Biggest health insurer plans to deny ER bills if it doubts you had an emergency
arstechnica.com
arstechnica.com
My primary concern is healthcare costs. How am I supposed to budget for healthcare costs during retirement when it's already so complicated.
530,000 American households are bankrupt each year due to medical costs [1]. It seems like the most complex piece of the retirement planning puzzle.
[1] https://www.cnbc.com/2019/02/11/this-is-the-real-reason-most...
The bigger issue is that I shouldn't have to think about this sort of problem in my emergency or estate planning.
I once quit a bay area tech startup job in my 20s due to burn out (5 years no vacation, easily 50+ hour weeks) and in those few months of taking time for myself I got hit by a bout of what I assume was appendicitis. I delayed going to the hospital because I didn't have insurance since I had just left my job. The pain passed that day, but then a few weeks later the same excruciating pain came back -- just really indescribable pain -- to the point where I semi-consciously was asking my partner to make sure I didn't die. Ended up at the hospital, they confirmed appendicitis, did the surgery in less than an hour, and I got hit with a $25k bill. I remember an administrator coming into the room before the surgery and asking me for a credit card while I was completely out of it, because I assume someone told them I didn't have insurance.
After it all happened I was talking to a friend of mine who is an ER doctor and he told me, quite frankly, that if you ever find yourself in a situation like that to just leave your wallet at home and give a fake name. As a doctor they're going to treat you no matter what.
It's horrifying that we have to deal with this system in the United States. It does make me consider seeking citizenship elsewhere, which I consider more seriously the older I get.
Why are there so many Americans with so little savings and yet hyperconcentration of wealth by a panoply of billionaires? Income inequality derived from the rich owning the political establishment.
Thank you for saying that. I will add: The US has some sucktastic housing policies that are an underlying cause of this social cancer.
I still write about it sometimes on various blogs of mine, like Street Life Solutions.
It's really tempting to just stay and work a data science job, though I do enjoy the time teaching gives me off, the fact it'll pay off my loans and that I can live comfortably with plenty to save to travel abroad for a few weeks every summer (I realize I might be one of the few teachers like this and I credit it solely to being single and no children).
And, yeah, I'll get state insurance when I retire, but it just sounds nice living in Europe (using the Ireland masters as a jumping-off point for networking) and not having to worry about it at all, even if I have to give up a lot of the stuff I value about teaching (namely, 75+ days off a year and a decent work schedule)
That would only make the situation even worse, hospitals would raise their absurd gouging rates even higher if government required it.
Reform is needed but on both sides of that table.
Is this related to the article? Probably not. But I never get enough chances to point out the myriad abuses and misuses of the health care system.
This is likely due to an inability to access "regular doctor" care. Either for lack of insurance (which they can't afford), or a giant deductible (which they also can't afford). The doctor's office can turn them away for an unpaid bill; the ER cannot.
Specifically, people without insurance end up at the ER because the ER can't legally turn them away for not having insurance or not being able to pay.
Another predictable consequence is patient dumping, where patients who cannot pay at one hospital are sent to the ER at another.
Perhaps you are in a local minima of bad conditions.
Even if what you saw is widespread, it is still no excuse for this kind of stupid response from insurers. It is not even close to justified.
The idea that the ER can't triage non-emergency care is some sort of bureaucratic construction designed to facilitate making money.
So, not the patient, who has played by the rules their entire life, and properly paid into the system, is now literally fighting for their life, probably without a job, and is now denied the healthcare that they had paid for their entire life.
And when a case manager denies their claim and saves the company $500K, they get promoted for killing the patient.
This is not rumor. This is sworn testimony before congress.
"Fuck these people" indeed!! (except they may no longer qualify as people)
Citation please?
It was systemic in the industry before it was banned by the ACA/Obamacare. This is one of the most important features of the ACA.
I've posted below only one of the first appearing links to articles on the testimony of industry insiders [1]. I don't have handy the link to the video I found most memorable. It was a woman who worked at a large insurer, who rescinded the insurance of a man with an expensive disease, who'd never missed a payment, and who died fighting to get the insurer to pay. so he could get treatment. She felt badly enough about it to testify, and was also promoted for saving the company money.
Just because it sounds outrageous and dishonest does not mean that people won't do it.
[1] https://abcnews.go.com/Business/Health/story?id=7911195&page...
Maybe a stretch, but possible.
But it's very profitable.
Physician salaries have certainly outpaced inflation over the past 50 years (in most specialties - pediatrics and internal medicine seem to have dropped slightly) and the profit share of insurance companies has drastically increased over the last 20 years.
After Obamacare, health insurer profitability has actually improved, and health insurance stocks have outperformed the S&P 500 by more than 100%.
If you want a cut, you should really buy some stock.
Your kid bumps their head.
"There was no blood, but the baby was inconsolable. Jang and her husband worried he might have an injury they couldn’t see, so they called 911, and an ambulance took the family — tourists from South Korea — to Zuckerberg San Francisco General Hospital (SFGH).
The doctors at the hospital quickly determined that baby Jeong Whan was fine. He took a short nap in his mother’s arms, drank some infant formula and was discharged a few hours later with a clean bill of health.
... the bill finally arrived at their home: They owed the hospital $18,836, the bulk of which was for a mysterious fee for $15,666 labeled trauma activation"
Hahah. For the insurance companies this happens over and over.
Of course, the lobby groups will get everyone riled up over this and HN contributors will be calling UnitedHealth scumbags / capitalist pigs.
"UHC’s parent company UnitedHealth Group posted a 35 percent year-over-year jump in operating profits in the first quarter of 2021"
* Significant reductions in demand for standard services. * Generous compensation for COVID services.
In particular see the chart that shows 2018 and 2019 profits
You'll have honest / primary care providers going bust under Medicare / Medical and folks who get aggressive on billing / switch to lucrative areas (medicare advantage is mentioned) and milk like crazy.
Large corps shop and cost shift to employees who also shop on price etc so margins are poorer there (where the issue in article is more relevant).
The insurance companies have contributed to making American healthcare so dysfunctional. They are not the victims here.
Then people can and do pay on top of that for private care. Super wealthy are in their own system, many others go for basic stuff to public option but might pay privately for speed / fancier results.
This mirrors libertarian model in most cases.
The US is a bit unique. For example, end of life care is both fully covered in most cases and insanely expensive - we spend far more than many other countries on things like last 3-6 months of life doing "heroic" measures, full intensive care etc etc. Again very lucrative to hospitals so don't see it stopping, but yes, other countries do not do this unless you pay yourself.
Then I got the bill which insurance paid. The hospital decided to code it as a broken limb and everything that goes along with it, xrays (which I didn't have), plaster cast (which I didn't have), etc... Even though insurance paid, this sort of thing just pisses me off. So, I spent hours on the phone getting it fixed which made the bill maybe 1/4 of what is was originally.
Fast forward 12 months and I get a letter from collections for ~$500. WTF is this? I never received a bill from the hospital. It took me a bit to even realize where this might be coming from. Once again, this type of stuff annoys me, so I call collections. "It's not much just pay it" - they cut it like $100. Not going to happen. So I wrote them and the hospital asking for the bill details which neither could produce and the delinquent bill was cleared.
I rarely go to any ER type care and I have 2 stories of bills being f'd up. So yeah, the rate of errors seems beyond that of simple mistakes.
The risk here is having patients doing their own triaging. If the insurance company really wants to reduce costs, they can partner with a network of ERs who commit to triaging and transferring to lower cost providers if the issue is not an emergency. The patient is not qualified to make that decision.
I worked at a health tech company where we analyzed bringing down costs through claims data, I can tell you that there are actually hundreds of ways insurance companies can reduce costs that won't risk patient safety, but do not. For example, there are billing mistakes all the time, but insurers do not give a crap. We tried building features to help identify billing mistakes but we never could get insurers to care about it. The amount of times I saw insurers undermine patient safety for "costs" was staggering so I'm really skeptical that the insurers are doing the right thing here. As another example, we saw insurers build "Centers of Excellence" and push patients towards taking care there. Basically what they did was find crappy hospital systems who were willing to take lower rates and they would tailor their insurance plan to push patients that way. Unfortunately when we analyzed claims and outcomes we found these Centers of "Excellence" actually had way worse patient outcomes. We raised this point with the insurers and again, they did not give a crap.
But being charged $18,000 for a doctor to look at you for 15 minutes? If people paid out of pocket these bills would be uncollectible.
Another problem with the policy, though, is that many people are forced into ED use because there are simply not better options. Urgent care in the US has become fairly restricted in scope of services in a lot of areas, so the grey area between "urgent care worthy" and "ED-worthy" is larger than it should be. Many things that are maybe less ED-worthy become ED visits because urgent care is inaccessible, and delaying to urgent care or outpatient might make them emergency in nature. Even things like routine medication refills for certain groups can become ED visits because urgent care is closed, outpatient visits might be scheduling too far out, and so forth.
Do some people abuse the ED? Sure. But then find another solution for those people.
Ironically they tend to be the uninsured because the ER can't turn you away. The solution is to get them insured.
For some comparison: Since I moved out of the states, I pay less than $300 a year out of pocket (in general). My biggest expenses - a neurologist, for example - costs less than $50. As does the ER, honestly, or the clinic that deals with injuries (the ER will send folks over there). The rest is taxes, and taxes are lower than federal + state + insurance premiums in the US.
Additionally, it isn't just insurance. If you work while the normal doctor is open and you don't have paid sick days, you might not be able to go to the doctor even if health care is free simply because you can't afford to miss work. You need paid time off for this sort of thing - and honestly, parents need more days since they have responsibility for than one person.
Look I’m sorry my minor stroke annoys you, but something beyond go home and see if it turns into a major stroke would be appreciated.
From the study:
Findings This cross-sectional study found that 1 insurer’s list of nonemergent diagnoses would classify 15.7% of commercially insured adult ED visits for possible coverage denial. However, these visits shared the same presenting symptoms as 87.9% of ED visits, of which 65.1% received emergency-level services.
https://jamanetwork.com/journals/jamanetworkopen/fullarticle...
I agree with the implementation because it puts the burden in the right place. The error here is not that the insurer is denying payment, but that the hospital is then passing the bills onto the patient.
Somehow, we have to reduce unnecessary use of emergency services. The doctors correctly point out that patients can't make that decision. Since the doctors _can_ make that decision, they should be involved in helping reduce ER misusage. The insurance company is setting up the correct incentives for the hospital to do exactly that; however, the hospital is dodging the incentives by passing costs to the patient. So the hospital is in the wrong here.
Serious abdomen pain can be gas or something serious. You can cough hard enough to fracture a rib. Chest pains can be acid reflux or a heart attack: I had gastritis when this happened to me.
And this is a good deal of the issue: You don't know how serious it is until you go to the doctor.
Now, this doesn't cause all of ER misuse, but we aren't doing anything to make that better. A doctor won't see you if you can't pay upfront. This is the same problem with urgent care: Either pay upfront or don't get helped. The ER, though, will bill you. Which does mean that if you are poor - especially just over the income level to get help with a lot of expenses - you either go to the ER when you need a doctor or you don't get seen and have to wait until it IS serious enough for the ER.
We can solve this by making sure everyone can very easily afford health car (I no longer live in the US: My out of pocket is $300 per year, and this includes necessary prescriptions, doctors, physical therapy, some dental stuff, and so on). The rest is paid in taxes, which are less than federal + state + health insurance was in the states: Nevermind having to pay a deductible before the out of pocket. (I know my GP will bill me, by the way).
But another way to handle this is to have something akin to urgent care on hospital grounds - a place that folks can see a doctor/nurse practitioner for non-emergency things and get billed later.
That is because ambulance are charged on use basis in the US. The ambulance company has to provide the service even in the patient cannot pay for it. So they charge high rates with the hopes that they can recover from someone with good insurance. There are many rural ambulance systems that are failing due to insufficient insured patients. The real solution is cities/counties fund the service through taxes just like police/fire.
If something happened in the middle of the night to you, where you would find a doctor in the middle of the night if not at the ER?
And let me tell you, that rash is absolute agony. So. Much. Freaking. Itching. I wished it was pain instead. I would have tried about anything to get it to stop. It was all over my torso, and just horrible. It is really important to get it taken care of before it gets worse - you don't want to, say, take more medicine and not be able to breathe.
The other thing that can cause a rash-like appearance is an infection, though they usually describe this as red streaks (from a cut, anyway). If this is happening on a friday night, you shouldn't wait until monday to take care of it.
But: "UHC’s parent company UnitedHealth Group posted a 35 percent year-over-year jump in operating profits in the first quarter of 2021. Despite earning $6.7 billion in a single quarter, UHC enrollees are being asked to pay more for their coverage."
The greediest, most depraved people in the country are responsible for keeping us healthy.
"UHC’s parent company UnitedHealth Group posted a 35 percent year-over-year jump in operating profits in the first quarter of 2021. Despite earning $6.7 billion in a single quarter, UHC enrollees are being asked to pay more for their coverage."
The insurance companies should lobby to make that illegal, if it's already illegal lobby to have that law enforced (if criminal) or take them to court (if civil) or both (if both). In the meantime they shouldn't be shifting the liability to the patients.
Ergo it can't be a human right because it is limited, a right is something that everyone should have.
Also what do we mean by "healthcare" is it anyone should be allowed to have any medical procedure they want whenever they want it? I ask because by simply having access to penicillin, aspirin, benedryl and ibeprofun you now have better healthcare than any person in human history that lived before the 1950s. So when we say healthcare is a human right we really need to define what we mean by healthcare.
I also want to make clear I in no way support the insurance companies or hospitals as I think they are all greedy filthy parasites, and have been in constant combat with them for years, but I also don't understand how any rational person can justify the comment that healthcare is a human right.
We fund police, fire, infrastructure as a society, we can fund healthcare as a society as it is generally cheaper than whatever the fuck we are doing here in the US.
In any common sense Healthcare is most definitely not a limited resource. In fact, due to more preventative Healthcare options available it would definitely decrease the loads on hospitals.
See- every other developed nation with basic health care.
Big companies don't want healthcare to go away, because it's means to control employees, it's a way to suppress competition from small businesses, and is suppresses wages.
This could kill.
Really surprised how much shit Americans are capable of taking.
Color me surprised!