It’s intentional. They save billions using this practice because some people don’t have the time, knowledge or resources to dispute.
It may be just anecdata, but In Hong Kong, my family has an insurance agent whom we work very close with. We're just middle class. E.g. only my dad has a car; my sister is 42 and I'm 38, and we still don't have our own car. Whenever something related to making use of the insurance plan comes up, the insurance agent would be very helpful and ensure we get our money's worth. She would teach us what to do in order to not miss out on benefits. The claims process is also easy. We don't get this nonsense where the insurer tries to deny us and hope that we don't dispute.
It’s also not the case in 99% of US claims. The ones you hear about are typically due to healthcare providers not providing sufficient justification for the healthcare or medications they are prescribing, which can easily cost tens of thousands, if not hundreds of thousands of dollars.
The “insurers” are many times not even the payer. In many cases, the government hires insurers to adjudicate healthcare according to the government’s rules, which will specify under what scenario and documentation they will pay for certain treatments.
Surely, there are mistakes made, but there is no standard operating procedure at insurance companies to deny healthcare. They employ teams of doctors and pharmacists to review cases and determine what is evidence based medicine and what conforms to the payers’ guidelines.
So is it just sampling bias that we hear constant stories outside the US of everything from broken legs to cancer patients being denied coverage or being covered but having life destroying out of pocket costs? Because it really is constant.
It would be nice if someone brought data to the discussion.
And specifically about health insurers erroneously denying coverage. I have first hand knowledge from a doctor at an insurance company that audits other doctors’ work at the same insurance company to ensure they are not erroneously denying claims, as there are heavy penalties from state governments and CMS.
That is a separate conversation from out of pocket costs destroying someone’s life that has nothing to do with health insurers and everything to do with how much US voters are willing to have their taxes go to those with less.
There is some information in this link:
https://www.kff.org/private-insurance/issue-brief/claims-den...
> The ACA guarantees external appeal rights to enrollees in all non-grandfathered private health plans. When issuers uphold denials at the internal appeal level, consumers have the option of requesting an independent review by an outside entity, whose decision is binding. Consumers also can bypass internal appeal and go directly to external review in emergencies and certain other circumstances. Consumers seldom avail themselves of external review.
Even that link you provided doesn't really back up what you said: "denial rates ranged from 1% to more than 40% across insurers"
And yes, I know the link doesn’t have statistics in erroneous denials of coverage (I couldn’t find it anywhere quickly), but it did note that the law requires insurers to abide by an external reviewer’s decision.
Surely if there were that many erroneous denials of coverage, there would be lots of people clamoring to get it overturned via the external reviews.
It’s probably just the case that most denials are justified (in the legal sense) that the requested healthcare lacked sufficient documentation, did not have efficacy data, was using brand name medicine instead of generic, etc.
However, many people's "hearing" is a slightly less biased sample than that. It's that every American they have personally talked to about any visit to a hospital seems to have a horror story about (at very least) crazy bills, hours on the phone with insurers for months to years afterwards, etc. That's also not unbiased since people like telling these stories, but at least the denominator is two digits not seven. (The stories may also not reflect the latest reality, as you say.)
> We don't get this nonsense where the insurer tries to deny us and hope that we don't dispute.
Restated, this is claiming that health insurers in the US erroneously deny coverage as a policy. And that is the specific statement I am saying is untrue.
The crazy bills are true, you should of course budget to be able to afford the out of pocket maximum for healthcare costs in any given year. The hours on the phone might also be true, but I know how complicated of a topic US healthcare is (perhaps needlessly, but it is what it is).
Personally, I have more issues with the healthcare providers than with the insurance companies. The insurance company has picked the phone pretty quickly when I call, and tell me the price of a procedure they have negotiated with the provider if I give them the code for it. You can even search it online on a map to shop around the prices.
The problem that I have in US healthcare is that no healthcare provider is willing to give me a code, even for simple checkups or X-rays or what have you, where everything is known in advance. The healthcare providers don't want to risk
And to finish, I'll provide with an anecdote about one of my experiences with healthcare:
My wife gets an ultrasound. The healthcare provider charges $15 for "towels" used to clean up the gel they put on my wife for the ultrasound. In reality, it was a few pieces of paper towel. The insurance company denies to pay for the towels, so we get a bill for $15. I call the healthcare provider and asked why I'm being charged $15 for a few pieces of paper towels. The person in the billing department says to ignore the bill and not pay it.
As a consumer, what am I to understand here? That healthcare providers are overcharging? Or maybe insurers are underpaying (or paying late, or causing too much paperwork) so that healthcare providers are overcharging to make up for some of that? Or healthcare provider is just charging and collecting payment from anyone who doesn't contest, and letting it go for anyone who does?
I inquired multiple times as to all the charges that will be had during the ultrasound. It's a completely routine procedure with no unexpected costs, but the healthcare provider told me they can't give me the codes they will bill. Had I been provided the codes beforehand, I would have brought my own paper towels to wipe the gel off. So I can conclude that the healthcare provider was not really trying to recoup paper towel costs.
The policy may not be explicitly stated, but having dealt ( and likely having have to deal with both this year ) with medical issues ( and related bills ) in US, to me it is clear that everything is stacked against the recipient of healthcare benefits. In other words, actions speak louder than words. The moment I have to spend multiple hours a day, faxing stuff, confirming receipt, complaining, contacting various overseeing bodies, I think the unstated policy is pretty simple. Deny and delay is a tactic. And it works. Not everyone can devote time and energy to this. It is exhausting.
"The problem that I have in US healthcare is that no healthcare provider is willing to give me a code, even for simple checkups or X-rays or what have you, where everything is known in advance. The healthcare providers don't want to risk"
I am willing to agree here. There is a fair amount of issues that are created for a patient by the providers ( coding, communication with insurer or lack thereof, now standard 'you are responsible for everything insurance doesn't pay' clause and my current favorite 'some of the providers in our hospital may bill you separately' ). It usually takes some yelling to get some of the charges to 'reasonable' level and I have the feeling the only reason I got away with it is, because the election was in full swing and no one wanted another crazy hospital story.
This is so out of sync with the experience of everyone i know that i wonder if you've interacted with the healthcare system at all beyond checkups and occasional antibiotics.
https://www.npr.org/sections/health-shots/2014/04/14/3025478...
https://www.capradio.org/articles/2014/04/01/patients-win-ab...
>Insurers say only about three percent of claims are denied.
>California data show about half the time a patient challenges a denied health care service through a third party, the patient wins and gets the health service.
If we assume that denied claims that were overturned were erroneously denied coverage by the insurance company, then half is a huge error proportion, one that would make me think the insurance company is doing it intentionally, or at least intentionally not doing it right.
But maybe the ones that got appealed are closer to being decisions that could go either way and the ones that don't get appealed are black and white cases that were clearly covered or not covered.
At this point, it would be cheaper and easier to manage everything myself. The only problem is, if I don’t use my insurance, the out of pocket maximum for inpatient treatment would be so expensive I’d refuse treatment and risk killing myself or harming other people. (Which is very much non-zero.)
As a child, my parents constantly fought insurance to get life-threatening allergies treated.
Of course he is of Medicare age, so this is a Medicare Advantage plan that is still bound by many of the Medicare rules and copay schedules. I can't imagine going through the same thing with my own insurance.
In my anecdotal experience I have had insurance deny claims on medicine prescribed by my doctors frequently, in one case they would not cover a medicine costing $50 over the counter, but instead had me switch to an alternative with a $10 copay which turned out to be billed at $170 to the insurance company once i got the detailed statement!! how does that even make sense?
It makes sense to them because the insurance company benefits from higher cost of delivering health benefits as it justifies higher premiums. Since they are by law limited to earn a capped percentage on premiums minus costs (at least in my state), the only way they can deliver increased returns to shareholders is by increasing our costs and hence our premiums.
I’m claiming that insurers do not erroneously deny claims in the hopes that people give up. I don’t have data for it, but I’ve also never seen data that shows insurers deny coverage just to dissuade people (post ACA).
> experience the problem with our health care system is not just denial of claims, but about the cost of medical services and medicine.
Yes, I agree here about the cost of healthcare, but that is a separate issue from insurance companies erroneously denying coverage.
> how does that even make sense?
Prices for medications are extremely obfuscated, and you will never know the true price paid due to various rebates and fees on the backend between manufacturers, insurance companies, and retailers. There are various reimbursement rules from CMS (centers for Medicare and Medicare services), state Medicaid, various employers, and it’s a very, very inefficient method of price discrimination.
> Since they are by law limited to earn a capped percentage on premiums minus costs (at least in my state),
ACA caps health insurer profit margins federally, so it applies to all states. Assuming there are multiple competing health insurers, then unless they collided, they would not be able to arbitrarily raise prices to increase the absolute value of their profit margin.
The problem was the political compromise that had to be made in order to pass ACA, which is that it allowed employers to maintain their silo’d group of employees. So you have a whole bunch of healthy white collar lives taken out of the healthcare.gov market, which leaves it with all the sick and poorer lives, making it less viable for multiple health insurers to exist. If everyone had been forced onto healthcare.gov, then it’s feasible for multiple health insurance companies to exist and compete. Also, there should be no state boundaries, since some states’ populations are so small that they can’t afford to spread around the healthcare costs.
I always tell the same story in opposition to our current capitalist healthcare model:
1. When my oldest daughter was born 10 years ago with Spina Bifida we had private insurance through my employer. The premiums for this were something like $15,000/yr. At the time this was probably 1/3 of my total income.
2. Despite that, we continue to receive bills that we couldn't possibly pay for years after that.
3. Since my third child was born, the children have been covered by a state program (Georgia), and pretty much everything has been covered, no questions asked. As a consumer, this is pretty much all I care about.
I recognize that the current system is bad for the service providers as well, as evidenced by this article. The doctor in question gotten all he's gonna get from insurance companies. He has no hope of collecting this money, so he may as well turn it into good PR (cynical perspective, I guess, but that's me).
And your GA state program is most certainly made possibly by the expanded Medicaid funding due to ACA.
>There isn't any trust - as many posters here describe, paying medical bills in the US is (feels like?) a constant struggle against being defrauded by both your insurance company and your doctor.
This is true, but it would help if healthcare providers would list the codes they will charge so that people can look up the cost with their insurer and aren't signing blank checks every time they enter a medical office.
You keep saying "erroneously" but I'm not sure what you mean by that.
My experience is that for any major change in medication (either dosage or brand, but for the same chronic condition) the insurance will initially deny the claim. This kicks off many hours of phone tag between my family, the insurance, and the doctor. Eventually the insurance company will pay up, but usually well after we've already paid out-of-pocket for the first month, which then requires another few hours on the phone to get reimbursed.
This isn't a single insurance provider. This has spanned decades, 4 employers, 5 insurance companies, and at least 3 medical providers.
"Erroneously" as in denying coverage for something that should be covered (per the terms of the contracts).
It's unfortunate that you have to go through all of that when changing medications. I don't know the reason for it in your specific case, but I would hope it's not widespread fraud across all of those companies.
Assume it is. It’s the normal way of doing business. Deny things and hope that most people will give up.
This is all public information per their SEC filings. You can drop the compensation for all the bosses down to zero and it wouldn't move the needle on how much more healthcare they could be providing the insureds.
Cigna alone posted annual profits of $122 billion in the same year that General Motors and Ford combined made less than $7 billion.
As far as I can tell, it's a byproduct of an adversarial relationship between the 3 parties (consumer, doctor, insurer). Insurance doesn't trust the MD to do his job, so hires their own MDs to second guess. And on anything that costs more than $100, that second guessing is the default action - the insurance company's own MDs are only there to provide legitimacy to the initial denial. I say this because in ALL cases, my medical needs have eventually been covered, but not before committing more time and energy than should be necessary.
At the end of the day, we pay more money (and time) for worse outcomes than most of Western Europe and the wealthier nations in Asia.
I have first hand knowledge that this is false. Especially if the insurer is just acting as an administrator for a state Medicaid or federal Medicare or other payer, since there are big penalties for denying coverage just to save money. The insurers even have MDs and PharmDs to audit their own MDs and PharmDs to see if they are appropriately approving or denying treatment.
A lot of the problem is probably coming from lack of proper EMR and supporting documentation justifying treatment, and subjectivity in justifying treatment because there are many gray areas.
This same approval denial situation happens under taxpayer funded healthcare also, since no one has unlimited resources. But yes, the US implementation of it with myriad payers and rules certainly makes for an unpleasant experience and results in subpar healthcare.
If that was true, there would be an insurer doing that and offering lower premiums on healthcare.gov
But it's not true, and the review processes do control costs (even if wrongly at times). I think the government farms this task out to insurers specifically so the insurer can take the heat for the denials, when it's actually the government's rules and standards for the requested therapies that is resulting in denial of coverage.
I've personally seen this with Medicaid or CMS penalizing for erroneously approving payment for treatments and also erroneously denying payment for treatments. And it gets very fun when the rules are not clear and there is a lot of gray area.
However, w.r.t. long term medications getting denied, keep in mind that every claim starts denied until a path through to an approval can be traversed. This is a fundamental starting pount for any insurance related system. It is fundamentally a filter.
You as the customer do not have readily available access to many of the clinical programs going on in the background. Opting in and out by a plan sponsor can substantially change the footprint or character of approvable claims. Especially if paired with formulary changes.
If you happen to be on any type of high cost or specialty treatment, you're on course to misery-town, because you just popped up on the radar for entire divisions worth of second guessing justified by fiduciary duty, but often implemented in ways that leaves the patient both helpless to know what is going on, and holding the bag.
There's no reason why all these billing codes and coverage conditions should be shrouded in mystery.
I don't really care whose fault it is, I shouldn't have to play phone tag with two powerful entities over the course of 8 months as they try to figure out if they're going to fuck me over or not. It's a huge waste of time.
From what I observe with people I know the number is way higher. If you have a serious disease like cancer you there is a very good chance that you will spend a lot of time fighting providers and insurance. It can turn into a full time job.
They offer services for adjudicating services and prices for self insured and non self insured clients.
Self insured clients would be governments (Medicaid, Medicare, large corporations that can afford to pay for all of the healthcare). Non self insured are clients like smaller companies and people on healthcare.gov that pay insurance premiums, but are not liable for the entire amount of healthcare.
In the event the MCO is administered a self funded plan, they are simply following rules laid out by the payer. The payer (usually government) can come in and audit the MCO anytime and penalize them for approving healthcare that the payer deemed outside the scope of the rules. This works out quite well for the payer, as the MCO serves as the fall guy and takes the heat of being a “bad actor” and denying people healthcare.
The reality is that healthcare in the US is rationed, and MCOs are tasked with rationing it. The government gets to avoid being blamed for denying care.
However, I was able to tell my doctor's office that I want the wellness visit charge code only, and they did that. I don't even see a reason for the new patient visit code to exist, since they are allotted the same time and subject matter.
For example:
https://content.highmarkprc.com/Files/EducationManuals/Geria...
If a doctor bills for code 99387, that might not covered under "annual wellness visit" or "annual physical" by the insurer, so you end up having to pay the whole amount if you haven't met your deductible. If the doctor bills code 99397, then it would be.
But it shouldn't be this hard. The insurer should be forced to show the codes that qualify for the free annual wellness visit, and you should be able to inform the doctor's office that you want to purchase services for that code and that code only.
The problem is you can´t easily opt back into the public system once you´re out (especially once you´re old), so there are tens of thousands (if not hundreds), that get stuck in the private system without being able to pay the fees because they´ve become poor (possibly because of health reasons), and then they get denied coverage and thus access to medical services.
Immigrants can fall through the cracks in the over-complicated system as well.
The problem is not as insane as in the US, happens "at the fringes", but it still affects thousands and is mostly outside of the perception of society, since everybody just assumes they got the best system in the world.
However, I think we can still say "America's system is totally screwy" and also say "and btw, as a warning, X country seems to be heading down that route too" - I don't think, phrased the way ant6n's post was, it takes away from criticism of America.
Essentially, in a perfect world, nobody would be made bankrupt because they got ill, and it seems right that governments should do everything they can to prevent that. If there is a class of people who get forced into that position because of something they cannot change, then that system is broken - whether or not that broken system adversely affects you personally. For example, the American system is not broken for rich people, and especially those in perfect health. For those people, it works just right.
And even if you are the only person in a country that is given the choice between feeding their family or investigating an abnormal lump, it doesn't matter how many people benefit from the upsides of that system, it doesn't matter if all your neighbours can visit their GP for a weekly checkup without penalty - without a doubt that system is broken and unjust and needs fixing.
But yes, I think most developed-country-based non-Americans would rate America's system as somewhere between "more broken than mine" and "perverse and cruel". The fact that we all use America's system as the yardstick for what a bad system looks like says it all.
Although I recognize the personal hardship this can cause, I fail to accept this as a general injustice. In the German healthcare system nobody is forced to choose a private insurance instead of the public one. Choosing a private insurance when you're allowed to (which often means because you're in a higher income bracket) is usually only cheaper if you're young and healthy. It's basically a gamble on your own health for wealthy people.
And if the wealthy young and healthy population don't contribute to the public health insurance system which also pays for the not-so-wealthy and not-so-healthy (older) population, the public insurance system isn't sustainable.
The real problem with this system is its division in public and private insurance. Mandatory public insurance would mean lower insurance fees for public insurance and the problem of being stuck in private insurance would no longer exist.
So while I get your sentiment you're really arguing against the wrong person here.
Besides that in my opinion there is a significant difference between "falling through the cracks" and making wrong decisions poorer people aren't even allowed to make - and then wanting those poorer people pay for your errors.