> 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.
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.
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.
> 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.)
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.
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.
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.
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.”
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.
Health Insurance companies grow their bottom line by growing the topline cost of healthcare since they're margins are limited.
https://www.statista.com/statistics/214504/total-revenue-of-...
https://www.healthcaredive.com/news/unitedhealth-2022-earnin...