You have a right to know why a health insurer denied your claim
propublica.org
propublica.org
I spent months fighting a claim for mesalamine DR tablets (and getting nowhere) only to discover that the insurance personnel were treating it as a different claim for mesalamine EC capsules—a totally distinct formulation. Any doctor or pharmacist could tell you that they're not equivalent. But they had different approval criteria in the insurance system, and even though I met the criteria for the former (the drug I wanted) they kept denying me for not meeting the criteria of the latter (the drug I did not want).
But those are both oral forms. I think if they'd tried to run the claim as the suppository version, the error would've been more obvious.
> Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method, spending an average of 1.2 seconds on each case, the documents show.
https://en.wikipedia.org/wiki/Rick_Scott
Meanwhile a Democratic Senator from New Jersey is credibly accused of taking bribes from Egypt (evidence included literal bars of gold discovered in his home pursuant to a search warrant), but he refuses to resign.
Corruption is endemic in the US, it just has good lawyers and PR people.
In Florida, though, my experience has been that corruption is far more endemic and culturally accepted.
There's a reason no president has ever come from Florida politics -- despite being the 3rd most populous state (more people than NY!) -- the skills and acceptable approaches down here don't fly in the rest of the county.
F.ex. the publicly-regulated utility covering most of the state (FPL) financed a third party candidate (up to $3m) in a state senate race. That candidate didn't campaign, but did happen to have the same last name as the incumbent, who had been critical of FPL and pushed reform efforts. The incumbent lost by 32 votes. [0]
Or the (again regulated-FPL-adjacent) takeover attempt of the sole remaining city-run utility company in Florida (JEA) that collapsed in a flurry of federal charges over kickbacks and undeclared secret bonus clauses. [1]
And this is just "business as usual" in Florida.
Shady stuff happens in other states, sure, but at least people elsewhere have the decency to be ashamed about what they're doing.
[0] https://www.orlandosentinel.com/2022/07/22/operatives-workin...
- Alabama
- Illinois
- Kentucky
- Louisiana
- Mississippi
- New York
Although problematically, most are measured as having strong anti-corruption laws, which would likely increase the number of convictions and journalist coverage of corruption (thus, stronger laws = more visible corruption).
Here's probably a more objective number: https://pols.uic.edu/wp-content/uploads/sites/273/2023/11/Co... from https://pols.uic.edu/chicago-politics/anti-corruption-report...
Which produces this ordering per capita: (federal convictions only, in decreasing order, ignoring DC)
1. Louisiana
2. Illinois
3. Tennessee
4. New York
5. Pennsylvania
6. Virginia
7. Ohio
8. New Jersey
9. Georgia
I wouldn't be so sure to think that strong laws ~ more visible corruption, but I could be wrong.
Unless you're a wealthy litigation attorney who has friends that will rack up enormous bills as insurance takes it to federal appeals court.
https://www.propublica.org/article/blue-cross-proton-therapy...
It's absolutely infuriating. A friend who is a therapy physicist left the country and went back to work in Canada taking a 40% pay cut because he couldn't stand it anymore.
> How are these guys allowed to stay in business?
Afaik, that's exactly how the ACA was written -- there's a ceiling to non-care expenses that insurance companies can include in premiums.
One consequence of this is pushing insurers to be hyper-efficient. One consequence of that is the average case needing to take 1.2 seconds.
Granted, that likely includes a huge amount of happy path cases that flow through automated rules engines, which effectively take no time.
So really, it's more like (most cases take 0 time) + (a low number of cases take non-zero time) = 1.2 seconds on average.
So this ProPublica article is great; they say to someone relatively important at the insurance company, "hey, the individuals you wronged are actually well-connected enough to get journalists involved" and the companies get REALLY SCARED, because step 2 after the newspaper article is published is every junior US Attorney in the country tripping over each other to cart them off to prison as quickly as possible. (OK, it's probably a fine. But shareholders do not like your stock when you are routinely fined, and CEOs are paid in stock. See why competent people might get involved when that's at risk?)
You can read this article as "evil companies are evil", but I read it as "evil companies are learning". There will be eventually a day when your entire claims packet is on the same website as your EOBs, and you can click a link to report a mistake. The companies will have to act on your reported mistakes, because a paper trail that says they did something illegal is super bad for the shareholders. It takes time, but journalism like this is what gets it started. If you feel depressed, don't. The system is slow, but the system is working. This is what we have democracy and a free press for!
When will that be? In 100 years?
That's not the same as what doctors and nurses do.
They get a bunch of test results and a first opinion (from doctor) then they issue a new (second) opinion of no treatment. Doctors give out second opinions all the time; it's a thing patients do when they want to make sure the first one is correct.
Doctors have direct contact with the patient and are pursuing leads via testing and originating a treatment plan.
Ergo, "what might work"
A medical reviewer is limited to generated documentation only (though can request more) and is then comparing that to relevant regulations, standards of care, and reasonable/necessary tests.
Additionally, they are a technical expert in recognizing fraud that may be hidden in individually-reasonable, unreasonable-in-aggregate cases.
Ergo, "what can be justified"
Here's the CMS-version explainer, for context: https://www.cms.gov/data-research/monitoring-programs/medica...
Generally, criminalizing malpractice is a counter-inventive to actual system improvement. See doctors. They just add malpractice insurance, and the cost is added to everyone.
If the real concern is that medical reviewers aren't fairly reviewing claims (which afaik, they generally are, contingent on documentation being available), then the supply side should be addressed -- mandate a specific, minimum review time per claim, a standard appeals chain that all insurers are subject to, and staff a centralized, independent (probably under CMS) final appeal arbiter.
Or is there a possibility that they could lead nowhere?
https://www.propublica.org/article/unitedhealth-healthcare-i...
> At one point, court records show, United inaccurately reported to Penn State and the family that McNaughton’s doctor had agreed to lower the doses of his medication. Another time, a doctor paid by United concluded that denying payments for McNaughton’s treatment could put his health at risk, but the company buried his report and did not consider its findings. The insurer did, however, consider a report submitted by a company doctor who rubber-stamped the recommendation of a United nurse to reject paying for the treatment.
> But the records reviewed by ProPublica show that United had another, equally urgent goal in dealing with McNaughton. In emails, officials calculated what McNaughton was costing them to keep his crippling disease at bay and how much they would save if they forced him to undergo a cheaper treatment that had already failed him. As the family pressed the company to back down, first through Penn State and then through a lawsuit, the United officials handling the case bristled.
It’s complicated. On the other hand are fraudsters and private-equity owned hospitals maxing the bill button. If the insurer is lax with payouts, it depletes its capital and could be left insolvent. It’s a scummy system more than a system of scumbags. (To be clear, there are scumbag insurers. But it’s reductive to cite that generally, or designate it as the source of the system’s troubles.)
"Remaining solvent" doesn't seem to be the goal, rather "maximising quarterly bonuses regardless of lives destroyed" seems a more fit description.
Nobody said they aren’t. The point is, given the volume of claims, to do a proper analysis, we’d need a material fraction of doctors doing insurance reviews (instead of seeing patients). So we get a reliance on heuristics.
If you’re lenient, you get targeted by fraudsters. So we get a bias towards denial. (Nobody is getting a material quarterly bonus for denying a few more claims. That nonsense occurs at the level of PBMs and other scale operations.)
Since that probably won't happen, heuristic usage should at least come with penalties attached, otherwise the incentives are lopsided. If an airline's overbooking heuristics fail and get you bumped, you either get put on another flight and/or receive financial compensation. If an insurance company's "heuristics" fail and deny a legitimate claim, there should be a penalty. If Google terminates your account because of a mistake, they should pay a fine. They shouldn't be allowed to have their cake and eat it too.
The scale probably helps. The point is if every billable decision is medically reviewed for more than a few seconds, a material fraction of the healthcare workforce needs to be diverted from patients to review.
There is simply no solution, given the current industrial structure, to avoid some combination of non-expert, high-speed review without making even stupider trade-offs.
We soundly agree. Health insurance, where risk is pooled, makes sense. Health "insurance," where payments are pooled with a bunch of needless intermediation, is unnecessary.
Why do we need to bolt on a secondary system that sucks up an untold wealth of time and money?
https://www.axios.com/2023/06/14/medicare-advantage-overpaym...
> Overpayments to insurers administering Medicare Advantage plans now exceed $75 billion a year due to aggressive coding of patients' health conditions and easily-achieved bonus payments tied to quality, researchers with the USC Schaeffer Center for Health Policy & Economics found.
If anything, that would mean more claims should be denied.
Looking at the study, it seems like the government made some erroneous assumptions about who would be taking advantage of the policies the government created, resulting in the extra costs. (Third paragraph of “policy context” section).
https://healthpolicy.usc.edu/research/ma-enrolls-lower-spend...
> Anthem, a large insurer now called Elevance Health, paid more to doctors who said their patients were sicker. And executives at UnitedHealth Group, the country’s largest insurer, told their workers to mine old medical records for more illnesses — and when they couldn’t find enough, sent them back to try again.
> Each of the strategies — which were described by the Justice Department in lawsuits against the companies — led to diagnoses of serious diseases that might have never existed. But the diagnoses had a lucrative side effect: They let the insurers collect more money from the federal government’s Medicare Advantage program.
> Eight of the 10 biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to the federal audits. And four of the five largest players — UnitedHealth, Humana, Elevance and Kaiser — have faced federal lawsuits alleging that efforts to overdiagnose their customers crossed the line into fraud.
So in this scenario, it sounds like the fraudsters are the medical insurance companies, and the group being lenient are the regulators.
A place taking (on average) 1.2 seconds to review each claim shouldn't be in business.
As another commenter pointed out, average review time is likely a misleading figure, since the overwhelming majority of decisions are made automatically, using predetermined rules engines.
So nearly all decisions take zero seconds, and a small minority take much longer, leading to an average of 1.2 seconds, when in reality, those claims that are reviewed manually take far more than 1.2 seconds to review.
As the other commenter put it: “(most cases take 0 time) + (a low number of cases take non-zero time) = 1.2 seconds on average.”
https://www.statista.com/statistics/214504/total-revenue-of-...
https://www.healthcaredive.com/news/unitedhealth-2022-earnin...
Health Insurance companies grow their bottom line by growing the topline cost of healthcare since they're margins are limited.
Or we can skip scapegoating and fix the system. This is a fundamental lesson from aviation crash analysis: the goal should be a better system, not assigning blame.
Read the synopsis [1].
Blaming the co-pilot would be fruitless. He's dead. There's no chance for retributive justice. And if he's the problem, the problem's solved: he's dead. Nothing more to do. Except, of course, there is. Blaming him is simply an unproductive emotional comfort.
Instead, the report examines the crash's root causes. The "co-pilot’s probable fear of losing his right to fly as a professional pilot if he had reported his decrease in medical fitness to an AME." The "financial consequences generated by the lack of specific insurance covering the risks of loss of income in case of unfitness to fly." The "lack of clear guidelines" on when conditions need to be reported.
Addressing these factors helps prevent the next problem. Blaming the co-pilot actually does the opposite.
[1] https://bea.aero/uploads/tx_elydbrapports/BEA2015-0125.en-LR...
Of course the co-pilot is to blame. But that isn’t where the report starts nor ends. It’s incidental to fixing the problem. Those who choose to focus on blame are indeed propagating the root problems that led to the crash. Same in most other circumstances.
The doctor that treated my spouse literally published a paper about the case, so uh... not routine. I got super lucky with the insurance person, though -- she actually called the hospital for me and got them to re-code it.
Infuriating to say the least.
Think about it. A health care company collects money under the premise that "these premiums you're paying will cover you if something bad happens". If that something bad does happen (and for most people, it never will), that money should be available to pay for whatever happened. The insurer, now concerned about their margins and profits more than providing you the service that you've already paid them to do, just gets to trot out some poorly paid rep with no medical knowledge to override the medical advice of a trained medical professional. Now, you're not only injured, you're paying out of pocket for a service that won't actually do what you've paid it to do. The only winner here is the insurer's C-Suite and stockholders who get to brag on quarterly earnings calls that they've denied tens of thousands of claims (and they even get fiscally rewarded for it!).
In a more modern and honest society we would call for-profit insurers what they actually are: a racketeering organization operating under the guise of fraud.
That's not the premise of insurance, though. The premise of insurance is that a large group of people pools their money (through paying premiums), out of which the people in need of assistance get paid. It's not that you'll be "repaid" your premiums in services. It's pooled risk, not a kind of savings or investment.
In order for it to work financially, most people have to never have claims in excess of what they paid in. The whole point is to be able to cover exceptional and rare disasters.
I think one of the ways that health insurance (at least in the US) has gone horribly wrong is that it became a means to pay for routine medical things rather than just exceptional ones.
Then why isn't this a problem in any country with socialized medicine or other required health "insurance" things? They have increasing costs but not nearly to the extent the US experiences.
The cost of childbirth in the US is insane. It is literally cheaper to fly to another country, pay out of pocket the purposely inflated "tourist medicine" price, hang out in a nice hotel for a few days, and then fly back!
I can top that...
In my part of the US west coast, if you need to have two dental crowns done, it's cheaper to fly to Taiwan and have it done there than to have it done locally.
As a bonus, the quality of care and materials will be much better and the dentist may even actually apologize for having to charge you at all.
This is exactly what I do.
I would take the kids back to my home country, pay out of pocket for any treatment, and have a nice holiday in the process.
Last time we went back, I was chatting with the dentist and casually told her about the treatment costs in the US - she was flabbergasted. Markup prices in the US seem to be 500%+ of those in many European countries.
That’s not what I paid out of pocket; that’s what the hospital cheerfully billed and collected from my insurance company, and what I theoretically could have opted to pay myself to retain my annual reimbursement level (3 months of premiums after several no-claims years on a higher-deductible policy)
- malpractice insurance
- cost of living difference
- government rationing of care in public systems
- lower capital expenses for nice looking buildings and top-of-the-line equipment
- unpaid bills turn into higher prices
Countries with socialized medicine have their own problems. It can be great for average people with average problems, but outside those lines you run into things that would be trivial in a US healthcare setting.
Obviously, it varies by country, and there are plenty of things I hate about how healthcare works in the US.
This is solved by high deductible health plans.
> In order for it to work financially, most people have to never have claims in excess of what they paid in. The whole point is to be able to cover exceptional and rare disasters.
This is where the problem is. Humans will have health problems and will have claims, especially after age 50. Which means (assuming a stable population), the present value of premiums has to equal the present value of all the healthcare you will need (until you get to Medicare, age 65). Which is a large number, especially considering the obesity/hypertension/diabetes/heart disease rates.
Which means premiums are effectively just another tax (except they are no longer mandated). A big wrinkle here is declining proportion of younger populations to pay for older populations, so the premiums young people pay for healthcare older people receive now, but when the young people are older, there will be fewer younger people to pay for them, so it is also a marginal “age” tax, where the younger people pay for more than what they will receive. Exactly the same as Medicare taxes.
- Young with no health issues? HDHP.
- Suddenly get sick or are older with medical needs? Wait until next year's open enrollment and switch to a higher tier plan.
Guess which risk pool has to pay out more in claims (against a neutral population average). And therefore has to increase premiums.
The issue is that we should categorically ban non-catastrophic health insurance.
Everyone gets an order-of-magnitude yearly disposable income * 2 deductible plan.
Everything else is out of pocket.
Surprise! Suddenly discount options appear. Suddenly hospitals are competing on price. Etc.
> The issue is that we should categorically ban non-catastrophic health insurance.
This is basically banned as all ACA compliant health plans have to have out of pocket maximums, which are limited by law (currently ~$10k/$18k for single/family).
However, there was a political compromise to allow non ACA plans due to some extremist “religious” factions, which I doubt had anything to do with religion.
The root problem will remain however, because the supply of doctors and non patented medicines relative to demand is very low, and hence prices will not come down.
If we look at two plans: (Plan HB) an HDCP bronze plan and (Plan P) a traditional platinum plan.
Each can set premiums on the basis of their expected payouts, no?
So if, for the last 5 years, plan HB had an average participant age of 35, few health complications, and low payouts and Plan P had an average participant age of 55, more health complications, and high payouts... Plan HB could set lower premiums and Plan P could set higher premiums (against all-of-population neutral rates), no?
Or am I misunderstanding limits on actuarial use under ACA?
(Disclaimer: I haven't done much work on the actuarial side)
I don't this needs to be true. If you say pay 10,000 and they invest that and it returns at 10,500 at the end of the year then if your claim is 10,300 they've technically made $200 still.
Given that they're raking in billions in premiums I think they have access to better rate of returns than each of those individuals could've done on their own.
> I think one of the ways that health insurance (at least in the US) has gone horribly wrong is that it became a means to pay for routine medical things rather than just exceptional ones.
I really am surprised that most insurance networks don't become more vertically integrated. Like manufacture their own drugs, hire their own doctors, etc since a lot of their expenses are extremely predictable.
Not really, as far as I know claims reserves have to be kept highly liquid (Treasuries or High Grade Corporate Bonds maybe?, especially for a health insurer which pay out almost all the premiums it collects every year.
They are not going to be invested in VC/PE/REIT/etc.
The root problem is healthcare is an extremely complex field, requiring extremely specialized knowledge that takes extreme investment to get. And everyone wants it, the demand is infinite and the demand has no elasticity.
So a buyer of healthcare has a problem. They have no idea what they are buying, and have no idea if the seller is scamming them or incompetent. So you need a second opinion. But as stated above, people who can provide this opinion are few and far between.
It is not like paying $100 to get a second opinion on your car. It is more like paying $500 to $10,000 or who knows how much to get a second opinion.
So the root problem is people simply cannot afford the level of healthcare they desire. Everything else is just papering over that intractable problem.
It's worse than that, important healthcare decisions are often made while you are unconscious, and you just have to pay for whatever choice was made. Not only do you not know what you're buying, you don't even know a purchase is being made.
I am convinced that it doesn't make sense to discuss healthcare as if it is a market. Patients are not "buyers". You pass out, some random person calls 911 and they send a private ambulance, you wake up at the hospital, and now you owe money to the ambulance company. In what sense have you "bought" anything? There has to be more to the definition than just "money is involved". We don't talk about the parking ticket market or the taxation market (just move to a different country if you aren't satisfied with your taxation provider!), and we shouldn't talk about the healthcare market.
This is a problem, but it's not a major driver of health care expenses. Emergency care is around 5% of total spending: https://www.healthaffairs.org/doi/10.1377/hlthaff.2022.01287
Regardless, I don't believe determining an exact percentage is relevant to this discussion. I'm not an economist, but every definition of "market" I can find says something like "a system where two parties can engage in a transaction". If there's a significant chance that one of the parties is unconscious and/or about to die, they are not engaging in a transaction any more than a mugging victim is. 5% is the chance of rolling a 1 on a d20, that is certainly significant.
- https://en.m.wikipedia.org/wiki/Market_(economics)
> A market is a place where parties can gather to facilitate the exchange of goods and services.
I'll give you another example. The definition of "purchase" is "to obtain by paying money or its equivalent". If I steal money from you while you're asleep and leave a baseball card, is it fair to say you purchased the card? Why not? The definition doesn't say anything about consciousness or decision-making.
Generally dictionary definitions of human activities do not explicitly specify consciousness when it is obviously necessary.
People even in a coma 'engage' in multiple activities, such as consuming oxygen, producing carbon dioxide, etc...
And if they are in a hospital, they are taking up a bed and floor space that cannot be used for another patient, that needs to be actively heated/cooled/ventilated and so on.
Their body would literally be engaging with the hospital HVAC systems, especially with 'smart' sensors nowadays that react to room occupants.
Even in a purely financial sense, just because someone is physically incapable of opening their wallet or consenting to a transaction, doesn't mean they can't incur debts, or that other entities aren't acting on their behalf.
More broadly, anytime you are dealing with limited resources (including time), you have to be buying and selling (i.e. there are opportunity costs to making a decision).
> We don't talk about the parking ticket market
You cannot buy a parking ticket, so this is not comparable. However, people do often calculate the cost of legally parking versus the probability * cost of potential fines.
>or the taxation market (just move to a different country if you aren't satisfied with your taxation provider!)
This happens all the time, but everyone may not have the means to do it. It was one of the factors for my relocation within the US.
Even businesses use it to determine where to expand or close operations. Warren Buffett mentioned it in his annual letter some years ago.
> You cannot buy a parking ticket
Exactly, just like you can't buy an unexpected medical bill. You still have to pay it though.
The fact that rich people sometimes choose to accept a parking ticket or choose to purchase citizenship in a more favorable tax environment is not evidence of a market, in fact it's the opposite. If 99% of "buyers" are forced to participate but have 0 decision-making power, and a handful of rich people are able to (sometimes) shop around, you are not describing a market.
I'm sorry but this statement flies rather in the face of 22 other industrialized modern nations that have managed some type of publicly funded healthcare. The United States being the one that hasn't, along with also being the richest nation in that group, along with already spending the most among that group per patient by a wide, wide margin and getting by far and away the shittiest service in return.
We're also unique in that we're the only nation which hosts slap fights between hospitals and insurers that last months and leave patients wondering as they recover from whatever went wrong for them if they're going to owe $20 or $20,000.
Now, do those other 22 nations have completely perfect healthcare systems? No, of course not. But to say "well it's just too complicated" and throw up your hands is just shit. You know what else those other nations don't have? They don't have people going bankrupt from being in a car accident that wasn't even their fault.
And you know what is also unique among the United States? We're the only ones in that group who have several corporations with fully seated C-suites raking in billions of dollars off a service people literally cannot live without. So it seems to me, removing that part first is a solid first step.
The problem of insufficient resources exists in other countries too, but of course they may be managing it better.
Health insurers have low profit margins. You can read their audited financial statements for the publicly traded ones. Some are even non-profit. The Affordable Care Act (Obamacare) set a minimum 85% medical loss ratio. The insurers have to cover their operating costs and profit margins out of the remaining 15%. Even if we were to replace commercial insurers with some sort of "Medicare for all" system that would have only a marginal impact on costs to patients and availability of care.
The real drivers here are the big employers. They are the ones ultimately paying most of the bills, and they insist that insurers ration care to control costs.
That's also a perverse incentive though. With capped "profit" windows, how is a company to make more money? Well if healthcare costs increase, then premiums need to. 15% of 1.3X is bigger than 15% of X, after all. And healthcare providers are unlikely to object to higher prices.
And what if your insurer gets involved in vertical integration - perhaps Kaiser style, perhaps less formal? Now you get to reduce the actual cost to you (the insurer) by removing the middleman, and you get increased profit by keeping the price the same. It might show up on a different ledger on your books, but nonetheless...
Regulators are not this dumb or corrupt.
This is not a big money making business, as evidenced by Buffett/Bezos/Dimon’s foray failing:
https://www.latimes.com/business/story/2021-01-04/buffett-be...
https://www.sec.gov/ix?doc=/Archives/edgar/data/0000731766/0...
It is reasonable to criticize insurer profits but overall those are only a small part of much larger systemic problems in the US healthcare system. Even if profit margins were somehow cut to zero that would have only a marginal impact.
Are US costs reasonably described as well controlled?
That seems more likely (apriori) than healthcare systems magically becoming efficient, responsible, and ethical actors.
'your policy is denied you are not covered for this because only your spouse is' 'thats interesting that is not how I wrote my OWN policy' 'uhhh we will get back to you' They approved it. But not before denying it.
He sold these policies for a living. He mostly quit exactly because of this sort of noise.
This is a feature health insurance companies, not a bug. Their entire purpose is to collect as much premiums as possible while paying out a little as possible.
I think this set a precedent, so if a doctor is not involved, there's a problem.
EDIT: can't find the case
Unfortunately when either side makes an error the patient gets stuck trying to fix it.
Gotta tell the insurance company where to stick it? :)
Maybe... they just can't deny without a reasonable alternative that your doctor agrees with? Like fine deny name brand prescription for generic.
The idea that your Doctor... who actually knows what is going on wants to do something and your Insurance can just say no is ridiculous.
If we are so worried about Doctors doing unnecessary things to get money from Insurance than lets tackle that also.
- come from an individual doctor (not just be signed off, but the doctor originates the denial)
- the doctor must be personally named and identified to the patient as the party responsible for the denial
- that doctor is *personally* and *professionally* liable for harms that befall the patient from a wrongful denial
By personally liable, I don’t mean “their reputation is harmed”, I mean “forced to file for bankruptcy, and will be paying off the court imposed damages for the rest of their life”.
By professionally liable, I mean medical licenses being torn up, and their right to practice medicine being permanently revoked due to committing medical malpractice.
I mean, these people need to be medical doctors, that are treated as making a medical decision, with all the requirements and liabilities that come from that.
When Dr. Nick spends 1.2 seconds reviewing a patient’s file before issuing a denial, I’m proposing that being a life ruining decision for Dr. Nick.
The issue we've got here is that the company has an immense amount of power and we need to punish bad actors at a level appropriate to that power - instead of just going after the individual bad doctors that are replaceable and numerous (we should still go after the individuals though).
Maybe you make it like jury duty; if you're a practicing doc, you periodically get randomly assigned some appeals in your speciality to review.
The current system already has a massive quid-pro-quo; if you aren't willing to spend 1.2 seconds to deny tens of thousands of claims a month (not an exaggeration! https://www.propublica.org/article/cigna-pxdx-medical-health...), they'll find someone else. The docs and companies doing these "independent" reviews are completely captured by the industry already.
Or send appeals to a committee of randomly-rotating reviewers. The state could administer the service to promote fairness and lessen the cost to the insurer.
https://www.youtube.com/watch?v=Vp7u58R41N8&list=PLpMVXO0TkG...
I know my sister at one point was having some critical medication for her denied so the doctor just kept giving her sample packs.
I went through an issue with a medication for me and it was still never resolved.
Insurers may also require step therapy. Try a cheaper treatment first, then if the patient fails to respond they will authorize a more expensive option.
I went through multiple appeal processes, my doctor tried to file multiple on my behalf, I called, and nothing.
They don't care.
This is bad too if you have more experience or misfortune with chronic medication usage.
You can't sue for medication side effects from generic medications.
A lot of these issues arise because providers fail to review payer coverage rules before deciding on a treatment plan. And in fairness to providers, this takes extra time which they don't get paid for and the rules are inconsistent between payers. The new HL7 Da Vinci Project prior authorization burden reduction standards can help automate this to an extent by giving providers an API to check coverage rules in real time.
https://www.hl7.org/fhir/us/davinci-crd/
At a fundamental level, medical insurance has to involve some form of cost control and care rationing. Much of what insurers do is preventing waste, fraud, and abuse by verifying that treatments are medically necessary as per current best practices and balancing costs versus benefits. Unfortunately, patients sometimes get caught in the middle.
A system wherein the trained professional with direct access to the patient has to defer to a board of anonymous bureaucrats to determine the course of treatment is absurd. These issues don't arise because "providers fail" they arise because the system is built to fail and the burden falls on everyone except the people making the rules (and the profit).
Medical insurers are the waste, fraud, and abuse.
Outsourcing that work to “insurers” helps keep the heat off the politicians.
Note: I’m not talking about Medicare Advantage which is a separate program whereby Medicare pays the premiums for private health insurance plans.
https://www.propublica.org/article/unitedhealth-healthcare-i...
When claims or authorizations are denied it's generally because large employers have been pushing back to control their own costs. Unfortunately, many consumers don't understand this market dynamic and direct their blame in the wrong direction.
I'm sorry but how with a straight face can you really write this paragraph. The Doctor, the person who is seeing you needs to check a system of what you they are authorized to do for you? That is dystopian.
FFS we had an episode of this on Star Trek Voyager showing how bad this system is and yet that is exactly what we do.
What you are describing id disgusting, end of story. There is no justification of any of this.
Are there corrupt doctors? Sure. But insurance should not have a right to say what can and cannot be done if here is a good reason and it should be an actual discussion instead of Insurance having all of the power. ALL
Technically insurers don't say what treatments can and cannot be done. Their role is purely financial. Patients can always pay out of pocket, and some do. But in practice an insurance denial does sometimes leave low income patients without access to care.
Ultimately though there does have to be some system for rationing care. Demand is effectively infinite and resources are finite. Even countries with single payer or socialized medicine restrict which treatments they make available, and often restrict patient access to expensive treatments by imposing queues.
I didn't claim that the current system is a good one. I have no power to change it. Any real solution will have to be mainly political so complain to go take your proposals to Congress.
Death panels for a captive market, so it's all good.
It'd just be changed to a federal-government sanctioned death panel system. Probably with an expected goal of deaths, and if the target isn't being met, methods to be encouraged to bring it about...
> It'd just be changed to a federal-government sanctioned death panel system. Probably with an expected goal of deaths, and if the target isn't being met, methods to be encouraged to bring it about...
It's not how healthcare work in other industrialised countries.
Regardless, I think the answer is transparency, reduced regulations (e.g. removing income tax penalties for just paying people more to then buy their own health insurance), and clear upfront pricing. Those steps should be done before any attempt to further ruin health care even more. Most of the things people hate about health care and insurance are encouraged or enforced by the feds.
I was getting nowhere until I started connecting with and then publicly shaming their executive leadership on LinkedIn. If you do that, you get transfered to their "executive relations team" who still are unable to get things done, but it's at least a different department you can file grievances that go nowhere with.
She used to do this working for a high net wealth family office for the entire family's medical expenses.
We were trying to think of a way that she could offer this skill as a service for people. It would require some difficulties with HIPAA, but I think there is a opportunity here to help people.
Totally understand the HIPPA challenges.
I'd totally pay her to teach me how to do it for myself. Perhaps she could do it as a coaching or online course type model?
I need this skillset in my life and don't know how to acquire it. I would pay someone to teach me how to acquire it.
It would never scale to a full time business, but she got paid well to do this for two very rich people. (Who want to keep as much money as possible).
Another funny anecdote. They have a 1.1 star yelp review. The San Francisco DMV has 1.8. 1.1 is a statistically significant difference thsn 1.8. They have almost 800 1 star reviews on yelp, as a non profit!
I don't see how you can claim that without seeing all the records in question. Maybe it was deliberately obfuscated, maybe someone just screwed up. Guess what, human error is a thing. In fact, the article itself showcases a bunch of human errors -- those of people not knowing that their employer is required by law to provide claim files within 30 days.
Could the claims have been rejected due to a simple human error? Sure, it's plausible. Was there another human error that caused the claims to be rejected after we appealed? Maybe, but probably not. Could a third human error cause the claims to be rejected again after our second appeal? Seems pretty unlikely.
I guess I'm not seeing why the poster I was replying to declared that getting access to the claims file was useless. Wouldn't getting access to that file make it easier to prove that claims were wrongfully denied?
Its beyond infuriating, especially when you are on the hook for a large bill
The entire system is an exercise how capitalism fails where there's inelastic demand. Health insurance companies exist to extract wealth from consumers and governments by not providing health care to increase profits. It's that simple. There is a direct link between denying prior authorizations and increasing profits [1].
Fun fact: Obamacare (ie the ACA) snuck in a ban on physician-owned hospitals [2] thanks to lobbying efforts. Just more artificial barriers and rent-seeking to increase profits.
Health insurance companies continue to consolidate (eg requiring prescriptions are filled by their PBM-approved pharmacists, buying up medical providers).
It is utterly insane to me that anyone can defend this system who isn't a major shareholder in United healthcare. Yet ordinary people do, which usually comes down to "I don't want to lose my insurance", which is so insanely short-sighted and selfish, it blows my mind.
[1]: https://www.healthleadersmedia.com/revenue-cycle/cost-denial...
[2]: https://www.fiercehealthcare.com/providers/hospital-groups-a...
Literally nobody involved in the entire chain of providers had any idea how much it would cost. The best advice anybody could give me was to get the treatment, then look at the bill afterwards. (Oh, and nobody had any idea when I might get a bill either-- my wife is still receiving bills from the birth of our most recent child, 18 months ago.)
I've been dealing with this as well, and the uncertainty has been the most frustrating thing.
Medical bills from the same institution should be required to be high watermarks - i.e. if you give me a bill in March, you can't send me a bill in April that has charges from February that _weren't on the bill from March_. It feels like fraud (and maybe it is, but who has time to figure that out?)
Isnt it lovely when a Private Equity firm decides what is or isnt medically necessary? They were obviously using some automated system to try and deny claims, to hell with false positives.
The best thing is to just repeatedly submit the legitimate claim until it goes thru. There seems to be some non-determinism in these systems and the same thing will sometimes be accepted and sometimes rejected. Bless my wife for taking care of this insanity.
I know heartless Europeans, but besides bureaucratic tips, there seems little to hack and it's all in all a daily downer to see sentient being beeing mutilated and thrown away cause it's cheaper. And then the whole population treats it like some selfflaggelating religious thing.
Yes I brought it on my self for clicking.
I'm a bright guy but I don't know how I'd live with the cognitive workload, stress and uncertainty over having to deal with all of this (the networks, the uncertainty over price and bills, the bills coming for weeks and months after care, the myriad involved parties, the rules and limits and interpretations and just... everything). More to the point, I don't understand how anybody, on any party or political spectrum, can say "Yup... this is a reasonable system that helps people and needs no change".
When you have a real issue, it takes hundreds of hours to deal with it. Smart employers know that this eventually comes out of company time and productivity, esp since most of these calls need to take place during business hours.
Smart employers will advertise "100% paid health plans, etc, etc."
Penny-wise employers, even white-collar jobs/offices, will often provide the bare-minimum coverage, and pretend it has no effect. Except it does. You can see it when your cubicle-neighbor is on a 2hr call with insurance, etc. I've had colleagues who will block a 4hr meeting on their calendar titled "calling insurance companies to figure out bills" as open protest. I've had people in the office just spend a day or two on the phone with doctors' offices, visible, both out of desperation and as a subtle form of protest for the organization's choices in health plans.
We need universal, single payer healthcare.
Further reading: https://www.chicagotribune.com/opinion/commentary/ct-obamaca...
And yet, sadly, even the "liberals" push for tying it to employment.
Nobody says that, and no one proposed the current system as is, either. Its not even a conscious, mutually unsatisfactory, compromise between competing visions, its simply the current state of an ongoing battle between multiple radically opposed views in a political system which is not good at resolving disputes of this kind, where some elements are successful attempts at implementing sabotage of broader components with the hope that the resulting failure will help politically support a conpletely different design.
1. Many of the most painful core issues dont manifest until you have a real issue. So people assume it will work for them, until it does not.
2. There is so much money being made on the other side that there is a huge push for lobbying to keep the system in place.
The commonality between this and (including, but not limited to) homelessness is that the tragedy is laundered into political ammunition used against their opponents in the next election. I dislike the trite expression "Don't let a good tragedy go to waste", but I'll say it to preempt the reply. But it's true: if you can't use human suffering (denied medical coverage | no place to live) to attack your party's enemy, you are less powerful as a candidate.
The other factor is lobbying. These companies (just like in many other industries) have US congress bought and paid for. The suffering aspect keeps people distracted and divided, so we never really hear about campaigns to end lobbying (because it would apply to both major political parties). Instead we joke about it and roll our eyes at how ridiculous it is (but still told to "get out and VOTE!" as if that somehow matters). My opinion is that it should go beyond financial contributions. Industry and trade groups should not have access to congress at all, it should be citizens only.
We were trying to think of a way that she could offer this skill as a service for people. It would require some difficulties with HIPAA, but I think there is a opportunity here to help people.
Your claims are paid with the money collected from your, and other members', premiums. Everyone wants insurance that covers every single claim with few questions or limits, but that insurance company would quickly have to make the choice between dramatically increasing premiums or going out of business.
Every time a government entity mandates that insurance plans cover additional services, the cost of care goes up and subsequently so do premiums. When premiums go up, people / businesses shart shopping around and leave the pool, meaning the risk is spread out among even fewer (likely sicker) people and the premiums go up even more.
The alternative is just having everyone in one giant "single payer" pool so risk is minimized, with participation mandatory. Then, that entity (government probably) would just pay all the claims because in theory there would be less incentive to watch the bottom line. In reality, we've already tried this: Medicare is the largest single-payer health insurance system in the world, plus we have 50 Medicaid single-payer systems at the state level and additional single-payer systems at the federal level (Tri-Care and VA benefits). All of these systems face the same fiscal challenges and have been implementing every cost control measure they can think of for the past 2 decades. Medicare has been trying to move from Fee For Service (FFS) to outcome-based reimbursement for a long time now.
Those of us who know, know: the problem is COST in the system. Healthcare is EXPENSIVE.
My perspective is being under Tricare. You can imagine it like a closed system in which Tricare beneficiaries just go to Military Treatment Facilities (Defense Health Agency and service-run hospitals and clinics) for everything, and everything done in those facilities is covered with no questions asked and no bills or money changing hands. But that isn't how it works in practice. A large amount of stuff, like most specialty care, gets referred to places "out in town" (at local, for-profit, civilian providers). Most ER and urgent care visits happen out in town. At times, my wife and kids have been on Tricare Select which works like a PPO and involves all the usual discussions about who does or doesn't take Tricare, in-network or out-of-network, whether something needs pre-authorization or not, why a claim has been denied and how to appeal it, whether we've reached our annual deductible or catastrophic cap, etc.
So under Tricare, I think I feel more protected from profit-driven shenanigans and expensive mistakes than most Americans, but there's still a "cognitive workload, stress and uncertainty." I think a true single-payer system means that you don't have this (because it works like the closed system described above).
My sense is that Americans are equal parts traumatized by our healthcare system(s) and under-educated about how it works in other countries. We hear about how the rest of the developed world has had socialized medicine for 80 years and just assume that means you can go to any doctor, for any reason, anywhere, and get unlimited care with no cost sharing.
In reality it doesn't work like that anywhere. As you described well, certainly Tricare doesn't work like that, and neither does VA, Medicaid, Medicare, the NY Essential Plan, the UK NHS, or the Canadian provincial health systems. Every system has cost controls in place and almost all are facing fiscal pressures to implement more. Care is rationed with deductibles, coinsurance, waiting lists, limits on covered services, hybrid public-private managed care plans that implement closed networks, and so on. Not to mention the fact that when other countries' governments artificially limit what can be charged for certain drugs, equipment, and services, they're often doing so under a de-facto subsidy by the US government and the US healthcare industry. This is because so many of these innovations are made by US companies; the cost of care is meant to recoup the development expense. The less these companies can earn worldwide to recoup expenses, the more that cost is passed on to US rate-payers and to the US government (read: US taxpayers) in the form of grants and other transfers of money from government.
HN, Reddit, and the rest of the internet have become really good at sharing horror stories, but increasingly many of those horror stories are either misleading or based on old laws that no longer apply. A popular trick on Reddit is for people to post the part of their bill that goes from their provider to the insurance company and say "This is how much it costs to have a baby in the United States!". However, nobody actually pays the amount that gets billed to the insurance company. They pay an amount determined by their insurance deductible, co-pay, and out of pocket maximum. Once you go past the out of pocket maximum for a year, everything is covered 100% in network.
We even recently had new laws against surprise billing, which plugs many of the holes that created those horror stories about going into a hospital and discovering you were out of network after the fact. Technically there are still holes where this can happen, but if you look carefully most of the horror stories online are from many years ago.
Is the system perfect? Of course not. However, in practice people aren't going bankrupt every time they go to the doctor like you'd think from Reddit posts. When it comes to pre-authorizations, these tend to get negotiated between your doctor's office and the insurance company. Doctors offices know how to push pre-authorizations through if they want to put in the effort, but many some will shrug it off because it's not billable time for them.
Especially, I have no interest whatsoever in having my health insurance tied to my job.
> They pay an amount determined by their insurance deductible, co-pay, and out of pocket maximum. Once you go past the out of pocket maximum for a year, everything is covered 100% in network.
You know how much deductible, co-pay, and so forth we paid for my father's 3 month long stay in the ICU with leukemia and chemotherapy? $0.
The signaler, conductor and roper all work for different faceless corporations constantly trying to screw each other and/or you though, the semaphore language is so complicated no human being can speak it, and the message in it can't be known until the locomotive is a few hundred feet away though. You can only choose 1 of 2 options for every role too, so everyone involved is terrible.
Sure we closed some of the loopholes where the locomotive could start again after braking, or the signaler could refuse to do their job because the brakes were offbrand. Really though what I'd like is to just not be in mortal peril at all, which is not the same thing as barely avoiding getting liquified by a steel behemoth by a complex confluence of forces beyond my control.
While mostly true, the system always strikes me as insane when I see the amounts billed to my insurer alongside the amounts "allowed" or paid by my insurer (or paid by me until we hit the deductible). I'm talking about the negotiated rates, I guess, not even co-pays. I regularly see things like $8,889 billed and $149 "allowed."
2. There are no penalties for not having insurance, that part of the ACA has been torpedoed.
3. The people who torpedoed it have no intentions of fixing a damn thing about this country's medical system.
In my opinion, this was a brilliant strategic move by those opposed because it guarantees the eventual financial inviability of all of the ACA. Decreasing the size of the risk pool by allowing people to opt out will guarantee that it won't work long-term.
But, the doctor has been able to get us in due to a cancellation, before the insurance expires.