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Comment by didgeoridoo | Hacker News Reader

My wife is a clinical psychologist who used to take insurance. She got tired of not being paid for months for patients she saw. Legally they have 90 days to pay you, but in practice it’s closer to 4-5 months. Every January they claim to have “computer problems related to the new year” and simply lose huge numbers of claims, requiring you to resubmit — oh that claim is more than 90 days old even though it was their system that “lost” it? Sorry, can’t submit! Guess you just worked for free!

She takes cash now. It was an abusive system and I’m not surprised it’s falling apart.

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Up and down the board this is the game insurance companies are playing.

For example, I had need for a medical device. My doctors office submitted the claim for that device with documentation of it's necessity 5 times over 6 months before it was finally approved. The prior 4 times it was "You didn't include all the required information" even though each submission was identical.

There's simply far too little oversight on insurance agencies. They are perversely incentivized to give the worst outcomes for everyone which being to command high premiums because of the relatively low amount of competition or threat of "switching" (After all, you are using your employer's insurance. You didn't get to pick it, HR did. And they picked it based on who's cheapest. How did they become the cheapest? A race to the bottom in terms of service).

All of this burdens the whole system with cost and delay.

I'm all for universal healthcare, but if we can't get that can we at least get stronger regulations and punitive measure against insurance companies for playing these games? It's crazy that everyone has stories, regardless of agency, of illegitimate claim denials.

And to be clear, they do this because it saves them money and costs them nothing. By denying by default, a certain percentage of the population and doctors offices will ultimately just go away because of the headache it takes to convince the agency to provide the product you pay for.

It's astounding that the care plan created by myself and my team of doctors is regularly denied by a statistician at Blue Cross Blue Shield.

This means my care is ultimately in the hands of someone with zero medical training.

Astounding.

I think this is the most infuriating thing about US healthcare. Your doctor thinks you need a diagnostic test to make sure you don’t have cancer?

Sorry bud, random bureaucrat at Premera thinks not! But you’re welcome to spend hours of your time filing and following-up on an appeal with absolutely zero chance of a different outcome!

Craziest thing is if you tried to institute the rules of health insurance on credit card fraud (where banks have full liability) heads would roll. However no one bats an eye when it’s for something as crucial as people living or dying.

On that note, why do I have to pay $200 to see a specialist who misdiagnoses me? Any other field, they’d be fired, sued, or at least not get paid for the service.

I would love, love for it to become a thing for Employers to put your money in a special type of account (similar to a Roth 401k) where the only thing you can do with it is buy insurance on the open market.

Heck, even have a list of 2-3 'preferred' plans that employees can choose from, if they don't want to do all the research. But seeing all that money go into their pay-stub, and then right back out for insurance is going to be very, very eye opening to people who currently just have their employer pay it, and they ever see it in their check.

Yeah, I'd do that with a public option that insurance companies have to compete with.

The problem here is the open market insurance is all garbage compared to basically any employer plan. Especially for those of us in tech.

It might not be if health insurance companies actually had to compete to consumers directly rather than only to CFO/CHROs, who in turn provide 2 or 3 "choices" from a single carrier.

That's exactly what my current job does. I buy a policy on the government marketplace, submit my premium statements, and I get reimbursed every month.

My allowance is quite generous, and it pays for 100% of the cost of the most comprehensive insurance I could find for both me and my husband. The platform is called PeopleKeep.

It's really, really nice to pick my own policy. Now I never, ever have to deal with CVS Caremark ever again.

The CMS Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule (CMS-0057-P) may solve some of those problems starting in 2026.

https://www.cms.gov/priorities/key-initiatives/burden-reduct...

Yep, I've submitted for prescription reimbursement for compounded medication. I submitted photocopies with just the dates and signatures changed - the formula and everything was the same. One time they gave me the full $45 in reimbursement. The next time it was $17 (cost of the prescription med without the other ingredients or compounding). The third time they gave me $1. I tried asking why each was different. They had no explaination but were emphatic that they paid the correct amounts.

> My doctors office submitted the claim for that device with documentation of it's necessity 5 times over 6 months before it was finally approved

I have had a profoundly deviated septum since childhood. A couple of years ago I went to an ENT to get it fixed. "Yup, 90% deviated on the right side." "Great, when do we schedule surgery?"

"Well, first, I prescribe you these two nasal sprays so that you can come back in four weeks and tell me they didn't fix your breathing, so I can tell the insurer that so they can approve surgery."

Also a practicing clinician and this is such a terrible problem that goes well beyond what you’ve described

Someone comes in and has insurance “x”. “Am I in network?” I don’t know. Probably. I take those plans most of the time. I check Navinet, or provider express, or one of the many other insurance benefits verification websites because the various insurers can’t agree on one centralized platform for this.

It says you’re good and I’m in network, great! Or you checked the provider directory online and I’m listed. Most of the time we’re okay. Sometimes this is out of date though (the “computer issues” you mentioned). The only way to truly be sure is to call the insurance company and have them check their systems which I simply don’t have time to do, sorry, or submit billing. This is why I and basically every healthcare practitioner have the policy that you are ultimately responsible to verify your benefits.

So we meet and it’s fine and I collect your copay. Then I submit billing. Then we meet again weekly. Then the insurance takes four fucking months to process your intake session only to come back and say “hey wait, this actually isn’t covered because it’s technically out of network so neither are the 15 sessions that happened afterward”. Now you suddenly owe me 2-3 grand out of pocket and I either have to collect that, probably worsening your mental health by adding a signicant sudden expense, or write it off and basically say goodbye to any renumeration for the 16 hours of work I did. I will ask you to appeal of course.

This isn’t even a “rare exception” situation. It comes up like once a month and I run an independent solo outpatient practice. Low volume.

It’s a fucking nightmare. I get why your wife went to out of pocket. I don’t blame her. but then it’s the conflict of making services less accessible. My patients often have no clue how to submit for reimbursement and insurers seem to purposely make this a difficult process. It really just sucks. I tend to work with lower income populations that really rely on insurance coverage so it’s not an option to go cash only for me but I definitely understand those who do. the system we have is deeply flawed, maybe irreparably.

The only setting that alleviated this was larger settings. Major healthcare networks/hospitals, large agencies, etc. it still came up but less often and when it did there was an army of billing staff to appeal. But the downside is that imo care was inherently compromised in these settings due to demands placed on staff. There were benefits of having teams, training resources, increased supervision, etc. but all of these were outweighed by significant overhead costs and productivity demands. For perspective moving to private work allowed me to earn 35% more while working 20% less within the first year. I’m not struggling to make ends meet and I’m not constantly flirting with burnout anymore. So imo those institutions aren’t the solution unless they can make real systemic changes

> Then the insurance takes four fucking months to process your intake session only to come back and say “hey wait, this actually isn’t covered because it’s technically out of network so neither are the 15 sessions that happened afterward”. Now you suddenly owe me 2-3 grand out of pocket and I either have to collect that, probably worsening your mental health by adding a signicant sudden expense, or write it off and basically say goodbye to any renumeration for the 16 hours of work I did. I will ask you to appeal of course.

Not a clinician but did (previously) work in software developing claims benefit management software.

One of the parts of the recent Surprise Billing reforms was that if a patient "could reasonably believe" that they were in network (and in particular, the prominent example of note being the insurer's website or a provider they use lists the provider as being in-network, because they ostensibly have control or input thereinto), then the insurer was obligated to remunerate the claim as being in-network.

i.e. if insurance's directory says "sure, provider X is in-network", they don't get to turn around after you use their service and say "You know what, they're not, so this is uncovered/out-of-network".

My billing subcontractor has mentioned this as well but in practice it hasn’t worked extremely for us. Sometimes we resubmit and it gets paid, sometimes not. That’s where I often have to get the patient to directly appeal to their insurer. But I’m not sure if the subcontractor is necessarily following necessary procedures.

That’s a whole different issue though; I’ve had to change subcontractors twice in my career because after auditing I found they were dropping the ball on stuff like this and just billing clients when there was a path to insurance reimbursement that could be pursued. To insurance companies credit this is an issue at least a part of the time; billing departments and subcontractors that flake on their own work. Far less common but a non zero part of the issue.

Thankfully as things transfer to software solutions this becomes less of an issue; I’ve moved a portion of my billing to a software based billing solution rather than a human one and while it still has issues it has less. Sucks for job creation but better for my patients I guess

Now I might do another deep billing audit

Even beyond insurance, the system is fucked. My wife finished her master's program and started working under supervision. But, of course, the only places which offer supervision are (generally) community mental health centers. So my wife was fresh out of school, with a client load of 55 people, getting paid $20/hr -- and those 55 people were generally the people with the least resources and support, thus some of the most challenging non-inpatient clients you'll find in mental health.

Beyond that, she learned that these community mental health centers, despite being nonprofits, are still aiming to constantly reduce costs; in her first six months, she saw many support structures for both clients and clinicians cut. This included laying off most of the case management staff, expecting the counselors to pick up the slack. She rarely even had time to keep her (legally-required) notes.

She lasted less than a year before quitting. She's not sure she'll ever go back.

Counselors are being squeezed from both sides here: They either burn out early, or the insurance companies fuck them over in perpetuity.

I don’t miss those days. My condolences to her.

When I was a student the rule was you had to do a year in community mental health type setting during school as an internship prior to graduation. I forget the exact hours requirement. It was supposed to be a learning experience but almost all of us were just put to work with a full caseload from day 1, paid $0 and hour, and the agency billed on our behalf. It was very burnout inducing to be making nothing working in the setting you describe. Then you’d graduate and get to have the honor of making $15-25/hour, the low end of which was offered over at target.

It’s also why I don’t understand how those programs struggle so much. AFAIK the practice continues to this day and it means they have a sea of interns providing free labor. The interns don’t get the same session rate as a fully licensed therapist but at the same time they literally cost $0/hour, they are slave labor. Medicaid and the community mental health system is built on it. It’s why low SES individuals are by default used to never having the same therapist for more than a few months or so; the turnover is crazy

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