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Comment by hornban | Hacker News Reader

Cigna denied my claim for an ER stay for a broken leg because it "wasn't medically necessary". This whole "click and close" thing is so obviously happening that I find it hard to believe that the company is even bothering to deny that they do that.

One of the worst parts about this for me was that while I was dealing with trying to get my life back together from that kind of injury, I thought I was also going to go bankrupt as well.

In my case, everything did turn out fine because apparently the hospital has an entire department dedicated to dealing with insurance claim denials. This whole system is an absolute joke.

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There's so much ancillary work around medical care. Like 20% of US workers are in some supporting industry. Insurance companies pay a bunch of people to find reasons to deny claims, hospitals pay a bunch of people to fight the insurance companies. They all ultimately get paid by my medical bills and premiums.

In my mind's eye is a political-style poster depicting the patriotic duty it is to pay your medical bill. Insurance company takes a cut, people who fight insurance companies take a cut, CEOs take a cut, everyone takes a cut, my medical bill is keeping half the nation afloat it seems, until at the end there's even a few dollars left over for the doctor. All because I spent 5 minutes talking to a doctor about an ear ache.

Fixing this will require eliminating a lot of these ancillary jobs and it won't be popular among those groups.

I think as the industry moves from a post-pay model, to a pre-pay/real-time model, this antagonistic relationship between providers and payers should slowly improve. Definately not a silver bullet though.

In terms of aligning incentives, there is a lot of potential in shifting from a fee-for-service model to a capitated value-based care model. But this will force further consolidation by provider organizations. Only the largest, most sophisticated multi-specialty health systems have the scale to take on and manage those risks. Small, independent practices will essentially be forced to either sell their businesses or switch to something like concierge medicine.

Nah prior auths (prepay) can get screwed up just as much as claims (postpay) for the same reason.

Sorry, i used some jargon most people don't know. Prepay the way I meant it is not referring to prior auths, but rather pre-adjudication. Not everything can go through a pre-pay process, but I believe most claims can.

A hair over 17% of the US GDP is spent on health care. That's the highest among peer nations.

Not just healthcare, the US outspends everyone at everything: infrastructure, education, defense, research, police, housing, prisons, etc. both in relative(by % GDP) and in absolute numbers.

It does so because it can. It's the wealthiest country on Earth so such high inefficiencies where a lot of the money is squandered to the benefit of few wealthy and unscrupulous parties, can be financially absorbed while still delivering a system that's functional enough for its citizens to not revolt over and want to hang someone. After all, it's still better than scary communism.

How can it outspend everyone in everything using relative numbers?

Everyone has the same 100%, just distributed differently.

Relative meaning as a percentage of each country's respective GDP. I edited now to make it more clear.

I don't see how this solves the problem?

If Country A is spending 10% of it's GDP on 10 things, Country B cannot possibly outspend it in every category as a percentage of their respective GDPs, because "percentage of GDP" is always a 100-point scale.

If you go up one percent in one category, you have to go down one percent somewhere in the other categories.

Don't forget that us Americans pay 120% of what we should be paying, so there are extra percent points to go around.

This is one reason I hate it when productive jobs are destroyed. Economists say we'll find new things things for people to do, but those often seem extremely low value, like insurers/providers paying people to fight with each other over billing questions. And a lot of the time it seems like the replacement is either that sort of bullshit-esq job, or else some minimum-wage thing which is not acceptable to a lot of people - especially those carrying tens of thousands of debt in student loans from college.

Look, the denial created at least one extra job! Cigna is out there creating jobs, and it only cost you the very real fear that you could have your life ruined from a broken leg!

We couldn't fill the job locally, nobody could meet the requirement of extremely low ethics.

“One of the worst parts about this for me was that while I was dealing with trying to get my life back together from that kind of injury, I thought I was also going to go bankrupt as well.”

I have seen the same with people I knew who had cancer. They are already super sick but are then in addition expected to navigate this insane system or accept to pay tens and hundreds thousands of dollars. All this while they can barely function at all.

There is a whole niche industry in cancer care navigation. Perhaps that shouldn't be necessary in the sense of working around defects in a broken system but those care navigators can help a lot.

https://www.cancer.org/cancer/patient-navigation.html

They are probably helpful but are also a symptom of a perverse system.

A co-worker here had a neighbor who broke his leg falling out the back of a pickup truck (doing a job unsafely which seems to be SOP in rural Texas). He never worried about a bill since he didn't have money to pay anyway and I assume the hospital just ate the cost. The system is indeed a joke.

Quote from Obama on single payer. The system is set up quite specifically so certain parties can profit from it.

“Everybody who supports single-payer health care says, ‘Look at all this money we would be saving from insurance and paperwork,’ ” the former President noted. “That represents one million, two million, three million jobs.” https://www.newyorker.com/books/under-review/the-bullshit-jo...

Give them a shovel and have them go plant trees somewhere.

It's a reasonable statement, though. There's a LOT of people that think a single payer healthcare system is the right goal. And a LOT of those people also realize that getting from where we are right not to a single payer system is HARD. One reason it's hard is that there are millions of jobs that will go poof when that happens. Those people could be put to work doing something that's actually beneficial to society. But the transition from <working in bullshit job> to <working in useful job> for millions of people is not trivial.

The change isn't something where you just pass a law / flip a switch, and everything is better. It's HARD.

Maybe this is an upside to the looming AI-taking-jobs issue.

I bet a ton of these bureaucratic approve/deny/request-more-information workflows in current EMR systems will be replaced by AI in a few years, putting the people out of work.

Once AI eats their jobs, less resistance to changing the system.

Unemployed people: "Oh wow, now I see why we should shutdown the people eating machine"

Trillionaires with killbot armies: "No, I'm not seeing what you're seeing at all"

>I bet a ton of these bureaucratic approve/deny/request-more-information workflows in current EMR systems will be replaced by AI in a few years, putting the people out of work.

The EU AI act prevents exactly this scenario.

Most of it doesn't even require AI. The majority of those jobs can be eliminated just by implementing existing interoperability standards between payer and provider organizers, and then writing some simple deterministic rules. I previously worked on projects to do just that. There is a tremendous amount of waste (and associated jobs) that can be eliminated without buying a single GPU.

They could also be replaced with even simpler code:

    bool should_approve_claim(int claim_id)
    {
        return false;
    }

Ha ha, but even single payer or socialized systems have similar mechanisms for preventing payments for treatments that don't meet medical necessity criteria. Blindly approving all claims would only serve to make the system more expensive and overloaded than it already is.

Hopefully these jobs go away sooner than later, they are not exactally fufilling work & there are much better jobs out there.

I am now buidling an aprove deny API, going to call it dPANEL for deterministicPanel. Also chatGPT seems ungodly enthusiastic to help me build it...

Pricing Strategy for Health Insurance Approve || Deny API Pricing Structure Base Subscription Fee: Annual Subscription: $120,000 per year, covering up to 50,000 API calls. Volume-Based Pricing: Beyond the initial 50,000 calls: Tier 1: 50,001 to 100,000 calls at $1.50 per call. Tier 2: 100,001 to 200,000 calls at $1.25 per call. Tier 3: Over 200,001 calls at $1.00 per call. Multi-Year Discounts: 2-Year Contract: 10% discount on the annual subscription fee. 3-Year Contract or more: 15% discount on the annual subscription fee. Additional Services: Custom Integration: $30,000 one-time fee. Premium Support Package: $25,000 per year for dedicated support and quarterly performance reviews. Early Termination Benefits: Early termination within the first year incurs a 50% fee of the remaining contract value. Termination in the second year or later incurs a 25% fee of the remaining contract value. Cost-Saving Benefits Labor Cost Reduction: Automation of approval and denial processes reduces the need for manual labor. Increased Efficiency: Faster processing times improve operational efficiency and customer satisfaction. Error Reduction: Minimized human errors reduce costs related to claim reprocessing and disputes. Scalability: Efficiently manages varying loads without significant staffing changes. Regulatory Compliance: Helps ensure decisions are consistent and compliant, reducing potential fines. Data Insights: Offers valuable analytics that can lead to better risk management and operational adjustments.

“That represents one million, two million, three million jobs.”

Isn't this a flavor of the "broken window" fallacy?

There is more productive work these people can do than the adversarial "deny-fight-ok approve" system we have today.

It is, but that doesn’t change the political calculus at all. If you’re the president who does something which cuts millions of jobs, that’s a LOT of people who are now voting for the other guy. Obama won reelection by 5 million votes, so that could be all of his margin when you think about friends and family.

I am not saying we shouldn’t try, but you really do need to think carefully about how to phase things in so people have time to adjust.

Think of all the poor horseshoe makers out of work today lining up for soup

Full quote for context: https://www.thenation.com/article/archive/mr-obama-goes-wash...

> “I don’t think in ideological terms. I never have,” Obama said, continuing on the healthcare theme. “Everybody who supports single-payer healthcare says, ‘Look at all this money we would be saving from insurance and paperwork.’ That represents 1 million, 2 million, 3 million jobs of people who are working at Blue Cross Blue Shield or Kaiser or other places. What are we doing with them? Where are we employing them?”

If Kaiser could figure out how to cut those jobs themselves, it’d be done by next week. When it’s for the good of society, we have a conscience; when it’s for the bottom line, there’s no conscience and that’s celebrated. I have no solutions, only a pervasive anxiety.

Would they? Internal corporate politics says a team's manager, who's going to best know the value the team provides, is not going to declare their team is redundant and fire them and then quit themselves because what they're doing isn't necessary.

I sustained significant injuries last year in New York which requires $50,000 PIP coverage for every driver. The driver's insurance, Geico, illegally refused to cover me because I "wasn't related to the driver". Fortunately the insurance company of the car owner was willing to comply with the law.

New York is a no fault state. Billing those NF3 claims almost always requires going to arbitration. It’s a terrible arrangement.

Basically every single US healthcare provider needs someone whose job involves insurance claim disputes, just because there's just too much money in it. The person denying claims, and the person maximizing billing on the other side are ultimately getting paid by the rest of us.

These are normal semi-competent doctors who hate their day jobs.

Bigger medical services vendors contract out "Revenue Cycle Management" to third parties, and they're exceptionally good at capturing value.

Can you imagine how much worse it would be if we had 'socialism'? /s

We've not hit this point overnight - it's been decades in the making. But I'm not sure we'll ever 'fix' this by small incremental reforms around the edges. We need some moonshot revolution, but I'm not sure we have enough collective appetite for that.

Medicare/medicaid denies for medical necessity all the time.

Do the workers making those decisions get "bonuses and stock options" like Cigna's do in the article?

As do the European healthcare systems that have so many advocates here. In any system, there is a finite amount of money that can be paid out. Some level of review and denial of some claims or authorizations is unavoidable.

I'm not saying that the current system in the US is great, but moving to a 100% "single-payer" model will not get rid of claim review.

Pretty much. I'm insured in the public system of my relatively wealthy EU country but I still pay for a lot of stuff out of my own pocket. Not life threating stuff, that would usually be free, but still, things I need to make my conditions more bearable or for prevention, or physiotherapy for back pain, or getting appointments sooner than 3 months for a checkup.

With the ever increasing ageing population, and stagnating economy, the pressure on the healthcare system balloons while the money pot is finite, so the existing resources keep getting split more and more aggressively creating a system of winners and losers. It's inevitable when the resources are finite but the demand virtually infinite.

Yes but are they denied by accountants or doctors? Death panels already existed, it's just a question of who's on them.

Nine times out of ten it’s because the provider did not document or code it correctly when they billed your insurance.

Of course the insurance companies always get the heat but it’s probably the minimum wage biller at the office that justified the bone set with an incorrect urinary tract infection diagnosis code that will obviously get denied.

In the future it’s useful to call the provider and ask for a copy of what they submitted to your insurance.

Medical establishments are stupid everywhere. If your employer doesn’t choose an insurer or self-funded benefit administrator like Cigna, you don’t have these issues.

I have had a generous United Healthcare plan for 15 years. That time period included a high risk pregnancy, a spinal fusion, and a high risk cancer treatment program.

I’ve had zero billing issues. Zero. We did have some prescription formulary issues that were a result of some drugs being specialty drugs with a different process.

My sibling has Cigna, and literally has a problem of some sort with 80% of claims. The latest is an 8-year olds ear infection was determined by Cigna’s subrogation process to be related to a car accident.

That is because you likely went to a provider with a competent billing department. If you go to one with a bad one you will get results like OP. It does not matter if your employer was self funded or if you got the plan over the marketplace. The claim simply will not adjudicate correctly.

    > In the future it’s useful to call the provider and ask for a copy of what they submitted to your insurance.

Because the consumer -- a layperson -- will be able to decipher the paperwork and code it correctly and resubmit.

If the visit is in-network or an emergency the insurance company will prevent the practice from billing you anything until the denial is fixed. You don’t have to do anything other than throw the letter away and just wait for them to fix it.

If the practice tries to bill you anyway that’s called balance billing, is illegal, and violates their contract with your insurance company and you can call your insurance’s hotline to report them.

I hate to suggest adding yet another layer to the US healthcare system, but you are right and it seems there is a huge space for some kind of private (third party) health advocate/Sherpa - not the free ones that many health plans are offering now to find in-network doctors for you - that you PAY and in return they maximize the healthcare system for you the way that a good tax accountant/lawyer will minimize your taxes

These companies exist for out-of-network billing. Unnecessary for in-network billing.

Maybe the move is to call your credit card concierge service and have them argue with your insurance company for you.

It is purposeful obfuscation. The number of people that can't get the paper work correct, is profit for the insurance company.

I knew someone whos wife got cancer. But good luck, she actually worked in the insurance industry and knew everything. Yet, it still turned into a Full Time job for her to get all the paper work corrected. How is the common person going to fight the system if insiders have difficulty.

It is a terrible specification that causes all kinds of problems but is one mandated by law and must be used.

Specification? The coding system?

I didn't realize that was mandated by law? Surely not down to individual codes?

If that is what you are talking about, it kind of makes sense. Part of how the industry obfuscates is by using a lot of different terminology for the same thing, thus nobody can do price comparison across vendors. But of course, trying to impose order onto something purposefully confusing, is going to be difficult.

Something I wrote about the ICD10 coding system many years ago. These are real billing codes:

It is possible to arraigned the codes in rather amusing orders such as:

I required a Face Transplant, from a Cadaver; “0WY20Z0 Transplantation of Face, Allogeneic, Open Approach Transplantation of Face, Allogeneic, Open Approach” after my many spacecraft crashes into the ocean; “V9541XD Spacecraft crash injuring occupant, subsequent encounter”.

Sadly the first Face Transplant failed so one was grown in a lab for the second Face Transplant; “0WY20Z1 Transplantation of Face, Syngeneic, Open Approach Transplantation of Face, Syngeneic, Open Approach”.

Alas all of this made my “F52 Sexual dysfunction not due to a substance or known physiological condition” became so bad that I tried to harm myself with a jellyfish; “T63622A Toxic effect of contact with other jellyfish, intentional self-harm, initial encounter”. -- Amusement with the Medicare ICD10 Billing Codes –

ICD10 is not the problem - x12 is.

ICD-10 is only one of several code systems (terminologies) used in HIPAA mandated transactions. The actual billable procedures for outpatient care are typically coded using CPT / HCPCS. The ICD codes are usually supplementary, to indicate a patient's condition as part of establishing medical necessity. The industry will move to the new ICD-11 version in a few years.

No. The specification mandated by HIPAA law is x12 837 and 835 documents. They are awful.

The HIPAA final rule mandates ASC X12 as the standard format for certain interactions such as eligibility and claims. It's old and somewhat clunky, but it's not terribly hard to implement. Libraries are available for most popular languages. Even if we replaced X12 with a modern format like HL7 FHIR (which is now legally allowed for some interactions such as prior authorization) that wouldn't solve the fundamental business, legal, and clinical problems.

It’s terrible to implement at the business and industry level - the required details enclosed with the messages are wholly insufficient to properly communicate claims as well as claim payments between payers and providers. Yet nothing can be done as the law requires its usage.

Could you clarify which specific details are missing from the messages? Additional clinical documentation can be sent in 275 attachments.

The law does not specifically require X12. The law gives CMS the authority to set technical standards and they chose X12 for those transactions because there was no other practical option. But recently they have granted at least one exception to use FHIR instead.

My wife runs a small medical clinic. In the past, she worked as a physical medical biller contracting for large hospital systems, which gives her an unusually good understanding of how to submit a good claim to an insurance company. Despite this, for every hour of patient care, there's an addition 90-120 minutes of staff time to deal with insurance companies, plus additional time spent by a third party (who bills on a percentage, so we don't know exactly how much time they spend). That third party consistently complements her billing staff at being unusually good.

Sometimes a claim is denied because the insurer says they need additional documentation when that documentation was already provided. Sometimes this happens more than once. Sometimes prior authorization requests get "lost".

I think the problem is that if an insurer wrongly denies claims some of the time, nothing bad happens to them but they might save some money. The only fix I see is to change the rules of the system so that it the insurer gets no financial advantage for wrongly denying claims.

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