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Comment by inamberclad | Hacker News Reader

Seeing my health insurance deny hospital claims that were pre-authorized has been insane. The hospital checked in advance with my insurance that several operations would be covered and the insurance approved. Now that the bill comes, the insurance company has repeatedly denied and denied their claims. Health insurance companies are horrible and parasitic to everyone involved.

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I've had BCBS reject prescriptions they've already pre-approved multiple times. First time, they denied all knowledge of the REQUEST (when my doctor has their APPROVAL fax in hand). Second time they acknowledged they had approved it but had to contact their pharmacy group to put in an "override". I've submitted a complaint with the state insurance regulator though I doubt it goes anywhere.

Anyone for a class action lawsuit on the grounds of bad faith breach of contract and medical malpractice for obstructing access to care they already admit is medically necessary (by denying something already pre-approved)? I don't even want money. I want a Consent Decree enforced by the court that strikes fear across their whole industry.

Audio record every interaction you have with insurance and tell 'em you're on a recorded line.

> medical malpractice for obstructing access to care they already admit is medically necessary

This has been tried before and failed. The insurers argument is that they are not denying care, they are just not willing to pay for it, which isn’t practicing medicine.

> Audio record every interaction you have with insurance and tell 'em you're on a recorded line.

I’ve tried this. They just hang up. So I record and then have a transcript generated, and I save my call logs.

The big problem with health insurance is that it accounts for 17% of the US GDP, so although it's parasitic for everyone involved, it's basically indispensable to the economy. That's a big reason why the Affordable Care Act panned out the way it did, as a partnership with the insurance companies.

Under the ACA, 20% of that is overhead for the insurers. So you could boost the economy by 20% x 17% = a full year's GDP growth for free.

It's a closed circle, Tax money comes in, Insurance companies suck it up with a straw.

That same economic activity could still occur with that money, it would just be in other sectors, and ideally ones that produce real economic value.

If for-profit health insurance is really almost 1/5th of US GDP, something is entirely wrong.

Then again, maybe it makes sense the country that perpetuates suffering all over the globe through being global police and lately just fucking up any sense of stability is the same one where almost 1/5th of our "output" is built on top of making money off of prolonging our own peoples pain and suffering.

>it accounts for 17% of the US GDP, so although it's parasitic for everyone involved, it's basically indispensable to the economy

if people weren't forced to spend it on healthcare, they would spend it elsewhere. if healthcare was free tomorrow, the GDP would be fine, just redistributed.

They would also be healthier to contribute other economically productive labor and organization. When people get sick or die they stop working.

And more than half of my 50s-year-old friends would be able to retire from jobs where they do the bare minimum just to maintain their health insurance.

Won't someone think of the 50-year-old office workers?

Yeah, going single payer alone could reduce that 17% to 13%, maybe more, just through eliminating all the barriers insurers put up to providers being paid and administrative overhead.

Source? A study from KFF puts "administration" responsible for only 12% of the increase the US pays over comparable countries, or less than 1 percentage points.

[1] https://www.healthsystemtracker.org/brief/what-drives-health...

> Administrative costs include spending on running governmental health programs and overhead from insurers, but exclude administrative expenditures from healthcare providers.

From what I've read, healthcare providers spend an inordinant amount of time and effort dealing with insurance companies.

Don't forget the overhead created by PBMs and when insurance companies also own the PBM and the drugstore

Correct, it's cost both for insurers AND provider organizations. We have an entire team of humans who call insurance companies on the telephone to verify insurance benefits because most insurers make it EXTREMELY difficult to determine benefits in an automated manner because that makes it easier to bill them. They do everything they can to make it difficult for patients to get coverage and for providers to collect. We're actually working with an AI company to build a tool that uses AI and lots of data to predict with better accuracy benefit coverage. All because insurers want barriers to treatment to lower their costs.

Source is my own lived work experience. In the healthcare companies I've worked in, the size of teams to investigate benefit coverage, to bill, and then to nag insurers to actually pay us works out to roughly 15% of the total staff. This is where _providers_ are about 25% of staff. Add to those salaries the costs of the tools we have to employ to manage it all, track it, and management of all of those folks, and it bloats the cost by 20%.

We're actually working with an AI company to build a tool that uses AI and lots of data to predict with better accuracy benefit coverage. All because insurers want barriers to treatment to lower their costs.

If we went single payer, we would virtually eliminate benefits investigation teams because Medicare is honestly super easy to determine benefits of a patient unless they're on the private Medicare Advantage plans. We could eliminate the need to work with clearing houses as we'd have one payor, not hundreds of payors each with dozens of plans and single-case agreements. RCM departments would shrink because with one payor, providers wouldn't have to constantly nag payors to actually send the money.

The admin overhead is sickening.

The problem is the overhead of government is even worse.

[citation needed]

No, Medicare and CMS are run exceptionally well with some of the least fraud and waste in the entire government. CMS is NOT an agency you want to screw with because they come down like a ton of bricks when they find fraud. People go to prison. It's not like being a DoD contractor where they milk billions from the gov't.

How much worse? How do you know?

Reagan’s Nine Scariest Words quip sounds nice but it works just as well when you replace “government” with “corporate” or “church” or “next door”.

Also, if people get the medical attention they need on time, they’d be more productive and also be more active in the economy. The loss of productivity coming from inadequate healthcare because of insurance coverages is in the order of tens of Billions annually.

>Also, if people get the medical attention they need on time

Unclear whether that would bear fruit, given how socialized healthcare systems have a bad reputation of long wait times.

I think this is an incorrect impression caused by cherry-picking data. E.g. in the dataset linked below, while some European countries have longer waiting times for elective surgery, they have between 2x and 10x shorter waiting times than the US when it comes to seeing a primary physician. Which is arguably one of the most important metrics for getting people medical attention on time.

Furthermore, in many non-US countries you have "controversial" things like emergency contraceptives being prescription free, so people don't even need to see a doctor in the first place. Imagine how much more efficient that is.

https://www.statista.com/chart/33079/average-waiting-times-f...

That page says the lowest waiting times for surgeries are the USA and Switzerland, which has a mostly private healthcare system and private health insurance.

It also claims waiting times for a GP are only ten days on average in the UK which doesn't sound right given the difficulty people have even getting an appointment booked at all lately. I wonder how they compute these numbers.

One thing I don’t like about discourse around healthcare is that we automatically talk about socialized healthcare systems being bad.

Asking for more transparency and accountability in insurance companies is not unreasonable. You pay thousands of dollars every year to these conpanies only to have your medical procedure delayed because the insurance doesn’t think it’s necessary. If you can’t set up a system that requires insurance to fulfill their duty, make health insurance non mandatory and set up a public system with more accountability. Right now these companies want to have their cake and eat it too.

That's funny because I am disappointed that so many people talk as if socialized healthcare is the miracle cure for all our woes.

There are a couple things you just can't get around in any society. The Law of Supply and Demand, and that corporations serve their customers.

That second one is the number one problem we have currently in the US. We, the patients, are not the customer. We are are basically a cost of doing business for the "insurance" companies and medical providers.

Socialized medicine aims to solve this problem by removing all insurance companies and becoming the single customer for all medical providers, and then dictating how much they will pay. Due to Supply and Demand, if this single customer doesn't offer to pay enough, then the supply of medical care will go down. Again in this scenario, you and I are not the customer. If we don't like this reduction in supply, we don't have much we can do. We aren't allowed to offer to pay more to get what we want. If the government offers to pay more, the supply of medical care will go up, but where does that money come from? You and I, but again, we have almost no say in this.

Here is an observation from someone in a country (Australia) that has mixed public and private. In my country we are continually bombarded with news stories about how bad the public system is. This was puzzling to me, because after experiencing both I think you would be mad to use a private hospital if a public one was available.

There are two dynamics at play. The private hospital's customers aren't the patients, it's the doctors. It's the doctors that chose which hospital their customers go to. Thus if the doctor makes a mistake (or the hospital for that matter), it's in the hospitals interests to suppress the news. The information you do see about them is mostly paid advertising. The masters of the public hospitals on the other hand are the politicians. The opposition picks up on each and every failure in a public hospital, and parades it to every media outlet they can find to show had bad at the government in power is. Thus most of the news you here about public hospitals is bad, often very bad, and its a near continuous stream of unflattering news.

This means the public hospitals are terrified of making mistakes because it will be publicised. There are literally posters in every public hospital ward advising you how to get 2nd opinions, who you can lodge complains with, and urging you to discuss any concerns with nursing staff. They will follow them up, and they will discipline / exclude doctors that cause trouble. They are free after all, so if the patient can't pay the doctor has no choice. The net result is the public hospitals the standard of care from the patients point of view is usually outstanding. Meanwhile, I've had a father-in-law with heart problems literally half carried out of a private hospital, the nursing assuring us he was fine. I think they needed the bed for a patient paying higher fees. My father-in-law died from the condition a couple of weeks later.

It is true that free public hospitals are under funded, and chronically overloaded. Maybe that's probably a tragedy of the commons. The result is non-life threatening treatment can take a long while if you want it for free. But, the public hospitals do take fee paying patients. Insurance companies do pay those fees. When that happens I haven't noticed any wait times. In other words the USA system is available to those who can afford it, and those who can't wait. The major difference with the USA is they don't have the "free" option. The "wait times" thing you referred to is therefore 1/2 true, 1/2 myth.

>The big problem with health insurance is that it accounts for 17% of the US GDP

Healthcare overall, not insurance. Insurance is just how most of it gets paid. Conflating the two is like saying credit card companies account for 50% (or whatever) of the US GDP because that's how most people pay for their stuff.

Good point. However, it's almost impossible not to conflate the two (healthcare overall and health insurance) because, unfortunately, health insurance is pretty much required for healthcare. The credit card companies would be a good measure of GDP if they were required for every purchase.

Only fools pay for healthcare with insurance. If a doctor can't convince you to pay directly, don't use his services. Find a better doctor and pay for it yourself.

That's not how the economy works though — the GDP is correlated, not causated, with economic strength. What drives the economy in the end is positive-sum value creation, not trade in itself (although without any market failures, trade tends to create value). The only reason we use GDP as a measure is because actual subjective value created is very hard to measure.

If I start an extortion business, and make you pay me money in order for me to not kidnap your family, this will increase the GDP but not economic strength. This is particularly obvious during wartime, when GDP is artificially inflated, but the actual economy tends to be doing very badly regardless.

In other words, a trade that harms one party more than it helps the other makes the economy worse — regardless of how it affects GDP.

But fiscal and debt policies are built on GDP as primary indicator. That is why recently, some states/nations privileged GDP growth over economic wellbeing (gambling is such any easy example)

Goodhart's law strikes again. It's one of those things that explains so many problems in the world once you understand it. I wish there were ways around it, but I think it's a natural thing in matters involving a lot of people.

There was a way to solve it in a much more economically effective fashion with the Dr. Ben Carson plan. It was (and still is) the only feasible way to fix things long term.

So what you are saying is we could get a dividend by getting rid of these parasites of 8%, since Norway spends 9% of GDP on healthcare.

Sounds great to me!

https://en.wikipedia.org/wiki/Parable_of_the_broken_window

This seems similar to the broken window fallacy.

Do us a service and please name your health insurance.

Yep, no reason to protect the insurer here.

Statistically speaking, it's probably United Healthcare. The largest insurer and also has the highest denial rate

That makes zero sense. Largest number of denials? Certainly. Largest denial rate is not implied by being the largest insurer.

Yet by their denial rates, 30% above the industry average, you can reach one of two conclusions:

1. Every other insurer is acting as a charity and under denying claims it should, or…

2. UHC is issuing excessive denials.

This happened in our family a few years ago. It was a penny dropping moment when the hospital revealed to me thar they routinely record all calls with insurance companies. So they had a recording of the insurer approving the procedure. They still refused to pay nevertheless.

Obviously frustrating and shouldn’t be happening. If it was pre-authed, is it possibly a billing code mismatch? That may be correctable if you book an in-person appointment with the hospital’s financial office.

Who do you book an appointment or call with if it's corruption and not a simple billing mistake in their favor?

You call Luigi Mangione.

You’d start with that office and escalate to the ombuds of both the hospital and the insurer, with your lawyer and the pre-authorization document and communication trail. I get your question is facetious but it’s still worth knowing how to navigate a broken system.

"shouldn't be happening" is a weird way to describe the behaviour of health insurance companies in the US that they engage in every day.

Why? I wanted to express sympathy for suffering in our system while offering practical advice. It seemed rude to just launch into advice without acknowledging it shouldn’t be necessary in the first place. What phrase would you have used?

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