreds of years.
|
| What's weird about health insurance in the US is that it's
| often tied to an employer, and you can't freely switch between
| insurance providers on a whim. It's a way worse experience than
| insuring a car, which can be done on a phone in a few minutes.
| jacobsenscott wrote:
| It's weird you use your insurance to get a routine shot or
| exam. I don't use my car insurance to put gas in my car, or
| get the brake pads changed. I use it when someone does
| thousands of dollars of damage to my car.
| throwway120385 wrote:
| If the type of fuel or the type of brake pads you put on
| had a direct impact on your likelihood of getting in a
| giant accident in the future they would regulate that and
| require you to buy from insurance-approved brake companies.
|
| In effect this is how home appliances are regulated. You
| have companies like ETL Intertek and Underwriters
| Laboratories performing fire and electrical safety testing
| of home appliances, originally on behalf of homeowner's
| insurance companies(See the definition of "Underwriter").
| It's effectively self-regulating because the Intertek or UL
| stamp implies a certain degree of care. And based on some
| lease provisions I've seen the insurance companies for
| buildings do require use of certified equipment as a
| condition of coverage in many cases.
| DennisP wrote:
| It's not weird if you consider that paying for preventive
| care tends to be profitable for the insurance companies,
| because it's cheaper than paying for the problems that
| arise if you skip preventive care.
|
| Auto insurance doesn't pay for your gas because they don't
| have to pay a claim if you run out of gas.
| chimeracoder wrote:
| > It's not weird if you consider that paying for
| preventive care tends to be profitable for the insurance
| companies, because it's cheaper than paying for the
| problems that arise if you skip preventive care.
|
| This is often repeated, but it's simply not true.
| Preventive care is _better_ for patients in the long run,
| but at a population scale it is more expensive than
| foregoing it.
|
| And that is _before_ you account for the fact that
| patient churn is quite high (especially since most plans
| are linked to employment). An intervention that cost
| money today and may increase costs within the next few
| years (due to followup care) is much more expensive for
| insurers if the savings will only be realized in 10+
| years, when the patient has moved on to another job and
| so is no longer on their plan.
|
| Very few medical interventions save money in the short-
| and medium-term at a population level. That's reflected
| in the fact that health insurers didn't cover most
| preventive care until required to by law (the ACA), and
| even then they routinely simply ignore this provision of
| the law. If it were profitable for them to follow the
| law, why would they go out of their way to break it?
| II2II wrote:
| If you don't put gas into your car, it does not run. The
| chances of the car incurring thousands of dollars of damage
| is negligible. The insurance company will pay for the
| routine shot or exam since they both help to avoid medical
| complications that would drive up the cost of care.
|
| Granted, the comparison is imperfect. Medical insurance
| won't pay for a healthy diet (another way to reduce health
| problems) and replacing the brakes on a car would reduce
| the chances of an accident causing thousands of dollars of
| damages ... but we are human, and sometimes it is a miracle
| that we even take half measures.
| recursive wrote:
| Oil changes seem like a perfect analog for flu shots in
| the comparison. I think it's a reasonable and good
| question why health care is so thoroughly intertwined
| with insurance.
| alphazard wrote:
| It's weird that you can't see the prices for those things
| and that the insurance companies pay a different price than
| individuals. That's evidence there isn't a functioning
| market for most medical services in the US.
|
| But it's not weird that the insurance company wants you to
| get a flu shot or exam, since those things prevent them
| from paying out more money later.
|
| In reality there is some cross over point, where the flu
| shot isn't worth it for younger people, and is for older
| people. If you are young/healthy, get the flu and totally
| recover with a few Tylenol, and no insurance claims, then
| it clearly wasn't worth a $10 vaccine to prevent. That's
| the analysis for the insurance company. Depending on how
| you value your time, and time spent sick, your individual
| analysis may be different.
| pyuser583 wrote:
| Group insurance isn't weird at all.
|
| Health insurance is new, because until the 1920s/30s the
| salary loss from sickness was more expensive than medical
| care, so that's what was insured against.
|
| But no sooner was demand for health insurance created than it
| was pushed into groups. In America, there's never been a time
| where non-group insurance was the norm.
|
| The reasons is clear: healthy people would not get coverage,
| but sick people would.
| gnopgnip wrote:
| >You insure yourself against exceptional things. Yet we use
| insurance for our yearly flu-shot, hardly exceptional.
|
| Insurance makes it free to get a flu shot because it makes
| everyone healthier and lowers their expenses. Similar to how
| you get a discount on car for installing a theft prevention
| device.
|
| Insurance isn't just about insuring for exceptional events
| either. It results in a better allocation of resources. By
| incentivizing reducing risk to reduce premiums. Insurance is
| also a huge boon to providers who would otherwise need to spend
| much more time pursuing non payment, or entirely deny services
| to financially risky patients. And then this goes back to the
| outcomes for society at large.
| Terr_ wrote:
| > Health insurance is such a weird thing. It shouldn't exist.
|
| Half-disagree: "Health insurance" is a big group that includes
| a whole ton of things, and only a _subset_ of those don 't make
| much sense.
|
| There are plenty of other maladies/treatments which _should_ be
| insurable because not everyone will get /need them but everyone
| has a risk that can be understood mathematically.
|
| > Yet we use insurance for our yearly flu-shot, hardly
| exceptional.
|
| _In isolation_ , no, but "unusually extreme case of the flu"
| _is_ something that can be insured because it is a rare
| stochastic problem.
|
| So out of enlightened self-interest, the regular boring
| preventative measure gets insured as a way to _reduce the odds_
| of the exceptional case occurring and needing a payout.
| fn-mote wrote:
| > Health insurance is such a weird thing. It shouldn't exist.
| You insure yourself against exceptional things. Yet we use
| insurance for our yearly flu-shot, hardly exceptional.
|
| Yes. The problem here is that (in the US) the "insurance" part
| is combined with the "price negotiating power of an association
| with lots of members" part.
|
| I think it is well known that the non-insurance "list price"
| for a procedure is many times higher than the actual price that
| should be paid. Witness the comment here about the $150k bill
| for a procedure that was settled for $30k once insurance
| admitted they had to pay.
|
| This is one of the reasons that you really can't be paying for
| medical expenses without the weight of the insurance company
| behind you - your bills will not be (what I consider to be)
| fair at all.
| parpfish wrote:
| i'd love to fight my insurance, but it's so unnecessarily
| confusing.
|
| instead of describing the process in plain language, everything
| is wrapped in so many layers of legalese that even the 'happy
| path' becomes impentrable.
|
| i particularly hate the 'EOB' which they tell you 'this isn't a
| bill' but then they make it look as much like a bill as possible
| and don't really tell you what its for other than to show off
| that insurance is... around
| peer2pay wrote:
| Kudos to her for making this open source and free to users!
| kayo_20211030 wrote:
| I see what's going on here. It's another example of
| externalization of costs. Doctors have no incentive to fight the
| denial of insurance. They should, but it's not important yet. If
| they have to sue you eventually for the billed cost, they will;
| or at least they'll sell the debt to a collection agency at some
| number of cents on the dollar. The Insurance company most
| definitely doesn't have an incentive. Once you're denied, they're
| off the hook. They kick it back to the provider, and ultimately
| to you through some debt collection agency. The only person that
| has an incentive is you. And now you're stuck with the cost;
| either in dollars or time, but what's the difference really? It's
| going to cost you either way. Maybe Holden Karau's approach is
| good and valid, but should it be converted to a paying service
| we're just back at square one where it's either time or money.
| Maybe there'll be a discount which makes it cheaper net/net, but
| who knows? The little person here is the patient. All the others,
| doctors and insurers, are the big persons. The little person
| absorbs the cost, whether they want to or not.
| baq wrote:
| I fully expect a disruptive startup to leverage large context
| LLMs to offer a service which understands policies and
| automatically (as much as possible) appeals any and all insurance
| company shenanigans with all means available. (Need a large
| context window to get all the legal and policy texts into there.)
|
| Also, not living in US, I wouldn't be surprised to learn that:
|
| - any attempts to implement this will be met with weapons-grade
| lobbying on all levels to make it illegal
|
| - it was attempted and litigated to hell and back and hence
| forced to shut down
|
| - this business model is illegal already, neither lobbying nor
| litigation necessary
| xyst wrote:
| Health insurance and this anti health insurance product reminds
| me of the "time share" industry and time share exit companies.
| However, unlike the exit companies. This is actually useful.
|
| Hope it ends up working out, and makes it sustainable. Although
| one thing about insurance companies is that they have made the
| rules of this game.
|
| Some sources indicate there is some legal requirement or right
| granted to patients for these internal reviews. But I can't find
| the exact law.
|
| If this service takes off, I wouldn't be surprised if the
| language of this law changes over the years to make it more
| difficult to file patient appeals (or make it outright
| impossible).
| SomaticPirate wrote:
| Wow! Amazing job! I briefly met Holden at Kubecon. What an
| incredible engineer.
| thih9 wrote:
| > "Part of that is an unreasonable willingness to take things too
| far," Karau said.
|
| How many people lack that? And how many companies have the
| resources to take things even further? I wish there was another
| way to get this outcome. Baby steps, I guess; and this platform
| in particular sounds like a good step.
| valenterry wrote:
| I don't think that's the way to go.
|
| First, insurance and everything else (including your job) should
| be strictly decoupled.
|
| Second, health-insurance and life-insurance companies should imho
| be required to be cooperatives. That makes it so that incentives
| are aligned.
|
| That the instance company is denying certain claims (both wrongly
| and rightly) is perfectly fine. In fact, that is good. It's part
| of the core business to protect against abuse. The balance is
| important here and will reflect in the premiums.
|
| Those two things should already fix most major issues in
| insurance in a working market with competition.
| LorenPechtel wrote:
| I think the real answer here is to have bad behavior cost rather
| than trying to legislate it.
|
| A company owes you something and doesn't promptly pay. If you
| prevail in the end and the original problem wasn't on your end
| what they owe gets a multiplier and then a high interest rate.
|
| Several years ago I got totaled. The woman came up with a few
| bits of nonsense that clearly didn't match up with reality but
| the woman from the insurance company saw right through that and
| knew there was no possible way I contributed to it. Then they
| ghosted me until I filed a complaint with the insurance
| regulator.
|
| Make that say 50% or 100% higher, then maybe a couple percent of
| interest from the date that they should have paid. This would
| make such tactics not in their interest because failure doesn't
| mean just doing what they should have anyway.
| ToucanLoucan wrote:
| I've considered several times what a difference it would be if
| legal work by individuals was considered a billable expense in
| the event of the individuals winning. I think it would level
| the playing field at lease somewhat with regard to the inherent
| advantage any corporation has via having a legal division full
| of lawyers over a regular Joe trying to get justice.
|
| But yeah, if some farmer has to sue John Deere to be able to
| fix his tractor or whatever, that's going to take a ton of his
| valuable time to deal with. Why shouldn't he be compensated in
| the event he was correct?
| joe_the_user wrote:
| Uh, Fines are part of regulation. Fines are what makes
| regulations stick. Regulation is based on legislation. Of
| course, it's bad to have Legislation that tries to enforce
| things that regulators already have the tools to enforce (but
| aren't using). But broadly, if you want a hammer big enough
| that a profit-seeking corporation will avoid any tap with it,
| you want legislation. The usual schemes that imply companies
| will face costs without regulation being in effect (basically
| "let the market decide") won't work with individual consumers
| versus health providers or insurance companies.
| blackeyeblitzar wrote:
| I have to say the worst health insurance company, that I
| consistently hear complaints about, is Aetna. Multiple parents
| have shared how difficult it was to get them to cover their labor
| and delivery costs even though it was clearly a part of their
| coverage. All of them had to spend hours on repeated phone calls
| over _several months_ to get them to cover it. Once a claim is
| denied initially, Aetna's appeals and reviews each take 30-60
| business days for each step, and they usually have wait times of
| 1-2 hours. Exhausted mothers who should be enjoying their
| precious time with newborns are instead drowning under stress
| from being on the hook for five figure sums, and Aetna knows that
| they cannot be on the phone for hours. I suspect it's all a
| purposeful strategy to frustrate people and prevent them from
| collecting on their claims.
|
| In my opinion, if an insurance company ends up paying a claim
| that was denied, they should be forced to compensate the person
| for all the time spent, including wait times on hold, at 5x the
| equivalent hourly wage that person would have earned.
| simonw wrote:
| This is such a great example of the kind of disruptive impact we
| can expect from LLMs.
|
| It exposes part of how the health insurance industry works:
|
| "Out of roughly 40 denials, she won more than 90% of her appeals,
| she estimates"
|
| Most people don't have the stamina to dig in when this happens,
| so my guess is the entire insurance industry is designed around
| the assumption that a lot of valid claims won't be paid out.
|
| It's obviously disgusting that the industry has incorrect denials
| baked into their business model.
|
| If we fix that with LLMs, what happens? It's going to have knock-
| on effects, since it could eliminate the profit margin these
| companies have right now.
| bluedemon wrote:
| I wonder if someone made one for credit card disputes.
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