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Comment by lotsofpulp | Hacker News Reader

Health insurers do not approve/deny claims based on what level (platinum/gold/silver/bronze) insurance you have.

What might happen is a generous employer funded or government funded (such as Tricare) plan might offer more coverage for brand name drugs, or less requirements for pre authorizations. And a less generous plan such as Medicaid (state government) will try to minimize costs by only covering generics or requiring more pre authorizations.

But the people reviewing the claims at the managed care organizations are not looking at what kind of coverage a patient has to decide if they do or do not need a medical procedure or a lab.

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Try booking a doctor's appointment in the US on a Medicare plan vs. under private insurance. You'll find that the former gets pushed out weeks and months, whilst the latter finds availability within days.

The claim I was responding to was that a healthcare provider would pursue expensive procedures (presumably not medically necessary) based on what kind of insurance a person has.

To which I would say that is wrong because the person working at the MCO reviewing the claim would not be evaluating the expensive procedure based on if the insured has Medicare or Medicaid, they will approve or deny it the same if they deem it medically unnecessary.

I agree that healthcare providers get paid differently based on the patient’s coverage, and that would influence the priority they give the patient. In fact, I would say the whole point of the convoluted MCO system (versus a simple taxpayer funded system like UK) is to give the government plausible deniability for segmenting the population into various groups of people getting different quality levels of healthcare.

I answered that indirectly. The point is that yes, services offered, both in time and manner, will vary by an individual's insurance status, coverage, and provider.

If think you’re mixing up Medicare (old people) and Medicaid (poor people).

Doctors love Medicare. It pays them nearly instantly, steady stream of clients, and known fixed rates commensurate with most private negotiated rates.

Medicaid is the one that has much stricter benefit rules and tighter price guidelines.

Quite possibly. Thanks.

Steady stream of clients, but it doesn't pay much. Many docs limit the number of medicare patients they'll take because of this.

As someone with high end insurance then to Medicaid not in my experience. It's how the request or referral is worked. You get something for a right heart Cath it's months. If it's a right heart Cath for XYZ a lot reserved slots open up but even then there is no guarantee

> Health insurers do not approve/deny claims based on what level (platinum/gold/silver/bronze) insurance you have.

If the patient has good insurance, they don't really care about providers doing a lot of expensive unnecessary things, because they're not paying.

If they have less good insurance, either the patient is paying more to you out of pocket and is more likely to balk, or you're waiving the patient's portion of the cost and you don't want to be doing unprofitable unnecessary procedures for them.

So the incentive is for providers to do lots of expensive unnecessary things on the patients with better insurance.

I will agree that a patient with a higher deductible and higher out of pocket maximum may be subject to less unnecessary things. And that is why I think high deductible health plans are the way to go.

I guess doctors could be basing their diagnoses and recommendations on the out of pocket costs for the patient, but I like to think that is not the case, by and large.

High deductible health plans might as well not exist a lot of the time because people don't use them and don't get preventative care in order to save money short term. Health care is a racket and a joke in the US.

Anyone getting rich in the insurance business or hospital administration, writing overpriced administrative tools or telehealth software, selling overpriced medical equipment, etc. is profiting from death and suffering, and should feel terrible for it every time they cash a check, but the thing is, they don't. There are too many exploiters milking health care due to inelastic demand and the extreme depravity of people eager for money that passes for virtue among the depraved.

> But the people reviewing the claims at the managed care organizations are not looking at what kind of coverage a patient has to decide if they do or do not need a medical procedure or a lab.

Unless it either meets preselected criteria (or gets lucky with the RNG for orgs doing random spot review) for manual review, or is an appeal, the “people reviewing the claim” aren’t actually people in many cases.

But, people or not, they don’t care if the patient needs it (well, they do as one factor, but its not the ultimate question), they care whether it meets the plan’s coverage criteria. Outside of what is minimally mandatory under health insurance laws and regulations, the coverage conditions for certain treatments (and even certain tests) are often more restrictive in “less good” plans.

So, yes, the systems and people reviewing claims do look at what kind of coverage you have when deciding whether or not a medical procedure or test is covered (and to what extent it is covered) by your insurance.

(I know, I’ve been deeply involved in building and maintaining some of the involved systems for a public sector payer.)

>Outside of what is minimally mandatory under health insurance laws and regulations

This is what I am referring to when talking about determining what is and is not medically necessary. If there is clear evidence of a lab or medication being helpful, then it will be covered due to stipulations in the ACA regardless of how expensive the insurance coverage is, since it is proven medically necessary.

Of course this gets into shades of gray, but such is life. However, I have not seen a treatment or lab well supported by data to not be covered because someone was on a worse insurance plan and the treatment or lab happens to be expensive.

One example of a controversial medicine to cover off the top of my head is palivizumab (Synagis) for RSV in babies. There is very sketchy data on its efficacy and in what conditions

https://publications.aap.org/pediatrics/article/134/2/415/33...

But lots of health plans will have varying levels of coverage with varying pre authorization criteria for it because it is extremely expensive. So would it be classified as medically necessary? Probably not in most cases. But still some plans might cover it for whatever political reasons.

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