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.”
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.