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Comment by GiorgioG | Hacker News Reader

Maybe they should hurry up and approve more claims. Seriously, my son’s insulin pump is sitting in “prior authorization” just so they can fuck me into paying the full deductible come Jan 1. Fuck United Healthcare.

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It ought to be the law that approved claims should be backdated to when the initial claim was made. UHC pulled this exact trick on me, denying something that ought to have been approved in order to push the date into the new plan year with a reset deductible.

It ought to be the law that every in-network claim must be automatically approved. In network providers have already jumped through hoops to have that contract with the "insurance" company, including the creation of documentation to satisfy the "insurance" company of their judgement. It's disingenuous for an "insurance" company to then claim to be second guessing the very professionals' judgement they've already examined and approved of.

> ought to be the law that every in-network claim must be automatically approved

This almost certainly requires vertical integration between providers and insurers. That or shifting approval/denial to the provider level, i.e. your doctor can fall off the approval list from month to month for submitting too many claims.

If not, providers will become the most profitable business on the planet right until every health insurer goes bankrupt. (We’ll probably get to blame it on PE-run hospitals, even if everyone is doing it.)

Providers are liable for malpractice if they approve un-needed treatments, and all drugs have side effects.

And they meanwhile have their own liability insurance to pay, as well as medical student debt. So not going to be profitable either. Unless they start prescribing Carnival Cruise therapy or stiff like that.

> Providers are liable for malpractice if they approve un-needed treatments

There is a lot of grey area between necessary to the point of malpractice if not provided and unnecessary to the point of malpractice.

Like, you’re not going to win a malpractice case because your doctor prescribed too many non-invasive tests and MRIs. And if my insurer is forced to approve every MRI, I'm probably going to ask my doctor for an MRI.

It is simply naive to think that the threat of malpractice discipline by state medical boards would deter bad actors from delivering wasteful or unnecessary care. The fee-for-service financial system heavily incentivizes over treatment. If you don't believe me then read "The Price We Pay" by Dr. Marty Makary. It documents many such incidents for which the providers were never punished.

https://www.bloomsbury.com/us/price-we-pay-9781635575910/

As both the payer and provider sides of the industry have consolidated to gain more negotiating power this sort of "payvider" vertical integration is inevitable. Kaiser Permanente has operated like that for many years and they only rarely authorize referrals to outside providers. UnitedHealth Group is moving in a similar direction by expanding provider groups under their Optum subsidiary.

https://www.optum.com/en/care.html

The other approach is to to shift from the current fee-for-service financial model to a capitated value-based care model. Under that model, claims basically disappear and payers hand over a set fee per member per month to a health system which then becomes responsible for doing whatever is necessary to keep that patient healthy. Early trial VBC pilot programs have been encouraging but it's tricky for providers to get the actuarial calculations right.

I don't see why it would have to be every month, instead of say a statutory minimum of at least six months notice with such changes only taking effect after an open enrollment period. The doctors and insurers can sort out how to handle the resulting dynamics in their professionally-negotiated contracts, instead of just falling back to blasting individual patients with fraudulent bills.

And yes, if we're going to continue to limp along with these "insurance" companies being the supposed market dynamic, the healthcare industry desperately needs more integration so responsibility can actually be taken and absorbed, rather than just continually punted. The whole industry has fallen into a state where each player passes the blame to someone else, including you as they tell you its now your new unpaid job to make many hours worth of phone calls as you get ground up passing messages between mutually-hostile bureaucracies.

I mean, it was fine for 50 years.

Ro Khanna said something similar a week or so ago. You all get that this would basically be the biggest corporate giveaway in the history of American politics, right? The reason you're getting health care denials is that providers are trying to rip your face off. I'm pleading with people on this site to go look at where the dollars in health care spending actually go. CMS, the government organization that manages Medicare (and somehow got vilified a few weeks ago when Blue Cross tried to adopt Medicare's anesthesia billing rules), tracks this stuff in a set of documents called the National Health Expenditures. They're spreadsheets, they're easy to go read, please, for the love of all that is holy, go look at them before designing policy.

One reason you may need to continually plead with people about this is because so many of us have had lived experiences with valid medical claims that should be covered under our policy, denied outright. Not a health insurance company saying “oh, that’s too expensive, go here for less,” but outright denial of coverage. And if we eventually succeed in having these claims covered, it is because we were willing to spend countless hours combing through paperwork, initial delays, and denials.

Also, the same CMS statistics you cite can be combined with other reports to conclude that 500 billion dollars of excess administrative costs PER YEAR are attributable to our lack of a single payer system — something UHC has lobbied heavily against in order to protect their profits over the improved health care of the average American. You can read the numbers here:

https://www.peoplespolicyproject.org/2024/12/10/health-care-...

“private insurers currently have administrative costs that are 1,000 percent what they would be under single-payer while hospitals currently have administrative costs that are 158 percent what they would be under single-payer. The excess administrative expenses of both the payers and the providers are because of the multi-payer private health insurance system that we have.

When you add it all up, excess administrative expenses — defined as administrative expenses we have under the current system that we would not have under single-payer — are equal to 1.8 percent of GDP, or $528 billion per year.”

Another reason your pleading falls on deaf ears is that, sure, provider payments can be reduced (and this addressed in the above article), but at the end of the day, private insurance is a purely rent-seeking enterprise that provides no value to Americans while these “overpaid providers” are actually delivering the care.

2.21 trillion dollars per year of provider costs, against 279 billion dollars net cost of health insurance.

But yeah, the one player in this market that has its profits capped statutorily, they're they're the whole problem, no matter what the numbers say. Sure.

I'm not telling you there's no problem. I'm saying that you've been conned into believing the problem is something it isn't.

The article I posted did not claim they were the whole problem, nor did I.

They are, however, a large part of the system that no one likes to deal with and can be fully eliminated without obvious negative consequences.

Health insurance doesn’t provide health care and is a purely extractive rent-seeking business. The article I posted even explains how single payer can help drive health care provider rates lower, as you now have a single, powerful entity (Medicare) negotiating against doctors, hospitals and drug companies.

And this “one player” (health insurance companies) heavily lobby against the implementation of single payer health care system. And their profit caps ensure that their goal is to grow the cost of medical care so they can take an ever higher profit in absolute dollars.

The article I posted makes a case that eliminating private health insurance will be VASTLY more than 5% savings and people can read the article to see why.

You’re choosing to avoid all of the other cost savings that will come from eliminating private health insurance and having a single payer who can effectively negotiate with providers without the goal of taking a slice of profits from an ever bigger pie.

You're citing Matt Breunig's figures about how much more efficient Medicare would be than private insurance. But the truth is, mechanically, the opposite. Medicare's efficiency is a statistical illusion. Administrative overhead is a simple ratio of fees paid to services rendered. The more services you render, the better your admin costs look. And Medicare's look good indeed, because virtually everyone in America over the age of 65 is covered by Medicare --- that's the point of the system, to do single payer at the point where costs suddenly ramp up. If you let people enroll in Medicare at age 25, they would incur lower service costs, while paying the same in fees. If you do the math, Medicare for a 25 year old looks a lot like private insurance for a 25 year old.

Meanwhile: all insurance costs, in the whole economy, across all of national health expenses, total less than 10% of costs overall. Providers drive all the costs in our system, not insurers. But Breunig is fixated on his preferred solution, so he's not telling you that. But the numbers are right there if you want to see them; just search [National Health Expenditures by Type of Expenditure and Program: Calendar Year 2022].

I honestly don't care if you want Medicare vs. private insurance. I don't love my insurer. But if you zero out the total cost of insurance, public and private, you barely make a dent in our health costs. There is no way around it; the numbers are stark.

Personally, I think the balance we've struck in our payment system --- private markets until age 65, at which point the state steps in --- is pretty smart. Our system is fucked, of course, but that's because health provider chains have been ripping people off for decades.

> Providers drive all the costs in our system, not insurers.

I like your proposed solution that the state somehow engineer a way to drive down the costs billed by providers. Perhaps if the state operated a (pseudo-)monopsony wherein they exercise their leverage as the payer to drive down costs.

It could have a snappy name like if you combined medical and care? Or maybe medical and aid?

Anyway I also cannot fathom why anyone would hold ill will towards an industry that lobbies to stop that from happening. They are simply smol beans and the fact that there is no single payer monopsony means they are splitting a measly fraction of a trillion dollars per year. The fact that somebody else makes money too is proof that they couldn’t be a problem uwu

Yes. They're a part of the problem. Specifically: they are less than 10% of the problem. If you replaced them with Medicare, you would get somewhere between 1-5% off your health care bills, if everything went optimally.

Meanwhile: we are commenting on a story about someone murdering a health insurance executive.

> Meanwhile: we are commenting on a story about someone murdering a health insurance executive.

Is this surprising? Motive is always of interest after a high profile crime. And apparently it requires assassination with manifesto to bring these robber barons into the spotlight. The only thing I find surprising is the use of a 3D printed gun instead of just buying one from a show or local gun store.

You are fighting a losing argument created by health insurance companies because they've created years of self-inflicted wounds. Everyone believes health insurers are the problems because almost everyone has dealt with the nightmare of valid claims being denied.

Health provider chains rip people off because that's how they maximize earnings from insurance companies. Insurance companies maximize denials because that's how they maximize profit. You remove one side from the equation and the problem of provider costs becomes easier to solve.

And as an aside, I dealt with my mother being denied healthcare from her insurance provider because they determined her stroke was a pre-existing condition.

There is simply no logical argument you can ever make that will change my opinion.

It is, obviously, exactly the other way around: the system is rigged to maximize earnings for health provider chains. I honestly don't see how you can look at the numbers and come to the other conclusion.

'Won't someone think of the poor rent seekers' is not nor will it ever be a compelling argument. The only way this problem can be solved is in the same way every other country solves it: Either tearing out private insurance and fully socializing healthcare or strongly limiting private insurance and having a public option which negotiates and keeps prices low.

You can argue that health providers charge too much and that's true. But the core of the rot comes from the health insurance scheme we've cooked up. And people rightfully blame the insurers for this problem.

Maybe if they dislike it so much they can put a fraction of the billions they're earning towards bribing politicians for a public option rather than constantly spiking things like that whenever they get a chance.

Health insurers make an order of magnitude less than providers, and our providers charge 3-5x more than European providers, but somehow insurance is "the core of the rot"?

OP said the "health insurance scheme we've cooked up" is the core of the rot - not insurers' on their own, but rather the whole regulatory environment ("we") that enshrines the dynamics of HMOs, imaginary prices, and whatnot.

I agree with a lot of what you are saying. Trying to demonstrate some common ground - my (somewhat shallow) reading of the Anthem Anesthesia issue aligns much more with your analysis than the pop narrative.

But how exactly is the denial of care suppose to function as a price feedback mechanism to form a working market between providers and insurers? Is an MRI provider supposed to be thinking that if they lower their prices by 10%, the insurance companies will increase the number of approved MRIs to make up for it? And this still ignores that prices are not the same as profit margins, which is a huge hand wave here. Also if those denied MRIs were truly unnecessary, then how would paying for them merely because they cost a little less make sense?

Which is the crux of where my original comment was coming from. The responsibility of deciding necessary medical care needs to be laid at one decision maker (eg the treating doctor serving the patient per their code of professional ethics while fundamentally still working for the insurance company), rather than this split-brain blame game between the patient-facing doctor having little downside to saying yes, and the back office "doctor" at an insurance company having little downside to saying no. An insurance company shouldn't really even have its own opinion on something decided by a medical professional they're already contracting with, especially when that opinion has been created purely based on formulaic paperwork processing. At most they should be able to refer the patient to a different provider to perform the service, or withhold some payment for the service per their contract with the provider (but invisible to the patient).

This is obviously not the only reform we need to get any sort of price signals and sane division of responsibility in this industry. Because yes, provider costs are the main problem and they've been marching ever upwards. But every one of these terrible dynamics that has been allowed to fester is in need of its own reform, especially if you aren't advocating for the blanket approach of single payer.

Correct. See: my experience with pre-existing condition denial.

I've read similar comments of yours in other threads, and have thought them on point. I certainly don't see "insurance" companies as the single source of bad of the whole system. Personally, I just got done dealing with an 11 month billing headache spearheaded by entitled "providers" double billing, and shamelessly telling me that they don't have the resources to follow up on claims I told them needed to be followed up on, while still continuing to send me fraudulent bills with fake amounts and fake due dates. Meanwhile, despite their "bucket of stomach fluid" bureaucracy, the "insurance" company straightforwardly communicated what I should (not) be responsible for (at least until the rep I was emailing back and forth ghosted me because he got memory-holed). Heck I'm not even really a proponent of single payer versus reforming the industry so it has to abide by the common sense norms of commerce like every other industry. So the "you all" grouping falls a little flat here.

But read what I wrote again - the point is that every "in network" provider of an HMO is already accountable to the HMO while providing care to their members. If an HMO wants to limit certain types of care, then that needs to be expressed to providers (through their contracts), who can immediately tell patients "As a doctor I would recommend you get this type of treatment, but while working for $HMO I cannot provide it as your plan doesn't cover it". My initial comment was phrased in terms of insurance companies, but this double approval blame game is actually more a problem with the entitlement of doctors never wanting to deal with the reality of what services cost.

  and somehow got vilified a few weeks ago when Blue Cross tried to adopt
  Medicare's anesthesia billing rules

LOL

That is absolutely fucking NOT why Blue Cross Blue Shield got vilified. Please stop making disingenuous arguments.

BCBS attempted to weaponize Medicare statistics and set a hard cap on anesthesia coverage based on the average time Medicare says a procedure takes. This is NOT how Medicare reimbursement works. Medicare pays anesthesia providers for the entire time a patient is under. Full stop.

No, from everything I understand about the situation, this is the opposite of the truth. Feel free to cite a source saying otherwise! I'll read it!

Yeah, go read the rules set forth by CMS. Medicare pays for the entire cost of anesthesia.

So here's why I'm so dismissive of your garbage argument. From Medicare's policy manual:

https://www.cms.gov/files/document/chapter2cptcodes00000-019...

  A unique characteristic of anesthesia coding is the reporting of time units.
  Payment for anesthesia services increases with time. In addition to reporting
  a base unit value for an anesthesia service, the anesthesia practitioner reports
  anesthesia time. Anesthesia time is defined as the period during which an
  anesthesia practitioner is present with the patient. It starts when the anesthesia
  practitioner begins to prepare the patient for anesthesia services in the operating
  room or an equivalent area and ends when the anesthesia practitioner is no longer
  furnishing anesthesia services to the patient (i.e., when the patient may be placed
  safely under postoperative care).

Compare this to BCBS's policy (which they've tried to scrub from the internet):

https://www.asahq.org/about-asa/newsroom/news-releases/2024/...

  Anthem will arbitrarily pre-determine the time allowed for anesthesia care during a surgery or procedure.
  If an anesthesiologist submits a bill where the actual time of care is longer than Anthem's limit, Anthem
  will deny payment for the anesthesiologist’s care. With this new policy, Anthem will not pay
  anesthesiologists for delivering safe and effective anesthesia care to patients who may need extra attention
  because their surgery is difficult, unusual or because a complication arises.

There's a vast gulf between those two approaches. Medicare pays for the time a procedure takes, BCBS does not. BCBS deserves every ounce of vitriol they got over that.

Your entire argument appears to be that doctors are corrupt and cannot be trusted which is entirely orthogonal to the the issue with pre-determining the amount of time a procedure will take. Meanwhile BCBS overcharged (a.k.a. fraudulently charged) the federal government for over $100 million. Doctors are not the problem with health care in the United States.

https://www.reuters.com/legal/anthem-must-face-us-government...

UHC? $7.5 billion (with a b) in fraudulent Medicare charges.

https://www.startribune.com/report-unitedhealth-group-tops-l...

Cigna? They settled their fraud cases for $200+ million.

https://www.justice.gov/opa/pr/cigna-group-pay-172-million-r...

https://www.justice.gov/usao-sdny/pr/united-states-reaches-3...

Independent Health Association? $100 million.

https://kffhealthnews.org/news/article/medicare-advantage-fr...

Private insurance is one of the biggest drivers of the obscene cost of health care in this country.

(this comment was extensively edited since I responded to it)

You haven't rebutted anything I said, and the source you quoted about Anthem's proposed policy is the summary from the lobbying group for anesthesiologists. As I pointed out downthread: CMS maintains a catalog mapping procedures to units of anesthesiology billing.

later

And again, edited, everything after "your entire argument".

Private insurance literally can't be the primary driver behind health care costs in the country. Again: look at the NHE. The numbers are right there.

  Private insurance literally can't be the primary driver behind health
  care costs in the country.

They literally can and literally do. They drain billions of dollars annually in fraudulent claims with UH accounting for $7+ billion in Medicare fraud in 2023 alone. UnitedHealthCare (the insurance arm) sucks in $4 billion (with a 'b') in earnings each quarter.

Doctors are not the problem.

https://www.unitedhealthgroup.com/content/dam/UHG/PDF/invest...

Provider costs are over 2 trillion dollars.

No, they do not. This was a whole controversy last year.

https://www.asahq.org/about-asa/newsroom/news-releases/2023/...

Lots of stuff to go find at this search:

[medicare anesthesia upcoding]

Reiterating: this is exactly why Blue Cross was vilified, and people angry about it were getting played by a lobbying group of some of the best-compensated professionals in America. Anesthesiologists getting paid more is not a consumer protection policy; it is the opposite of that, and it's wild that people think it might be otherwise.

Did you read what you posted? Because all you've cited is a bunch of complaints about the conversion factor and not the time factor. Medicare pays for the entire duration of the procedure. BCBS does not want to do that.

Again. Go through the CMS regs and show me where Medicare puts a hard cap on payment like BCBS was trying to do. I know that's a tall ask because, simply put, they do not.

> Go through the CMS regs and show me where Medicare puts a hard cap on payment like BCBS was trying to do

Where does it say CMS blanket approves? Because I’ll tell you this: if it does, I’m buying up some anaesthesiology practices. (They’re subcontracted within most hospital systems.)

  Where does it say CMS blanket approves?

It doesn't, and I've never made that assertion. However, Medicare and Medicaid both deny claims at a lower rate than private insurers. How frequently depends on where and when you look.

The guidelines however are important. BCBS wants to reject any claims for anesthesia out of hand if they exceed the average length of a procedure. Medicare does not. Because we all know that unexpected things never happen in the operating room.

After Anthem backed down I'd invest no matter what you find. Clearly: they run the health care system, and the public (including Kathy Hochul) is on their side!

Here's r/actuary on it:

https://www.reddit.com/r/actuary/comments/1h70wic/does_anyon...

I don't believe you're coming to this with a detailed understanding of the policy CMS has today or that Anthem was proposing. Sorry, at this point, unless you can cite a comparably specific source, I simply don't believe you, and we're probably at an impasse.

And you're coming at this from a profit doesn't drive up the cost of medical care which is in and of itself a pretty gross misunderstanding of what profit is. Again, did you read what you cited? That redditor is justifying the cap that BCBS wants to implement, not disproving that Medicare does not implement a time cap.

I'm not here to do your research for you. CMS regs and guidelines are a matter of public record. If you don't want to actually cite the comparable regs you claim exist that's not my problem.

  fleeing to abstraction.

You're citing an insurance actuary who posted to reddit claiming no, it's not the for-profit insurance companies that are the problem, it's the corrupt doctors. That's absolutely fucking asinine. What next? A fox claiming it's the chickens that are the problem?

Unlike private insurance companies, the rules and regs that Medicare puts forth are a matter of public record and you're still unable to cite anything supporting your claim that Medicare puts a hard time limit on anesthesia reimbursement. So go ahead, stop waving your hands and start citing something. You do understand what time units are, right?

www.cms.gov

What's that? You're going to continue tilting at windmills and railing against the evils of overpaid doctors instead of showing anything that supports your specious claims about Medicare? Okay then.

Following this thread all I see is you aggressively asserting a certain viewpoint, with no substantiation. I have no stake in the game but if you're going to come out swinging with aggressive naysaying but zero substantiation, all I'm thinking is: "citation needed".

You haven't presented any research at all, so it's not clear to me how that could a valid rebuttal to anything I've said. You're talking about how "profit" distorts this system --- I agree, for what it's worth --- and it looks to me like you're just fleeing to abstraction.

It is a giant pain in the ass to pull up Anthem's original proposed policy, since it's been memory-holed everywhere, but if I manage to do it, I'll post it.

You're on HN right now campaigning against reference pricing! Like I said: this whole situation is wild. You've taken the side of people making like 20x more money than the insurers. Why?

Like: the whole system of Medicare reimbursement for anesthesia is based on a catalog of procedure-by-procedure base units. Medicare sets reference prices for procedures. You can just go look it up. I've got the XLS open right now. I don't understand what you're trying to argue here.

You get that, at the end of the day, this is about how much money anethesiologists take home, right? People on Twitter were talking about anesthesiology being withdrawn in the middle of procedures. Obviously, that's not a thing.

Of all the players in this system, the insurers are the only ones who have their profits capped by statute, across the board. If anesthesiologists make more money from a procedure, that comes out of your hide: it's reflected in your premiums and co-pays. Please, help me understand, why are you making a moral crusade out of paying your doctors more money? They don't need the money! America pays doctors 3-5x more --- THREE TO FIVE TIMES --- than Europe does.

I know you're getting at a specific point. And I'm aware that health insurers are not the only moneymaking component in the health care pipeline.

I don't think eliminating profit is doable. Capitalism is the worst system other than all the rest. But surely we can agree that health insurers that are publicly traded do not prioritize human outcomes.

The profit motive needs to be tempered, if not entirely removed, from health insurance. Profit motive should be tempered in the basic healthcare space. Excessive testing and treatment are a thing too, I understand.

What I guess I'm saying is, I know it's complicated, but no amount of nuance absolves UHC and others for the kinds of denial stories that people have been telling.

(I don't work Monday... I may be rambling).

They're not just "not the only" moneymaking component; they're an order of magnitude and another integer factor away from being one of the most significant. The problem in American health care is (1) how much providers charge and (2) how many procedures and services are prescribed.

> Capitalism is the worst system other than all the rest.

This isn't anything to do with capitalism. It's all to do with Republicans bizarre obsession with 'small government'.

These kind of healthcare horrors don't happen in most western countries, because they have reasonable regulations and socialized healthcare in place.

Well, that, and they pay their doctors 3-5x less.

I can see where the money goes. That doesn’t absolve the insurance industry of being a festering sore worthy of every bit of scorn sent their direction.

For providers with a history of high quality PA requests and high approval rates, there is something similar. See https://www.uhc.com/news-articles/newsroom/gold-card

Other insurers have similar programs.

Sounds like another layer of "gotchas" to pin more work and blame on patients, while still not providing any guarantee. "Your healthcare was denied because while you may have checked the provider was 'in network', you did not also check to see if they have earned a gold star. I can email you a list of our highest quality providers that have earned gold stars"... Then most aren't taking new patients, and the one or two that do are booking out the better part of a year for a new patient visit.

I'll go out on a limb and say that the proliferation of these punt-the-problem administrative layers (in lieu of straightforwardly owning and solving problems) is one of the main things driving the medical industry's cost disease. A few years from now this "gold card" program will likely be administered by a newly spun out "third party" vendor that doesn't publish updated lists very well, but if you feel you were treated unfairly you can always file an appeal with them...

That is how Kaiser works- the doctors have internal guidelines, e.g. a set criteria for a diagnosis, and every treatment that is ordered is automatically approved. This isn't a perfect solution either though- the guidelines are often unreasonably strict, and still deny people treatments they very much need.

The difference being that in the Kaiser system, the doctors work for Kaiser, and not for health provider chains.

In terms of annual deductible, claims are always dated to the date of service regardless of when they were submitted or adjudicated. I think what you're asking for is that if a prior authorization request is submitted in one plan year then all claims linked to that request should be counted towards the deductible in that plan year regardless of the date of service. That might help some plan members but would hurt others depending on timing.

Health plans covered by the CMS-0057-F final rule are generally required to issue decisions on prior auth requests within 7 days. But that rule doesn't apply to most private commercial health plans.

https://www.cms.gov/newsroom/fact-sheets/cms-interoperabilit...

I, as a male, have a 4.5k medical bill from a breast cancer biopsy center. I had surgery on December 8th. They billed me for the biopsy on January 3rd, and of course UHC isn’t covering it.

Turns out joke is on them, I’m not paying it.

Males can/do get breast cancer, unless I am missing your point?

Ask me how I know!

It's very hard to have any compassion for architects of this company's system.

Congress claims this is what we the people want.

I believe that some people really needs that. Ironically the ones which need it most.

*really believe not need

Congress has a 17% approval rating.

But they’re still employed, still getting paid, and still getting bribed.

Sure, but I don't think they are meaningfully speaking for "the people" in any sense (even assuming that we even have such a singular entity in US, which I personally don't think is true anymore).

How is this legal?

Many of the shenanigans pulled by health insurers aren't legal, but they know a significant number of people will just pay or file bankruptcy instead of appealing or lawyering up.

It's not in many jurisdictions. The AMA tracks laws on prior authorization, and in an increasing number of states insurers must make a decision within 5 calendar days. (https://www.ama-assn.org/system/files/prior-authorization-st...)

Lawmakers need campaign money and shakedowns are profitable.

Think of all the times you've seen a news headline that reads "Company X settles with [regulatory body], does not admit guilt". Corporate malfeasance rarely reaches the courtroom, so their wrongdoing is not entered into public record in a way that can be cross-examined.

How would OP know that is the reason?

Dude, that’s horrible. I’m sorry you have to deal with that.

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