"Not Medically Necessary": Helping America's Health Insurers Deny Coverage
propublica.org
propublica.org
As a physician, I’ve had to speak to these so called “peers” in a peer to peer denials with both my clinic and hospital setting. They are usually people who aren’t physicians as a first line of their defense, ie therapist, nurses, etc. This weeds out the providers who either don’t care about the patient denial and blindly accept the denial, or patient has to take matters in their own hands just to get the care they need/deserve. Or worse, in the hospital that means the patient gets hit with a huge bill (already an insane number in the US even with insurance, so don’t get me started on this) or it gets delegated to another provider who has to deal with it. Quite often patients get denied medical and rehab services, esp after something debilitating like a stroke, trauma/accident, etc. and at that point the peer to peer is to weed the provider out. Usually someone will tell the patient you’ve been denied, either go home without the services they need or you fight it.
I fight it. Can’t count the number of times I’ve spoken to someone not in the field of medicine or if they are, not my field of medicine (both Family/Hospital Medicine). Often I’m fighting with an MD or “practitioner” who is some other field like a gynecologist about hospital medicine services or rehab. I’ve even had the pleasure of talking to a physical therapist and didn’t let me get a word in as we began the peer to peer. I now start of by asking for their credentials and field of speciality and demand a peer of my field to do the denying if they are so adamant about it “not being medically necessary”.
I have so much to say and could write a book about it. I just wish I had the money and connections to actually change the state of US of Corporate Medicine.
2 questions:
* This time, is it paid? Is it billable? Is it part of the visit I pay for?
* What can I - as a patient - do to make this process easier?Depending on the issue, the patient may be needed to provide supporting paperwork, like previous diagnoses or treatment for providers. Other than that, not really, short of taking legal action.
If there’s a billing code for it, I’m not aware of it and frankly I shouldn’t have to use it. For providers, it’s part of their “administrative time” which used to be a full day of catching up. In most hospital or insurance-owned clinics, that admin day is gone. You now do this during your lunch break and anytime you can squeeze a phone call. Fun fact, in the hospital, these peer to peers are at the mercy of the insurance company and only give you 24-48hrs to do it, so the hell to the overworked provider and their schedule, again this is exactly what they want. A overworked provider who doesn’t have the energy to fight. Providers are so overworked, they no longer can you catch up on charts and hence why the patient-provider relationship has eroded and become so cold when you see your provider just typing away instead of focusing on you.
2. Fight. Appeal your denial. Make sure your provider does the same. Follow this: https://news.ycombinator.com/item?id=48126000#48128288 Can’t speak to all providers, but most of us are good people trying to do their best to help people. Few bad actors out there give us a bad name, but every field has good vs bad. It’s not right to make hasty decisions based on legitimately a few bad providers out there because of their greed, corruption, fraud, etc and lump everyone to prove they’re not fraudsters. Your basic primary care physician/NP/PA or surgeon isn’t the problem. It’s the conflict of interests of the health care industry, private equity groups, etc who create these issues, exploit the system and make it a breeding-ground for fraud/etc then complain that it needs to be fixed with more middle men.
Did they ding you for bad performance after a while? Your job was to maximize denials, not approvals.
By deeming something not medically necessary they are (in my opinion) effectively practicing medicine. If they aren't qualified to practice that specialty, or aren't acting in the patients interest we should really be getting malpractice suits on them and stripping medical licenses.
Feels like convenient lawcraft to wash the health plan employee’s hands of liability. I’m sure the prevailing popular opinion would be that this is practicing medicine.
Although on the words having meanings front, whatever is going on here is pretty clearly not insurance at this point; it'd be better just to honestly call it welfare rather than force people to redefine the word 'insurance'. It is hard to talk to people in the US about actual insurance now because they don't have a word for it any more. Politically redefining 'medicine' too would be a mistake, important conversations will become incoherent.
If I build you a house and tell you the roof trusses aren’t necessary, you’d be pretty peeved.
Maybe an even better analogy is that I live in a rented home and after I report some weird respiratory issues, an inspector finds black mold all over the place. The landlord refuses to fix the issue because "black mold is totally fine, bro" and I get really sick. I could maybe have moved out, but I kinda feel like the landlord is going to have a bad time here.
The issue with teeray's original comment is that they are saying someone who isn't practising medicine should be considered to be a medical practitioner. In fact, in this context, teeray is annoyed with them specifically because they didn't practice anything. Your analogy became irrelevant the moment it involved you doing anything.
> “X is or is not medically necessary” seems like a decision a medical professional should determine, no?
No, that is ridiculous. If I think I need to go to a hospital I'm going to go to the hospital. I don't need qualifications to work out something is medically necessary. I'm unlikely to be involved with the medical industry at all unless I've already personally determined it is medically necessary that I consult a doctor.
As a rule of thumb, patients have the final word on what they actually consider necessary. Literally anyone can have an opinion on the subject. Like, for example, an insurance worker. If the patient or the doctor is of a different opinion then they can go pay for the work themselves. It isn't that uncommon to have to go through 3 or 4 medical professionals to find one who agrees that work is necessary; I have a cancer story like that in my family.
This doesn't make any sense. They're not handing over money for fun, they are supposed to pay for the medical services the insurance is supposed to cover. And the only person qualified to decide if that medical service is appropriate is a doctor who specializes in the field of that specific area.
https://healthlaw.org/wp-content/uploads/2025/11/Vanneman_Pr...
The overall situation is that the insurance company doesn't want to trust your doctor's judgement [0], so they insist on getting a second opinion about the care you might need to receive. That second opinion is still being performed by a licensed doctor who is supposed to be working in your interests - it's a straightforward practice of medicine the same as if you yourself were to go and seek out a second opinion.
[0] or really they want to play good cop / bad cop - remember "your" doctor themselves is essentially also an employee of the insurance company!
The reality is that this is the insurance companies trying to have their cake and eat it too. They actually want to be making a medical decision in denying coverage since it gives them a legitimate reason to do so, but want to avoid any liability if that decision was wrong.
That might not be actually an option. Well the provider can do it for free, probably; but they may not be able to accept money for care that was denied coverage. A Medicare provider can charge patients for things outside the scope of Medicare, but generally can't charge for things in scope but deemed not medically necessary: ex if Medicare says 6 PT visits for whatever and you would like to have 8, you can't pay the provider for two more; you'd have to find a non medicare provider or come back with a fake moustache.
Who decides this? You?
Should we allow everyone in the world who needs a procedure to receive one free and get ahead in line for Americans who need the same procedure? That's what the current climate looks like with unbridaled immigration under progressives.
These are hard questions. What's the answer?
Gating access to medical care is the job of the patient's PCP and or other doctor. If the care is truly, meaningfully rationed (like transplant organs and blood banks), there are triaged priority lists managed by medical organizations.
Two, that book may be a good idea:D
>> So, your doctor ordered a test or treatment and your insurance company denied it. That is a typical cost saving method.
OK, here is what you do:
1. Call the insurance company and tell them you want to speak with the "HIPAA Compliance/Privacy Officer" (By federal law, they have to have one)
2. Then ask them for the NAMES as well as CREDENTIALS of every person accessing your record to make that decision of denial.
By law you have a right to that information.
3. They will almost always reverse the decision very shortly rather than admit that the committee is made of low paid HS graduates, looking at "criteria words." making the medical decision to deny your care. Even in the rare case it is made by medical personnel, it is unlikely that it is made by a board certified doctor in that specialty and they DO NOT WANT YOU TO KNOW THIS!!
4. Any refusal should be reported to the US Office of Civil Rights (http://OCR.gov) as a HIPAA violation.
I suppose that if I did pay someone else to more effectively fight the insurance company for me the insurance would have to pay for more of the medical care I need, and would invest in new and better ways to fight back, and my insurance costs would increase even faster. I'm happy that for now at least I don't have to finance both sides of an arms race in order to get the healthcare I've already been paying for.
I suppose we're not yet at the point where this gates services for all -- but we're CERTAINLY at the point where hospitals refuse to help you if you can't show ability to pay up front.
Ugh, this is a total shitshow. None of this is what it should be. Profit motive has absolutely corrupted everything.
It certainly sounds like something that could work.
Example: I had an inpatient hospital stay where the payment assistant person was never available, never returned calls. Not while I was in the hospital for days, nor in the weeks afterwards.
Technically, I "left against medical advice", though the last doctor I spoke to agreed with what I was doing.
Over two days of trying to manage costs, then 36 hours of planning and asking to leave all basically got me nowhere and I had to kind of force walk out.
It will never happen.
This is largely what at least half the country wants.
“If I need to take a drug test to earn a check you better take one to get welfare.”
I’ve heard a working class person say this. I guarantee you the people who own defense contractors, the real welfare queens don't need to take a drug test.
Likewise, the horrific thought that someone unworthy might get free healthcare is appalling to half this country. They’d rather go without just to ensure *those people don’t get free healthcare.
This country doesn’t want to be fixed. It wants RFK to tell you to treat Autism with raw milk and sunshine.
Nothing much to do but try to find a civilized place to live
Traditional Medicare consists of Part A (hospitals), Part B (doctors) and Part D (drugs). Part A+B don't cover everything so you have a Medigap plan. I have Plan G which has very little paperwork. All up, I spend about $400/mo and I'm very happy with A+B+G+D.
With Medicare Advantage you sign over your Medicare rights+benefits to a private insurer. This may save you some money, especially early on. In fairness, not really a lot and the $0/mo plans are a scam. With Medicare Advantage, you will then have to argue with an insurance company for the rest of your life. You'll have to deal with preauthorizations and a restricted network.
With Traditional Medicare, what's covered is spelled out pretty clearly ahead of time. Docs know it. You know it. There's literally an app for that. With Medicare Advantage, medically necessary is at the discretion of the private insurance company.
Here is the scenario from a relative: he had a heart event which ended up needing a stent. He had to argue with Kaiser while this was going on. Kaiser is 240,000 people. He is one.
Medicare Advantage is very profitable.
It is possible to switch back from MA to TM which really revolves around your Medigap plan. You are guaranteed issue for Medigap plans for about 3 months before/after you turn 65. After that, you will have to undergo medical underwriting.
The insurers are such behemoths and so largely vertically integrated it is controlling the system instead of improving it.
Notice how there is rarely ever any new competition in the health insurance space to drive down pricing.
Insurance is brutally simple. Money in, money out. Trying to make your back office more lean with tech and automation has extremely limited returns, because the back office is such a small portion of the total cost structure. 95-100% of costs in any given insurance operation are claims. So everything to do making things more efficient and reducing costs has to do with reducing claims.
https://www.kff.org/medicare/higher-and-faster-growing-spend...
I've no idea how anyone ever thought this could work.
"Medicare Advantage" = HMO. All the usual HMO problems.
The best Medigap plan is Plan F, which is no longer available to new subscribers. "Discontinuation of Medicare Plan F was a strategic decision aimed at promoting responsible healthcare spending and ensuring the financial sustainability of the Medicare program." It covers just about everything Medicare doesn't pay, including the various deductibles Medicare has. If Medicare covered Medicare's part, the Plan F provider has to pay their part. They don't get to question it. I don't even see hospital bills, just statements that it's been paid for.
Plan G is one step down from that.
Not on Medicare, but I switched to an HMO over 10 years ago at work, and have never been happier.
There are fantastic and crappy PPOs, and fantastic and crappy HMOs.
After years on Kaiser because of familiarity, when I became eligible for Medicare, I had to make a choice between original Medicare or Medicare Advantage.
It’s incredible expensive to buy into adequate coverage if you’re under 65 and on disability and want original Medicare, but after the mixed experience I had with Kaiser, I wouldn’t have it any other way.
As I have some serious health conditions, I signed up with Plan G Extra and a high coverage tier for Part D. It’s going to cost about $1300/mo plus an additional $202.90/mo for part B, but it’s better than having to worry about future health issues putting me in financial ruin.
Nice to preserve choice being responsible for at most a $283 deductible per year on top of the monthly cost.
I had a 3 day hospital stay in December 2024 that was $75,000 and I didn’t have to pay for it, so it was worth it to have good coverage.
The entire framing on the inside is about helping the industry adhere to evidence-based medicine and reign in the skyrocketing costs of healthcare.
The analysts would periodically share results of their anomaly detection, finding physicians who order MRIs at rates multiple standard deviations above the average physician, and further find that these physicians own their machines.
There are a lot of examples of this kind of fraud. There’s also bloat and over prescription as doctors are terrified of malpractice and have patients demanding tests or procedures they read about online.
When I was working in the company, I really felt like I was helping reign in unnecessary costs. We had many people reading medical literature, consulting with other physicians, scientists and others to create guidelines that form the basis of the pre-approval decisions. It felt like we were centralizing all of that knowledge and “providing it” as a service to society.
One day, a brave junior employee asked the company CFO at a lunch and learn, “If we’re doing such a great service for patients, why is it the insurance companies paying us, instead of patients?” The CFO gave one of those replies that is only memorable because of how fumbled it sounded.
I realized quickly after that what purpose the company really served and how the incentives created a serious conflict of interest. But my time at the company has convinced me to this day that there are no “innocent” parties in the payer-provider-patient triangle. Every party involved has their own set adverse incentives against each other and the balance of power swings like a pendulum with every merger, acquisition, or regulation passed.
not the patient?
Patients have zero incentive to shop around on price, so if an academic research hospital MRI costs $6,000 and an independent lab has the same machine and charges $600, most patients don’t care or even know the price difference and let insurance foot the bill.
There’s also a small but expensive population of people who are uninsured and go to the ER very frequently and stay for a while (faking illness, requesting drugs, or simply a warm bed and meal). Clearly a societal problem, but hospitals foot the bill for those stays and raise prices for everyone.
A lot of the structure of insurance plans (deductibles, co-pays, co-insurance, HMO/PPO, enrollment periods) emerged to provide a counterbalance to patient behavior, characterized by adverse selection and moral hazard primarily
https://commons.wikimedia.org/wiki/File:OECD_health_expendit...
(And we’re middling in outcomes!)
Americans are not inherently three times as sick as Australians.
Side note: I'm an Australian citizen, living in the States.
An Australian hospital doesn't need a billing/collections department and the docs don't sit on appeals calls with insurance; when my wife broke her foot visiting, they basically didn't know how to bill her (for surgery and three days in a ward!). My son needed a badly ingrown toenail treated on a separate visit there last year; they just treated it and sent us on our way, no charge, despite his being a tourist.
I straight up don’t believe the drug use one, we have way more fentalyl deaths than you and it’s not even close.
You didn’t address crime. We have much more of it. More gun ownership and gun usage as well.
I’m not quite sure what this anecdote has to do with my comment.
Australians eat a substantially similar diet to Americans, and have similar health issues (obesity, heart disease, etc.) as a result. They are deeply related things.
> I straight up don’t believe the drug use one, we have way more fentalyl deaths than you and it’s not even close.
Gee, I wonder if not having healthcare (including access to things like therapy and rehab) might drive up drug death rates.
> You didn’t address crime.
Sure; you didn't address how it's responsible for 3x the healthcare costs.
Sorry I don't believe this
> Gee, I wonder if not having healthcare (including access to things like therapy and rehab) might drive up drug death rates
Lol, yeah that's why we have so many fentanyl addicts, the lack of therapy, I'm sure that's it
> Sure; you didn't address how it's responsible for 3x the healthcare costs.
Gunshot wounds obviously, we have way more guns and gun crime than Australia
Facts don’t require your belief. 30s in an Australian grocery store will have you feeling quite at home.
> Lol, yeah that's why we have so many fentanyl addicts, the lack of therapy, I'm sure that's it
Read again. You cited their deaths, not their drug use. Australia has plenty of drug users!
> Gunshot wounds obviously
You think the US spends 2/3 of its healthcare spend on gunshot wounds, accounting for the difference?
To quote you, “sorry, I don’t believe that”.
Deaths are pretty much 1:1 with drug use. Us having more fentanyl deaths mean we have more fentanyl users. Feel free to cite something that proves that Australia has the same amount of drug users as the United States.
It’s a contributing factor. Americans consume healthcare at much higher rates for many reasons, some of which I listed above. I’d fully expect Americans to pay more when they consume more.
https://www.abc.net.au/news/2010-04-14/australian-diet-worse...
https://www.nationalhogfarmer.com/market-news/study-finds-am...
https://www.youtube.com/watch?v=omT2ENVQziM
https://www.theguardian.com/australia-news/2025/nov/19/austr...
> I don’t believe claims made without evidence.
You're certainly making a few of them!
> Feel free to cite something that proves that Australia has the same amount of drug users as the United States.
https://www.aihw.gov.au/reports/illicit-use-of-drugs/illicit...
"According to the 2022–2023 National Drug Strategy Household Survey (NDSHS), an estimated 10.2 million (47%) people aged 14 and over in Australia had illicitly used a drug at some point in their lifetime (including the non-medical use of pharmaceuticals), and an estimated 3.9 million (18%) had used an illicit drug in the previous 12 months."
https://drugabusestatistics.org/
"Among Americans aged 12 years and older… 70.5 million or 24.9% of people 12 and over have used illegal drugs or misused prescription drugs within the last year."
That's broadly quite similar.
> Deaths are pretty much 1:1 with drug use.
You can absolutely reduce drug death rates with safe injection sites, needle programs, narcan distribution, safety education, substance abuse treatment, etc.
> Americans consume healthcare at much higher rates for many reasons, some of which I listed above.
Americans pay substantially more money for the same procedures and medications. Again: THE EXACT SAME THING; no difference in amount or quality consumed, just drastically more money going into corporate pockets.
https://nypost.com/2025/08/07/world-news/doctor-exposes-shoc...
"Atorvastatin, a medication to lower cholesterol and prevent cardiovascular disease, is priced as little as A$6.70 for 30 tablets in Australia, compared to US$2,628 for Americans."
"However, the biggest shock was Sofosbuvir, which treats hepatitis C, with a 12-week treatment roughly costing an eyewatering US$84,000 without insurance and discounts. Meanwhile, it costs about $31 for a packet of 28 in Australia on the Pharmaceutical Benefits Scheme (PBS)."
It "costs" much less--because in reality we end up footing the R&D bill. The drug companies tolerate sales to the UHC countries so long as it's above their marginal cost. If US customers were also paying $31 for that Sofosbuvir there's no way the company would recoup costs and they would not develop it.
Fixing this will cause big shakeups in the universal coverage systems and thus big political shakeups. It should be done, but gradually.
I will also say the comparison is false--my wife is on Atorvastatin, it's even less than what you are quoting for Australia. You're comparing the brand name with the generic.
> Today, many of those practices have been bought up by large corporations, including hospitals, private-equity firms and even health-insurance companies. It’s a shift that not only has changed how money moves through the health care system, but may also be helping some insurers boost their profits, according to new research published in Health Affairs.
> A study from researchers at Brown University’s Center for Advancing Health Policy through Research and the University of California Berkeley found that UnitedHealthcare, the nation’s largest health insurer, pays doctors who work for its own physician network, Optum, more than it pays independent practices for the same care.
(And the independent practicioners are having to use a significant portion of the money they take in to… fight the insurers!)
The idea that the problem with our system is health insurers is just slopulism. We have grave problems with our system! But they start with the providers, where the majority of all the funding in our system goes, not to the scapegoats they've stoop up in our insurers. The distinction is vitally important, because the most popular answer to this problem is to extend Medicare to everybody, and Medicare is just as victimized by this as everything else is!
We pay doctors too much, and we artificially restrict the supply of practitioners. Those doctors routinely overprescribe. Every other problem in the system is marginal.
And by inflating that amount...
> Using newly available federal price transparency data, the researchers found that UnitedHealthcare pays Optum physician practices about 17% more than non-Optum practices in the same region. In markets where UnitedHealthcare holds a large share of the insurance business, that difference was even larger, up to 61%.
their capped-by-law 20% cut of premiums goes up, too. "Oh, those mean old providers we own charge so much! We have to raise premiums again!"
Fun thing about the NHE: you can project it as far back as you want. The data is there.
What? Insurers have been playing this game far further back than 2023.
If an insurer doubles the time a doc has to fight over denials and has to hire extra billing staff to assist, where do you imagine that cost shows up?
Again: how will the “insurers force provider costs up” show up in said tables?
It’s caused by the insurer. It shows as a provider’s cost. But it doesn’t mean said doc is making any more money at the end of the day.
The insurer does, though! Their 20% cut got bigger, and the "computer says no" denials are cheap!
TL;DR: Where in your link does "doc spends needless hours on phone fighting insurer" show up as a cost?
But it's not a "Cost of Health Insurance" item. It's an expense at the practicioner level! They have to factor that non-billable time into what they charge for the procedure!
Read their definitions: https://www.cms.gov/files/document/quick-definitions-nationa...
"Administration" is the insurer's side of it.
If an insurer manages to double a doctor's administrative costs for billing/appeals/etc., where does it show up in your tables, per your link's PDF of definitions?
> Insurers are almost literally a rounding error.
Again, the argument is that the raw cost of health insurance does not reflect its externalities imposed on the other items in your list; that insurers drive up hospital and practice costs, as they have to staff up enormous amounts of staff and expensive physician time to deal with the insurer.
Some of which is those practicioners' admin cost from dealing with the insurers. (And, you know, doing the actual work.)
Denials are nice and cheap. Fighting them is not.
And as noted in that other conversation, this is one aspect of many. UHC isn’t pursuing vertical integration for funsies.
Again, I want to be clear: I'm not here to defend the American health system. It's a disaster. It's just clear to me you don't have a bead on why that is. (The answer is artificial scarcity of practitioners, overprescription, and lack of price transparency).
So is “insurance doesn’t have any externalities that might hide in my very broadly categorized numbers”.
It doesn't help that our healthcare billing systems are so outdated and broken. I once had a doctor visit denied with the reason code that it should charge the other insurance (for people on multiple plans). I was only on one plan, but my wife was on two. The doctor and I went through all the paperwork - my name was right, my birthday was right, my policy number was right and when I got notice of the rejection it had my name on it. Eventually we traced it to an error - not in my insurance company, not in the company that handles claims in this areas for my insurance, but instead in some middle-man company that was responsible for transferring claims between the two. Nevermind that all three companies claimed to be BlueCross BlueShield. This took over a year to resolve.
The numbers here are not close. They're stark.
> A new study finds that the extra time and labor physician practices spend on interacting with insurance companies and government entities cost U.S. physicians $82,975 each per year, while doctors in Ontario spent $22,205.
> Canadian physicians follow a single set of rules, but U.S. doctors grapple with different sets of regulations, procedures, requirements, formularies and forms mandated by each health insurance plan or payer. The average U.S. doctor spent 3.4 hours per week interacting with health plans; Ontario doctors spent 2.2 hours. The bureaucratic burden falls heavily on U.S. nurses and medical practice staff, who spent 20.6 hours per physician per week on administrative duties; their Canadian counterparts spent only 2.5 hours on paperwork.
All that falls in your $2.5T bucket. And their cleaners, HR, etc. And insurers have had 15 years of innovation since that study.
My local grocery store wouldn't even bother issuing a coupon for that small a discount.
This isn’t seventh grade math. This is kindergarten level cause and effect.
I said earlier we'd gone round-and-round on this topic before, and I was a little burned out on it, but I didn't expect you to refute your own argument like this. I'm glad we gave it another run this time! This is a great statistic; I'll be using it elsewhere. Thank you.
> I was a little burned out on it
I just did my taxes and am a little burned out by the $49k in healthcare expenses I got to deduct on them.
Even surgeons. Ask a surgeon how much time they spend in the OR. It's less than you think.
Who are the people who sleep at night after designing these policies?
There is an unlimited pool of people without empathy. Never forget that.
https://www.cms.gov/priorities/burden-reduction/overview/int...
Having several layers of private, for-profit companies incentivized to deny deciding that threshold is fairly unique.
As with so many situations where you have unreasonable corporate behavior the problem is the economics favors making wrong decisions. Thus there will be little attempt to prevent those wrong decisions. The only real fix is to make wrong decisions cost--look at airlines. You end up with more passengers that seats, you pay. It went a long way towards addressing the problem. (But it should have been higher and it should be indexed to inflation.)
But note the insurance is not always the bad guy. Patients want things that aren't medically warranted, especially when the right answer is "do nothing". And doctors like to run up the bill.
And note this article is focusing on things other than medical decisions--but describing a system that could only be a problem if they are making wrong medical decisions. How they decide what claims to examine is irrelevant, what matters is if they are making wrong medical decisions. It very much needs to be considered the practice of medicine and a denial should only come from someone of at least the same specialization as the doctor making the request. And "not medically necessary" should require an evaluation of why, you don't get to just say "no".
Feels like two wolves negotiating on how much of the sheep (the sheep is you) they get to eat.
Dare I ask, who is for the "consumer"? If we should even use those words in this system, which in my mind should be for a nation keeping its citizens alive and well both of their own sake and the state's sake.
I see why it can reduce costs in a runaway cartel based system, but how does it prevent the two wolf scenario? (It's the same wolf in this scheme.)
I found out that many insurance companies deliberately delayed approving procedures, in the hope that it would kill the patient.
back then, there was no AI. The decisions were made by humans.
Sometimes, people suck.
When they can't completely deny they delay and/or set up burdensome hoops for the patient to jump through before they will qualify for treatment. It's literally their business model.
They even brag about it on their website! > Reduced inpatient hospital admissions by 15% > Reduced use of skilled nursing facilities by 15% (because we won't approve them for nursing care!) > MedExpert clearly reduces rates of unnecessary elective surgery.
If you want entertainment go to their glassdoor reviews and sort by lowest ratings: https://www.glassdoor.com/Reviews/MedExpert-Reviews-E777566....
> Connecticut’s Insurance Department recently reviewed EviCore and Carelon. It found no problems with Carelon. EviCore was fined $16,000 this year for more than 77 violations found in a review of 196 files.
$16k is such a low fine that it’d be funny if it wasn’t so sad. fines should be increased to actually represent a threat to the company - maybe as a % of yearly profit?
our system is so fucked dude
How do you get accountable people in charge of healthcare policy?
I had the insurance written approval in my hand while the pharmacist told me it was being rejected for needing prior approval. The insurance phone rep said they could find no record of any REQUEST, let alone approval, for the drug.
So I go to the state insurance regulator. That does at least light a fire under their arse. They can't claim it's not medically necessary when I already have their approval.
During the complaint process I learn: - Front line reps don't have any access to any pre-auths. You need to talk to a supervisor. They ADMITTED the system is by design obstructive. - The person who entered my approval did it wrong and did not follow the SOP to run a test transaction that would have caught the error.
They then submit their reply to the regulator leaving out all of the above and blaming the pharmacy instead. I follow up with the regulator pointing this out. I have voice recordings.
Regulator closed it as resolved.
I'd class action their butts if I wasn't still exhausted by the experience two years later.
Yo! I’m literally asking you that question. I’m the implementer employee you’re the specialists and leaders. Did you read the report? Does it make sense? Did you see anything that seems off?
“What do you think we should do?”
This is how this stuff devovles. All nepotist C-Suites should be hollowed out and fired and we should rebuild our institutions without these useless people that can’t even remember how to run a business or make a decision 6 years into LLMs.
American taxpayers invest more public dollars per capita in healthcare than anyone in the world. This before a single cent is paid into the private insurance system. Through Medicare, Medicaid, VA and other public health programs, you pay about 40% more public dollars per-capita than the most socialist, gold plated single payer system anywhere else.
You are not only getting ripped off by your insurer, but you are getting ripped off a public system, which has more than enough money to provide every man, woman and child with a lifetime of world-class, free at the point of service universal healthcare.
https://commons.wikimedia.org/wiki/File:OECD_health_expendit...
Problem is you’ll go right to the emergency room when you have a heart attack.
Get an MD and help out, then you'll discover how you really DONT want the government to tell you which patients to serve.
Most people would consider money a resource, and quite a few rural hospitals are closing because of a lack of that specific resource.
> you'll discover how you really DONT want the government to tell you which patients to serve
Yeah, wait until you hear about private for-profit insurers doing that instead.
Slavery was estimated at ~12% and "hey, you need to lose a few % of your margin and actually pay those people" started a war.
Now, there's an argument to be made about ideology, geographic concentration of industry, etc. doing a fair bit of lifting kicking that off (their own neighbors telling them to stop surely would have gone over better than a bunch of smarmy northerners in their ivory towers telling them the same thing). But the fact remains that you cannot make a large fraction of the country take a haircut without causing strife.
The only way to fix this "nicely" at this point is to boil the frog over decades.
State politicians are much cheaper, and no one from the New York Times pokes around when you buy off the state representative of East Bumfuck, Montana.
Yes, the patient needs skin in the game. People need to take care of their own health. Most procedures are given to grossly unhealthy people.
Yes, completely privatize it. Make people pay for their care so their daily decisions are weighed against what affect it will have on their overall health.
Well, yeah. That's the idea behind "medically necessary". We don't do elective heart transplants on healthy people for funsies.
The hint here is that the random pricing needs to stop. Same procedure for the same price. No market can work if participants don’t know the actual price. Insurance and hospitals probably have a very good idea but patients are being kept totally in the dark. You are expected to just accept what this opaque machinery comes up with.
They just get to die, or what?
The reason healthcare in the US is expensive is very simple: too many cooks in the kitchen. Private insurance simply should not exist. The undeniable reality is that the only way to achieve maximum efficiency is top-down administration.
I understand that that makes libertarians uncomfortable. But what we all have to acknowledge is what we have is not working. Other countries have worked it out. There's no reason to reinvent the wheel here.
TLDR is that it’s a job that can pay enough to keep one housed, and sometimes there are no alternatives.
I’d redirect the outrage away from the grunts denying care, and towards the leadership that set up those incentives. And even further, when the shareholders demand more profit because the line must go up, what to do?
There's broad consensus that there is a ton of unnecessary and unwarranted care being done in the US. Doctors are not all experts in population health. Even the most well-meaning doctors are still subject to incentives that can lead to excessive testing and expensive treatments that have a low likelihood of improving patient outcomes.
Obviously it is also true that having a profit motive to deny claims incentivizes improper denials. But to simply say "no claim should ever be subject to review or denial, and anyone working to make the system efficient is evil" is deeply ignorant and fundamentally incompatible with the concept of insurance.
I did not say this. but you do you.
The more care that's allowed, the more dollars they can keep. It's a complex optimization though; people like to pay less premiums, so an insurance company wants to price coverage low enough to attract customers and then allow enough care to keep the premiums without allowing so much as to reduce their margin.