14 ms·

A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

160 points by fern12 9y ago

maxxxxx 9y ago
It's hard to believe that the country is putting up with a system that can bankrupt you any time you get sick and there is pretty much nothing you can do other than being lucky or having a lot of money already. The actual medical care is fine but the billing practices are just ridiculous. I would call them fraudulent in a lot of cases.
- ModernMech 9y ago
  Is it really hard to believe though? The ones who are lucky and have the money are fine with the situation. The unlucky ones with no money are too busy fighting diseases, insurance companies, and bill collectors, they don't have time to change the system. Dealing with insurance when you have a serious illness is a full time job. The people who need change most are literally fighting for their lives. Meanwhile, healthy people in America think "Gee, why should I have to use my money to pay for someone else's healthcare? What do I get out of it? I'm rich and lucky after all". The richest don't even understand what health insurance is as a concept. I mean, just look at what our own President Billionaire has to say: "Because you are basically saying from the moment the insurance, you're 21 years old, you start working and you're paying $12 a year for insurance, and by the time you're 70, you get a nice plan." [1] What does that even mean? Or our Speaker of the House: "The whole idea of Obamacare is...the people who are healthy pay for the...sick. It's not working, & that's why it's in a death spiral" [2]. That's literally the entire point of health insurance. This is what we're dealing with here. [1] https://www.cnbc.com/2017/07/20/trump-thinks-young-people-pay-12-for-health-insurance.html https://www.cnbc.com/2017/07/20/trump-thinks-young-people-pa... [2] https://www.washingtonpost.com/news/politics/wp/2017/03/09/either-paul-ryan-doesnt-understand-insurance-or-you-dont-understand-paul-ryan/ https://www.washingtonpost.com/news/politics/wp/2017/03/09/e...
  - dboreham 9y ago
    I have much more money than most people but I'm not fine with it. I pay more than a mortgage payment every month for insurance that pays for almost nothing.
  - maxxxxx 9y ago
    "The whole idea of Obamacare is...the people who are healthy pay for the...sick" This is the whole point of health insurance! What a stupid idiot (I am overly nice to Paul Ryan. His budget plan was the most ridiculous thing I have ever read).
    - powera 9y ago
      That is the whole point of socialized medicine. The point of insurance is that you pay slightly more than the expected value of your claims. So if you know you need $5000 worth of medical treatment for asthma, your insurance premium should be definitely more than $5000. This bizarre obsession with using the phrase "insurance" and insisting on a product that is not at all insurance is probably why the US health-care system is so fucked.
      - maxxxxx 9y ago
        " The point of insurance is that you pay slightly more than the expected value of your claims. " Not true. Car liability insurance is very similar to health insurance. A lot of people never get anything out of it.
        maxerickson 9y ago
        They are using expected value in a technical sense. In a pure contract between equally informed parties, it's exactly how insurance would be priced.
        owyn 9y ago
        You don't have to own a car. Everyone gets sick at some point, and everybody dies of something. Whether that's cripplingly bankruptingly expensive or not is partly the point. Although I suppose if the singularity happens, that will also solve the health care crisis in this country. (sarcasm)
- ThrustVectoring 9y ago
  My long-term plan is to get something like a million dollars in retirement accounts and a home and retire in Texas, where your retirement accounts have unlimited protection against creditors. If any random incident can bankrupt you, then your best bet is to ensure that you cannot be forced into bankruptcy.
  - knieveltech 9y ago
    I don't know if this is relevant to your plan but you are aware that Texas has like the 3rd worst healthcare system in the country and maternal and infant death rates on par with most 3rd world countries, right? Good luck, don't get sick.
    - maxxxxx 9y ago
      As long as you have enough money Texas health care is perfectly fine.
    - ThrustVectoring 9y ago
      I plan on picking up solid health insurance coverage as well, of course. This is just so that my insurance company and health care provider can't screw me over through balance billing.
- nitwit005 9y ago
  Look at how much political heat Obama, and Clinton before him, got for attempting to fix things. The other political party was more than happy to tell their constituents that their health care would be ruined, and grandma would be denied care by a "death panel". Even though I don't like the ACA, I give Obama a lot of credit for trying. There is no political benefit to doing so.
justinmk 9y ago
I've begun to suspect is that "universal healthcare" means "you weren't denied, you're just on a waiting list, and every physician is an interchangeable cog". I often wonder why health insurance companies don't use a similar tactic. Edit: Try finding a pediatrician in Berlin. (Seriously, I would love to hear recommendations)
- dboreham 9y ago
  Because doctors will happily tell you that whatever they plan to do will be covered by your insurance. So the work gets done, the money spent, before they get a chance to screw with you.
- John_KZ 9y ago
  Waiting lists for doctors can be long for non-emergencies. This applies to most countries with a public health system. Typically they are prioritized based on need, not money. Also arranging regular appointments weeks/months before allows for less downtime in the doctors office thus cheaper healthcare. It's annoying but it works. Also Germany suffers from an ageing population which is why there aren't that many experienced professionals of any kind.
aaavl2821 9y ago
This is a good article, but it only shows a few parts of a much more complex whole, and extrapolating from these anecdotes to a broader system is not really accurate Many hospitals lose money on every Medicare and Medicaid patient. The only reason they survive is because they can charge private insurance companies more. So hospitals and health systems have been consolidating to strengthen their negotiating position against insurers This article paints Medicare as the good guy, private insurance as evil, and hospitals as mixed. The reality is more complicated, and more regional, but overall healthcare is a zero sum game today between payers and providers fighting for dollars, and power comes largely from scale. In geographies where payers are bigger and stronger, they push hospitals and force many to consolidate or die. In areas where hospitals are stronger, they basically dictate price and rates can skyrocket There's a lot of bad stuff happening on all sides, and it isn't clear that private insurance is always evil. If we become a single payer society, small providers that are struggling to survive will probably be the first to die, and providers will probably consolidate much more aggressively into massive national chains, like the Walmart of healthcare The cause of a lot of healthcare issues is not one particular party (insurance, Medicare, hospitals) but a system that encourages monopoly seeking behavior without any good mechanism for regulating this
- maxerickson 9y ago
  I think it'd be a good sport to make hospitals eat denied claims. If two giant institutions want to argue about whether something is covered, the patient should not be the loser. We should also better fund Medicare and Medicaid. Taxes should be apparent.
  - aaavl2821 9y ago
    a lot of hospitals do eat denied claims. look at this [0], the annual financial report for HCA, the biggest publicly traded hospital company. ctrl-f for "provision for doubtful accounts". this represents denied claims / treatments for uninsured patients. this is ~7-10% of revenue. now look at EBITDA, a common metric representing cash flow. look at EBITDA / revenue, ie cash profit margin. this is around 20%, which is massive. this profitability is around the level of big tech and big pharma. however, most hospitals in the US have almost no profit. the profitability of large hospital companies is mostly due to their bargaining power. in fact, a decade ago, big hospital systems were some of the best private equity / LBO investments, bc they were massively profitabel, stable businesses that could take on a lot of debt. and this is before the ACA before the ACA, this was even worse, especially for smaller hospitals. see [1], financial statements for Community Health Systems, a massive (but smaller than HCA) public hospital company, from 2009. for some hospitals this figure was 30% or higher the problem is that not all hospitals are equal. the companies i mentioned are some of the biggest, most powerful hospital companies. however, many hospitals are completely different (often independent urban hospitals), and just bleed money. sometimes its because they have more under/uninsured pts, sometimes its because their contracted rates are lower, sometiems its bc they dont have enough commercial pts (instead having more medicare / medicaid). so a blanket law making hospitals eat more costs would just help the rich get richer and kill the little guys i worked in investment banking and these big hospital systems were some of our best clients. a business that can write of 10-30% of its revenue as bad debt and still generate 20-25% profit margins is an incredible borrower, and we'd underwrite multi billion dollar bond issuances for these companies, so they could issue dividends to shareholders, and because they were so profitable they could afford tons of high yield debt without breaking a sweat [0] https://www.sec.gov/Archives/edgar/data/860730/000119312518056057/d490041d10k.htm https://www.sec.gov/Archives/edgar/data/860730/0001193125180... [1] https://www.sec.gov/Archives/edgar/data/1108109/000095012310017194/g22179e10vk.htm https://www.sec.gov/Archives/edgar/data/1108109/000095012310...
tptacek 9y ago
If you're a tech entrepreneur, it's the first story in here that should alarm you the most. It's about denying coverage altogether, not about denying individual claims. Outside of the "guaranteed issue" ACA market, there is virtually no due process for coverage denial. You can be denied on a whim, with little recourse. The list of conditions for which insurance outside the ACA will be denied is long and opaque. The story makes it sound as if they're looking for reliably diagnosed conditions like diabetes. No. They're looking for indicators of a long list of potential conditions. If you or your spouse has a functioning female reproductive system, the chance of your family being denied is high, even without a diagnosed or treated condition. We were denied for something like that, and also because my daughter had an unexplained seizure when she was 4 (she's now 16 and just fine). To get insurance for the first couple years of Matasano, my wife had to take a crappy full-time job with group coverage. Without insurance, a typical working family is one major medical incident away from zeroing themselves out. My daughter has never met a pickleball net that didn't break her ankle (she has met one pickleball net). Even with insurance, the cost of that injury was high single-digit thousands of dollars. Without it? The cost of a pretty decent car. Find a friend who's had an appendectomy some time and try to find out how much the insurance company was (nominally) billed for it. A down payment on a house. If you work in this industry, intend ever to start your own business and potentially have a family at the same time, you should be extremely alarmed at the prospect of guaranteed issue regulated health insurance (the ACA) being replaced.
- ModernMech 9y ago
  My 5 day stint in the mental hospital was billed at $14,000. With my gold plated health insurance plan, it was still $3k.
  - pnutjam 9y ago
    Geez, that's enough to drive you crazy.
- mobilefriendly 9y ago
  ACA is horrendous, unless you're receiving a government subsidy. I'm self-employed and we have one option of insurance provider, and the cheapest plan for my family last year was $18,000 a year with a huge deductible. That's after tax, out of pocket, for a healthy family with no pre-existing. Like all self-employed people I know (who aren't getting government subsidy), I moved my family to Christian Medishare, which is basically catastrophic coverage for about $3,000 year that was grandfathered in when Obamacare was passed. However it isn't truly insurance, it isn't regulated for soundness. I'm seriously considering returning to wage employment for health care benefits.
sykh 9y ago
Every health care system rations care since no current system has enough resources to care for everyone without some form of waiting. The U.S. health care system rations care in the most immoral way of the advanced nations. A person should not profit by denying care to someone else. As a nation we should try optimizing for a more moral, just system. As I see it that would be something like Medicare for all but I'm open to suggestions/solutions.
- pg_bot 9y ago
  There is no silver bullet in health care. The field is too large for any one single solution to cover everyone (3 Trillion USD per year is spent on health care). There needs to be a lot of innovation in a lot of different areas in order to solve the problem. I started a company with my brother that is attempting to drastically lower costs for primary care. (https://scalpel.com https://scalpel.com) We build software that allows physicians to set up their own direct primary care clinics. Our beta clinic in South Carolina charges $49 / month for unlimited visits and charges people at cost for things like labs and procedures. So instead of dealing with a labyrinthine medical system people are just working directly with a doctor. We really only care about making money off our memberships which we charge what we believe is a reasonable amount.
  - bbddg 9y ago
    I think there's plenty of room for innovation but we should start from the principal that everyone gets full access to medical treatment regardless of their ability to pay.
    - pg_bot 9y ago
      We technically have this in the United States (for emergencies). It is illegal for someone to be denied emergency services regardless of ability to pay.[0] No government system guarantees "full access" to medical treatment there is some form of rationing everywhere. https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/index.html?redirect=/EMTALA/ https://www.cms.gov/Regulations-and-Guidance/Legislation/EMT...
downandout 9y ago
This story is couched in terms of how bad things were before Obamacare, but I’d like to point out that things aren’t great now either. To prevent Obamacare from bankrupting them, insurance companies are resorting to legally dubious mass-denials, one of which affected me personally. A few months ago, I woke up the next morning after eating some fast food and began vomiting. I couldn’t stop throwing up, and I couldn’t eat anything, for 2 straight days. I had a 101 degree fever at the worst point. At the beginning of day 3, when I vomited so hard that I passed out for a few seconds and fell on the floor, I went to the ER. They gave me IV fluids and anti-nausea medication, which worked. About 2 months later, I received a letter from my insurance company (Anthem). They had determined that my situation didn’t qualify as an “emergency,” and therefore they were denying the entire bill for this ER visit. I have appealed, and so far it has not been overturned. I am now on the hook for thousands of dollars, even though I had already covered my entire deductible for the year. I thought that this had to simply be a mistake, but then I learned this is actually a new policy that insurance companies are implementing in the era of Obamacare [1]. Patients are expected to self-diagnose whether or not their situation meets their insurance company's definition of an “emergency,” and are rolling the dice as to whether or not an ER visit will be covered. [1] https://www.vox.com/policy-and-politics/2018/1/29/16906558/anthem-emergency-room-coverage-denials-inappropriate https://www.vox.com/policy-and-politics/2018/1/29/16906558/a...
- lostlogin 9y ago
  The fact that this cost that much is alarming too. I get that the staff and bed bay aren’t cheap, but the consumables for the situation you describe would probably cost less than $10, and at bulk buy prices perhaps on a couple of dollars.
  - downandout 9y ago
    True, but as patients we obviously have no control over that. Also, ironically, if my insurance had simply processed the claim as they were supposed to, they would have paid far less than I'm being billed. ER cash prices are purposely inflated because insurance reimbursements are typically 1/3rd or less of the billed amount. But when the claim gets denied, they come after the individual for the full cash price.
John_KZ 9y ago
That's a very interesting insight into the world of American healthcare and privatized healthcare in general. Previously I thought that all these statements about the US healthcare system were seriously exaggerated, but I guess I was wrong. It's kind of terrifying that being sick excludes you from access to healthcare. In my experince, public healthcare has many problems, but you get what you need.
oldandtired 9y ago
Healthcare is a basic infrastructure problem, not that it is considered this. As a basic infrastructure problem, there are many who see a profit to be made in supplying services. Each country views healthcare from a specific point of view and that dictates how they will, as a country, provide the general healthcare service. A country like the USA see this in the light of healthcare as a business, make as big a profit as you can, irrespective of the actual services that you provide. In other countries where the relevant governments provide universal service they allow private businesses to dictate the price that the government pays for the supplies required. So, we have general commodities when supplied into the healthcare system being charged at 10x or greater for on item which, if not used in a healthcare environment, is charged a much lower price. This applied to things like computers, phones, chairs, tissues, matches, paper, toilet paper, gloves, etc, The suppliers get away with this because of the perception that these goods are of a higher quality. These goods often come off the same production lines as those sold in a normal commercial market. I have seen up to date medical equipment that cost a large fortune that looked pretty, but if you actually looked at the basic equipment was technology that was anything up to 10 years old and was superseded by stuff your could get commercially. The amount of money charged for drugs is based on the amount of money spent of research, which if you actually looked at the figures thrown about were spent by the public purse not the private. It is a captive market and those supplying into it want it that way to maximises their profits. Morality questions are not considered to be important unless it has regulatory considerations that will significant reduce your profit margins if you fail to live up to them. The problems within the healthcare system (insurance included) will not be solved any time soon. Even if there was a revolution that changed the entire basis of how and when healthcare was supplied, it will soon return to what we see today as greed is the basic motivator for society as a whole. To bring about real change requires people really changing and this will not happen because we are basically looking out for ourselves and our own. This occurs on the local level, on the regional level, on the state level and on the national world levels. The healthcare system is an area that needs a complete overhaul worldwide. It is not going to happen since most people do not have the ability to see past their local situation.
audio1001 9y ago
This is sickening
audio1001 9y ago
This is a sickening and inhumane system
pjdemers 9y ago
I'm old and deal with the health "care" system more than anyone else here. What I've learned: 1) You are responsible for your own health. Eat less, eat better, and exercise more. Get enough sleep. Don't over worry. Don't drink too much. Don't touch recreational drugs. Your own health must be your number one priority. Teach your children this, too. 2) ACA, for whatever problems it caused, will save many of us from bankruptcy. "Us" being everyone who is or wants to be a founder. 3) The biggest problem with health cost is lack of transparency. If I could shop around, even a little, I could save tens of thousands of dollars a year. But it's hard to negotiate for price when nobody knows what anything really costs, or what you actually get for that cost; even the people selling it. 5) Every day you are in good health is a good day. Thank God, nature, or other deity(s) of your choice for your lack of health problems.
hestefisk 9y ago
This is why I prefer Europe over US: we have realised healthcare is a human right, not a business.

160 points by fern12 9y ago

It's hard to believe that the country is putting up with a system that can bankrupt you any time you get sick and there is pretty much nothing you can do other than being lucky or having a lot of money already. The actual medical care is fine but the billing practices are just ridiculous. I would call them fraudulent in a lot of cases.

ModernMech 9y ago
Is it really hard to believe though? The ones who are lucky and have the money are fine with the situation. The unlucky ones with no money are too busy fighting diseases, insurance companies, and bill collectors, they don't have time to change the system. Dealing with insurance when you have a serious illness is a full time job. The people who need change most are literally fighting for their lives. Meanwhile, healthy people in America think "Gee, why should I have to use my money to pay for someone else's healthcare? What do I get out of it? I'm rich and lucky after all". The richest don't even understand what health insurance is as a concept. I mean, just look at what our own President Billionaire has to say: "Because you are basically saying from the moment the insurance, you're 21 years old, you start working and you're paying $12 a year for insurance, and by the time you're 70, you get a nice plan." [1] What does that even mean? Or our Speaker of the House: "The whole idea of Obamacare is...the people who are healthy pay for the...sick. It's not working, & that's why it's in a death spiral" [2]. That's literally the entire point of health insurance. This is what we're dealing with here. [1] https://www.cnbc.com/2017/07/20/trump-thinks-young-people-pay-12-for-health-insurance.html https://www.cnbc.com/2017/07/20/trump-thinks-young-people-pa... [2] https://www.washingtonpost.com/news/politics/wp/2017/03/09/either-paul-ryan-doesnt-understand-insurance-or-you-dont-understand-paul-ryan/ https://www.washingtonpost.com/news/politics/wp/2017/03/09/e...
- dboreham 9y ago
  I have much more money than most people but I'm not fine with it. I pay more than a mortgage payment every month for insurance that pays for almost nothing.
- maxxxxx 9y ago
  "The whole idea of Obamacare is...the people who are healthy pay for the...sick" This is the whole point of health insurance! What a stupid idiot (I am overly nice to Paul Ryan. His budget plan was the most ridiculous thing I have ever read).
  - powera 9y ago
    That is the whole point of socialized medicine. The point of insurance is that you pay slightly more than the expected value of your claims. So if you know you need $5000 worth of medical treatment for asthma, your insurance premium should be definitely more than $5000. This bizarre obsession with using the phrase "insurance" and insisting on a product that is not at all insurance is probably why the US health-care system is so fucked.
    - maxxxxx 9y ago
      " The point of insurance is that you pay slightly more than the expected value of your claims. " Not true. Car liability insurance is very similar to health insurance. A lot of people never get anything out of it.
      - maxerickson 9y ago
        They are using expected value in a technical sense. In a pure contract between equally informed parties, it's exactly how insurance would be priced.
      - owyn 9y ago
        You don't have to own a car. Everyone gets sick at some point, and everybody dies of something. Whether that's cripplingly bankruptingly expensive or not is partly the point. Although I suppose if the singularity happens, that will also solve the health care crisis in this country. (sarcasm)
ThrustVectoring 9y ago
My long-term plan is to get something like a million dollars in retirement accounts and a home and retire in Texas, where your retirement accounts have unlimited protection against creditors. If any random incident can bankrupt you, then your best bet is to ensure that you cannot be forced into bankruptcy.
- knieveltech 9y ago
  I don't know if this is relevant to your plan but you are aware that Texas has like the 3rd worst healthcare system in the country and maternal and infant death rates on par with most 3rd world countries, right? Good luck, don't get sick.
  - maxxxxx 9y ago
    As long as you have enough money Texas health care is perfectly fine.
  - ThrustVectoring 9y ago
    I plan on picking up solid health insurance coverage as well, of course. This is just so that my insurance company and health care provider can't screw me over through balance billing.
nitwit005 9y ago
Look at how much political heat Obama, and Clinton before him, got for attempting to fix things. The other political party was more than happy to tell their constituents that their health care would be ruined, and grandma would be denied care by a "death panel". Even though I don't like the ACA, I give Obama a lot of credit for trying. There is no political benefit to doing so.

justinmk 9y ago

I've begun to suspect is that "universal healthcare" means "you weren't denied, you're just on a waiting list, and every physician is an interchangeable cog". I often wonder why health insurance companies don't use a similar tactic. Edit: Try finding a pediatrician in Berlin. (Seriously, I would love to hear recommendations)

dboreham 9y ago
Because doctors will happily tell you that whatever they plan to do will be covered by your insurance. So the work gets done, the money spent, before they get a chance to screw with you.
John_KZ 9y ago
Waiting lists for doctors can be long for non-emergencies. This applies to most countries with a public health system. Typically they are prioritized based on need, not money. Also arranging regular appointments weeks/months before allows for less downtime in the doctors office thus cheaper healthcare. It's annoying but it works. Also Germany suffers from an ageing population which is why there aren't that many experienced professionals of any kind.

aaavl2821 9y ago

This is a good article, but it only shows a few parts of a much more complex whole, and extrapolating from these anecdotes to a broader system is not really accurate Many hospitals lose money on every Medicare and Medicaid patient. The only reason they survive is because they can charge private insurance companies more. So hospitals and health systems have been consolidating to strengthen their negotiating position against insurers This article paints Medicare as the good guy, private insurance as evil, and hospitals as mixed. The reality is more complicated, and more regional, but overall healthcare is a zero sum game today between payers and providers fighting for dollars, and power comes largely from scale. In geographies where payers are bigger and stronger, they push hospitals and force many to consolidate or die. In areas where hospitals are stronger, they basically dictate price and rates can skyrocket There's a lot of bad stuff happening on all sides, and it isn't clear that private insurance is always evil. If we become a single payer society, small providers that are struggling to survive will probably be the first to die, and providers will probably consolidate much more aggressively into massive national chains, like the Walmart of healthcare The cause of a lot of healthcare issues is not one particular party (insurance, Medicare, hospitals) but a system that encourages monopoly seeking behavior without any good mechanism for regulating this

maxerickson 9y ago
I think it'd be a good sport to make hospitals eat denied claims. If two giant institutions want to argue about whether something is covered, the patient should not be the loser. We should also better fund Medicare and Medicaid. Taxes should be apparent.
- aaavl2821 9y ago
  a lot of hospitals do eat denied claims. look at this [0], the annual financial report for HCA, the biggest publicly traded hospital company. ctrl-f for "provision for doubtful accounts". this represents denied claims / treatments for uninsured patients. this is ~7-10% of revenue. now look at EBITDA, a common metric representing cash flow. look at EBITDA / revenue, ie cash profit margin. this is around 20%, which is massive. this profitability is around the level of big tech and big pharma. however, most hospitals in the US have almost no profit. the profitability of large hospital companies is mostly due to their bargaining power. in fact, a decade ago, big hospital systems were some of the best private equity / LBO investments, bc they were massively profitabel, stable businesses that could take on a lot of debt. and this is before the ACA before the ACA, this was even worse, especially for smaller hospitals. see [1], financial statements for Community Health Systems, a massive (but smaller than HCA) public hospital company, from 2009. for some hospitals this figure was 30% or higher the problem is that not all hospitals are equal. the companies i mentioned are some of the biggest, most powerful hospital companies. however, many hospitals are completely different (often independent urban hospitals), and just bleed money. sometimes its because they have more under/uninsured pts, sometimes its because their contracted rates are lower, sometiems its bc they dont have enough commercial pts (instead having more medicare / medicaid). so a blanket law making hospitals eat more costs would just help the rich get richer and kill the little guys i worked in investment banking and these big hospital systems were some of our best clients. a business that can write of 10-30% of its revenue as bad debt and still generate 20-25% profit margins is an incredible borrower, and we'd underwrite multi billion dollar bond issuances for these companies, so they could issue dividends to shareholders, and because they were so profitable they could afford tons of high yield debt without breaking a sweat [0] https://www.sec.gov/Archives/edgar/data/860730/000119312518056057/d490041d10k.htm https://www.sec.gov/Archives/edgar/data/860730/0001193125180... [1] https://www.sec.gov/Archives/edgar/data/1108109/000095012310017194/g22179e10vk.htm https://www.sec.gov/Archives/edgar/data/1108109/000095012310...

tptacek 9y ago

If you're a tech entrepreneur, it's the first story in here that should alarm you the most. It's about denying coverage altogether, not about denying individual claims. Outside of the "guaranteed issue" ACA market, there is virtually no due process for coverage denial. You can be denied on a whim, with little recourse. The list of conditions for which insurance outside the ACA will be denied is long and opaque. The story makes it sound as if they're looking for reliably diagnosed conditions like diabetes. No. They're looking for indicators of a long list of potential conditions. If you or your spouse has a functioning female reproductive system, the chance of your family being denied is high, even without a diagnosed or treated condition. We were denied for something like that, and also because my daughter had an unexplained seizure when she was 4 (she's now 16 and just fine). To get insurance for the first couple years of Matasano, my wife had to take a crappy full-time job with group coverage. Without insurance, a typical working family is one major medical incident away from zeroing themselves out. My daughter has never met a pickleball net that didn't break her ankle (she has met one pickleball net). Even with insurance, the cost of that injury was high single-digit thousands of dollars. Without it? The cost of a pretty decent car. Find a friend who's had an appendectomy some time and try to find out how much the insurance company was (nominally) billed for it. A down payment on a house. If you work in this industry, intend ever to start your own business and potentially have a family at the same time, you should be extremely alarmed at the prospect of guaranteed issue regulated health insurance (the ACA) being replaced.

ModernMech 9y ago
My 5 day stint in the mental hospital was billed at $14,000. With my gold plated health insurance plan, it was still $3k.
- pnutjam 9y ago
  Geez, that's enough to drive you crazy.
mobilefriendly 9y ago
ACA is horrendous, unless you're receiving a government subsidy. I'm self-employed and we have one option of insurance provider, and the cheapest plan for my family last year was $18,000 a year with a huge deductible. That's after tax, out of pocket, for a healthy family with no pre-existing. Like all self-employed people I know (who aren't getting government subsidy), I moved my family to Christian Medishare, which is basically catastrophic coverage for about $3,000 year that was grandfathered in when Obamacare was passed. However it isn't truly insurance, it isn't regulated for soundness. I'm seriously considering returning to wage employment for health care benefits.

sykh 9y ago

Every health care system rations care since no current system has enough resources to care for everyone without some form of waiting. The U.S. health care system rations care in the most immoral way of the advanced nations. A person should not profit by denying care to someone else. As a nation we should try optimizing for a more moral, just system. As I see it that would be something like Medicare for all but I'm open to suggestions/solutions.

pg_bot 9y ago
There is no silver bullet in health care. The field is too large for any one single solution to cover everyone (3 Trillion USD per year is spent on health care). There needs to be a lot of innovation in a lot of different areas in order to solve the problem. I started a company with my brother that is attempting to drastically lower costs for primary care. (https://scalpel.com https://scalpel.com) We build software that allows physicians to set up their own direct primary care clinics. Our beta clinic in South Carolina charges $49 / month for unlimited visits and charges people at cost for things like labs and procedures. So instead of dealing with a labyrinthine medical system people are just working directly with a doctor. We really only care about making money off our memberships which we charge what we believe is a reasonable amount.
- bbddg 9y ago
  I think there's plenty of room for innovation but we should start from the principal that everyone gets full access to medical treatment regardless of their ability to pay.
  - pg_bot 9y ago
    We technically have this in the United States (for emergencies). It is illegal for someone to be denied emergency services regardless of ability to pay.[0] No government system guarantees "full access" to medical treatment there is some form of rationing everywhere. https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/index.html?redirect=/EMTALA/ https://www.cms.gov/Regulations-and-Guidance/Legislation/EMT...

downandout 9y ago

This story is couched in terms of how bad things were before Obamacare, but I’d like to point out that things aren’t great now either. To prevent Obamacare from bankrupting them, insurance companies are resorting to legally dubious mass-denials, one of which affected me personally. A few months ago, I woke up the next morning after eating some fast food and began vomiting. I couldn’t stop throwing up, and I couldn’t eat anything, for 2 straight days. I had a 101 degree fever at the worst point. At the beginning of day 3, when I vomited so hard that I passed out for a few seconds and fell on the floor, I went to the ER. They gave me IV fluids and anti-nausea medication, which worked. About 2 months later, I received a letter from my insurance company (Anthem). They had determined that my situation didn’t qualify as an “emergency,” and therefore they were denying the entire bill for this ER visit. I have appealed, and so far it has not been overturned. I am now on the hook for thousands of dollars, even though I had already covered my entire deductible for the year. I thought that this had to simply be a mistake, but then I learned this is actually a new policy that insurance companies are implementing in the era of Obamacare [1]. Patients are expected to self-diagnose whether or not their situation meets their insurance company's definition of an “emergency,” and are rolling the dice as to whether or not an ER visit will be covered. [1] https://www.vox.com/policy-and-politics/2018/1/29/16906558/anthem-emergency-room-coverage-denials-inappropriate https://www.vox.com/policy-and-politics/2018/1/29/16906558/a...

lostlogin 9y ago
The fact that this cost that much is alarming too. I get that the staff and bed bay aren’t cheap, but the consumables for the situation you describe would probably cost less than $10, and at bulk buy prices perhaps on a couple of dollars.
- downandout 9y ago
  True, but as patients we obviously have no control over that. Also, ironically, if my insurance had simply processed the claim as they were supposed to, they would have paid far less than I'm being billed. ER cash prices are purposely inflated because insurance reimbursements are typically 1/3rd or less of the billed amount. But when the claim gets denied, they come after the individual for the full cash price.

John_KZ 9y ago

That's a very interesting insight into the world of American healthcare and privatized healthcare in general. Previously I thought that all these statements about the US healthcare system were seriously exaggerated, but I guess I was wrong. It's kind of terrifying that being sick excludes you from access to healthcare. In my experince, public healthcare has many problems, but you get what you need.

oldandtired 9y ago

Healthcare is a basic infrastructure problem, not that it is considered this. As a basic infrastructure problem, there are many who see a profit to be made in supplying services. Each country views healthcare from a specific point of view and that dictates how they will, as a country, provide the general healthcare service. A country like the USA see this in the light of healthcare as a business, make as big a profit as you can, irrespective of the actual services that you provide. In other countries where the relevant governments provide universal service they allow private businesses to dictate the price that the government pays for the supplies required. So, we have general commodities when supplied into the healthcare system being charged at 10x or greater for on item which, if not used in a healthcare environment, is charged a much lower price. This applied to things like computers, phones, chairs, tissues, matches, paper, toilet paper, gloves, etc, The suppliers get away with this because of the perception that these goods are of a higher quality. These goods often come off the same production lines as those sold in a normal commercial market. I have seen up to date medical equipment that cost a large fortune that looked pretty, but if you actually looked at the basic equipment was technology that was anything up to 10 years old and was superseded by stuff your could get commercially. The amount of money charged for drugs is based on the amount of money spent of research, which if you actually looked at the figures thrown about were spent by the public purse not the private. It is a captive market and those supplying into it want it that way to maximises their profits. Morality questions are not considered to be important unless it has regulatory considerations that will significant reduce your profit margins if you fail to live up to them. The problems within the healthcare system (insurance included) will not be solved any time soon. Even if there was a revolution that changed the entire basis of how and when healthcare was supplied, it will soon return to what we see today as greed is the basic motivator for society as a whole. To bring about real change requires people really changing and this will not happen because we are basically looking out for ourselves and our own. This occurs on the local level, on the regional level, on the state level and on the national world levels. The healthcare system is an area that needs a complete overhaul worldwide. It is not going to happen since most people do not have the ability to see past their local situation.

audio1001 9y ago

This is sickening

audio1001 9y ago

This is a sickening and inhumane system

pjdemers 9y ago

I'm old and deal with the health "care" system more than anyone else here. What I've learned: 1) You are responsible for your own health. Eat less, eat better, and exercise more. Get enough sleep. Don't over worry. Don't drink too much. Don't touch recreational drugs. Your own health must be your number one priority. Teach your children this, too. 2) ACA, for whatever problems it caused, will save many of us from bankruptcy. "Us" being everyone who is or wants to be a founder. 3) The biggest problem with health cost is lack of transparency. If I could shop around, even a little, I could save tens of thousands of dollars a year. But it's hard to negotiate for price when nobody knows what anything really costs, or what you actually get for that cost; even the people selling it. 5) Every day you are in good health is a good day. Thank God, nature, or other deity(s) of your choice for your lack of health problems.

hestefisk 9y ago

This is why I prefer Europe over US: we have realised healthcare is a human right, not a business.