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Comment by nerdjon | Hacker News Reader

ok great, so I should get to know why things get denied.

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.

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I’ve long believed that denials that come from an insurance company should be required to:

- 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

I'd add a requirement that said doctor have practiced in the relevant specialty within the last decade.

This simply incentivizes a rapidly revolving door between practice and insurance, with a likely effect of making the actual practioners as a populace more friendly to the insurance companies in general (in expectation of quid pro quo).

There's something deeply wrong when a gastroenterologist who hasn't seen a patient in person for decades can deny a neurosurgical procedure.

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.

> Maybe you make it like jury duty; if you're a practicing doc, you periodically get randomly assigned some appeals

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.

As someone close to the insurance industry I suspect this would just lead to a revolving door of Doctor Nicks that get cushy jobs for life and sip margaritas by the pool while their "reputation is ruined" - we need a better approach than this like (similar to Canada) having national guidelines for treatment that for the payer to act responsibly. You don't want to know just how many bodies UHC is willing to throw under a bus in order to make .5% more money.

Set it up so if you make a mistake, you're suspended from being able to issue any denials for a month. Make a second mistake, 2 months. 3 mistakes, 4 months. 4 mistakes, 8 months... In a 40 year career each Doctor Nick would only get 9 mistakes. Maybe a month suspension for a first offense is too harsh; let's say a day instead, that's still only 14 mistakes in a career. Is the money saved from that handful of extra denials going to justify the cost of taking care of those doctors for life?

> reputation is ruined

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.

If UHC can get Dr. Nick to reject claims for six months before he gets canned they'll be happy to set Dr. Nick up on a caribbean island for life after he declares bankruptcy - then all the other Dr. Nicks will be happy to throw their reputation in the fire for a cushy lifestyle.

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).

My childhood doctor in the late 70's hated insurance companies over this. I'd hear him on the phone arguing with the insurance company reps asking if they had a MD Degree and would like explain the denial to him. Interesting to hear back in the day.

I have to imagine many do, it sucks since what the hell are their options. I would like to think that most doctors at least care somewhat. I can't imagine how they feel if they think someone truly needs something and insurance just says no.

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.

In many cases that issue can be resolved through an appeals process. But this takes extra time for providers, and they don't get paid for that.

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 call bullshit.

I went through multiple appeal processes, my doctor tried to file multiple on my behalf, I called, and nothing.

They don't care.

Sounds like you had a good doc. These days it seems like the insurance companies have won- every doctor I talk to has the most beaten-down expression when I ask them about coding and their relationship with insurance companies. For most I talk to, they got into medicine to help people, but find themselves spending a frustrating amount of their time fighting with insurance.

the youtube channel dr glaucomflecken did a series on this that were pretty funny

https://www.youtube.com/watch?v=Vp7u58R41N8&list=PLpMVXO0TkG...

Yeah, he was a cantankerous one. Always telling my Mom to quit smoking while he himself would be smoking at the same time. The 70's were an interesting time to be a child.

It’s even worse than that: now they have a bunch of corrupt medical practitioners who they use to rubber stamp denials to make them more legally defensible. Most often, they’re literally just clicking “CONFIRM” on some machine-generated auto-denial.

Very much so. They'll get presented with several bullet points of reasons for denial based on their system, and be asked "do you see any need to disagree with this reasoning?" rather than any form of differential workup.

"Like fine deny name brand prescription for generic."

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.

Payer coverage rules typically do include that. This is known as step therapy. If a physician requests prior authorization for a branded medication then the insurer might deny it and recommend trying the generic alternative first.

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.

> Much of what insurers do is preventing waste, fraud, and abuse

Medical insurers are the waste, fraud, and abuse.

US government employees would be doing the same things for Medicare and Medicaid and Tricare.

Outsourcing that work to “insurers” helps keep the heat off the politicians.

Not true for Medicare. How it works is that Medicare splits the US up into regions (can’t remember if it’s currently 5 or 7). For each of these regions, a private medical insurance company handles all of the claims paperwork and the money for said claims comes from Uncle Sugar. This is also why it’s disingenuous when folks trot out the “claim dollars per Federal employee” argument for Medicare.

Note: I’m not talking about Medicare Advantage which is a separate program whereby Medicare pays the premiums for private health insurance plans.

It seems like we are in agreement.

I'm not sure what you mean there. Even Medicare in the US and single payer systems in other countries have strict rules to prevent waste, fraud, and abuse. They will refuse to pay claims that don't comply with coverage rules. In many cases those are even more strict than US private medical insurers.

What I mean is that what insurers do is try to screw people out of money and receiving necessary treatment to line their own pockets. Here’s a fairly concrete example:

https://www.propublica.org/article/unitedhealth-healthcare-i...

Insurers do deny some claims and authorization requests, but in most cases this doesn't line their own pockets. Rather the opposite. Most large employers are now self insured, and the medical "insurance" companies just administer claims. Due to the 85% minimum medical loss ratio imposed by the Affordable Care Act (Obamacare), insurers actually make more profit when they approve more treatments.

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.

Apologies, but this is complete bullshit. They make money by denying expensive claims, regardless of whether or not people actually need the treatment, and optimize for this despicable behavior.

I have given you accurate information. If you choose to remain ignorant then that is your affair. The reality is that payers that offer health plans to self-insured employers don't make money by denying claims.

No, you’ve intentionally tried to deflect and deceive across this entire thread, as is obvious from all the downvotes and comments you’ve received. It’s quite bold to lie and say insurance companies don’t deny claims to make money, since there are only myriad news stories, court cases, books, films, etc about them doing so, but you do you.

> 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.

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

You're arguing with the wrong person. I gave you accurate information about how the system works today, and a reference to technical information that hackers can use to mitigate certain problems. And I can do that with a straight face.

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.

"A lot of these issues arise because providers fail to review payer coverage rules before deciding on a treatment plan"

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).

> 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.

Death panels for a captive market, so it's all good.

Republicans were a couple decades too late when they said single payer or Obamacare would bring death panels. We already have death panels wifh medicare, medicaid, and workplace insurance.

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...

> Republicans were a couple decades too late when they said single payer or Obamacare would bring death panels. We already have death panels wifh medicare, medicaid, and workplace insurance.

> 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.

USA isn't other industrialized countries. Any single payer system would be in context of the existing economic and political system, much like Obamacare was in comparison to other 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.

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