9 ms·

It’s intentional. They save billions using this practice because some people don’t have the time, knowledge or resources to dispute.

tlrobinson 6y ago
Are there services that will handle this nonsense for you?
- rangibaby 6y ago
  In rich countries outside of the US it’s called “the government”
  - ant6n 6y ago
    Other countries are slipping, though. For example, Germany does not actually have a single-payer system, but instead a "system" of public and private health insurance companies. As an employee you`re usually in the public system, which can be more expensive for higher-earners because the fees are based on your income (although the health taxes are regressive, capped above like 65K income per year). Self-employed people are often in the private system, and higher income earners can also opt into the private system. The problem is you can´t easily opt back into the public system once you´re out (especially once you´re old), so there are tens of thousands (if not hundreds), that get stuck in the private system without being able to pay the fees because they´ve become poor (possibly because of health reasons), and then they get denied coverage and thus access to medical services. Immigrants can fall through the cracks in the over-complicated system as well. The problem is not as insane as in the US, happens "at the fringes", but it still affects thousands and is mostly outside of the perception of society, since everybody just assumes they got the best system in the world.
    - yladiz 6y ago
      Please. Let’s not turn this into whataboutery. This isn’t about other countries doing things poorly, and more specifically Germany was not named by the parent commenter. This is about the US doing things significantly worse than basically any other developed country. I live in Germany, and know that the German healthcare system is not perfect, but I also know, as an American, that it is significantly better by essentially any metric than the US, and it’s unfair to pretend otherwise. I’m glad I don’t live in a society anymore in which I have to worry about taking an ambulance for an emergency because I can’t afford the fucking $500 price.
      - undecisive 6y ago
        I think all systems have their downsides. In the UK for example, we've started doing citizenship checks for anyone who looks remotely like a foreigner, which to my mind is perverse and unnecessary, and part of a governmental preoccupation with trying to become as racist as possible via the back-door. (essentially, if we can blame the foreigners, we can absolve the government) However, I think we can still say "America's system is totally screwy" and also say "and btw, as a warning, X country seems to be heading down that route too" - I don't think, phrased the way ant6n's post was, it takes away from criticism of America. Essentially, in a perfect world, nobody would be made bankrupt because they got ill, and it seems right that governments should do everything they can to prevent that. If there is a class of people who get forced into that position because of something they cannot change, then that system is broken - whether or not that broken system adversely affects you personally. For example, the American system is not broken for rich people, and especially those in perfect health. For those people, it works just right. And even if you are the only person in a country that is given the choice between feeding their family or investigating an abnormal lump, it doesn't matter how many people benefit from the upsides of that system, it doesn't matter if all your neighbours can visit their GP for a weekly checkup without penalty - without a doubt that system is broken and unjust and needs fixing. But yes, I think most developed-country-based non-Americans would rate America's system as somewhere between "more broken than mine" and "perverse and cruel". The fact that we all use America's system as the yardstick for what a bad system looks like says it all.
        allendoerfer 6y ago
        The rest of the developed world, especially Switzerland, also has to thank the US for single-handedly ensuring the profits for its pharmaceutical industry.
        allendoerfer 6y ago
        Downvoters might read up on which country those pharma profits overwhelmingly come from and why companies like Novartis or Roche are worth what they are worth. As a European the US healthcare system gives me a failed-state vibe, but there are people close to me profiting directly from the absurd prices it pays for drugs.
    - deleted 6y ago
      [deleted]
    - schlowmo 6y ago
      > The problem is you can´t easily opt back into the public system once you´re out (especially once you´re old), so there are tens of thousands (if not hundreds), that get stuck in the private system without being able to pay the fees because they´ve become poor (possibly because of health reasons), and then they get denied coverage and thus access to medical services. Although I recognize the personal hardship this can cause, I fail to accept this as a general injustice. In the German healthcare system nobody is forced to choose a private insurance instead of the public one. Choosing a private insurance when you're allowed to (which often means because you're in a higher income bracket) is usually only cheaper if you're young and healthy. It's basically a gamble on your own health for wealthy people. And if the wealthy young and healthy population don't contribute to the public health insurance system which also pays for the not-so-wealthy and not-so-healthy (older) population, the public insurance system isn't sustainable. The real problem with this system is its division in public and private insurance. Mandatory public insurance would mean lower insurance fees for public insurance and the problem of being stuck in private insurance would no longer exist.
      - ant6n 6y ago
        The point is that there exist cracks in that many people will fall through and society at large doesn't even know that they are there; society as a whole is in denial about the problem because they can look at utterly dysfunctional systems like the US and and say "we're so much better here". Part of the problem is that many of those who are aware of the problem blame the individuals themselves for falling through the cracks in the system (like you do, based on some notion of 'choice'). One possible solution (it seems you agree with me here), is to remove the division between public and private systems. The first step ist to accept the existence of a problem instead of denying it (blaming individuals is a form of denying systemic issues).
        schlowmo 6y ago
        I was commenting on a specific point made by the parent comment. It's pretty far fetched I'm in denial of the root issue when I even mentioned the real solution which you're agreeing with. So while I get your sentiment you're really arguing against the wrong person here. Besides that in my opinion there is a significant difference between "falling through the cracks" and making wrong decisions poorer people aren't even allowed to make - and then wanting those poorer people pay for your errors.
- alphabettsy 6y ago
  There’s a whole industry segment of attorneys specializing in denied medical claims.
  - tlrobinson 6y ago
    I want a cheap mostly automated service that monitors medical expenses looking for irregularities etc.
lotsofpulp 6y ago
It’s not intentional. Insurance companies are better labeled “managed care organizations” (MCO). They offer services for adjudicating services and prices for self insured and non self insured clients. Self insured clients would be governments (Medicaid, Medicare, large corporations that can afford to pay for all of the healthcare). Non self insured are clients like smaller companies and people on healthcare.gov that pay insurance premiums, but are not liable for the entire amount of healthcare. In the event the MCO is administered a self funded plan, they are simply following rules laid out by the payer. The payer (usually government) can come in and audit the MCO anytime and penalize them for approving healthcare that the payer deemed outside the scope of the rules. This works out quite well for the payer, as the MCO serves as the fall guy and takes the heat of being a “bad actor” and denying people healthcare. The reality is that healthcare in the US is rationed, and MCOs are tasked with rationing it. The government gets to avoid being blamed for denying care.
k_sze 6y ago
I don't even understand how the "health care" system and the insurance industry can be both so messed up in the US. It may be just anecdata, but In Hong Kong, my family has an insurance agent whom we work very close with. We're just middle class. E.g. only my dad has a car; my sister is 42 and I'm 38, and we still don't have our own car. Whenever something related to making use of the insurance plan comes up, the insurance agent would be very helpful and ensure we get our money's worth. She would teach us what to do in order to not miss out on benefits. The claims process is also easy. We don't get this nonsense where the insurer tries to deny us and hope that we don't dispute.
- lotsofpulp 6y ago
  > We don't get this nonsense where the insurer tries to deny us and hope that we don't dispute. It’s also not the case in 99% of US claims. The ones you hear about are typically due to healthcare providers not providing sufficient justification for the healthcare or medications they are prescribing, which can easily cost tens of thousands, if not hundreds of thousands of dollars. The “insurers” are many times not even the payer. In many cases, the government hires insurers to adjudicate healthcare according to the government’s rules, which will specify under what scenario and documentation they will pay for certain treatments. Surely, there are mistakes made, but there is no standard operating procedure at insurance companies to deny healthcare. They employ teams of doctors and pharmacists to review cases and determine what is evidence based medicine and what conforms to the payers’ guidelines.
  - faceplanted 6y ago
    > It’s also not the case in 99% of US claims. So is it just sampling bias that we hear constant stories outside the US of everything from broken legs to cancer patients being denied coverage or being covered but having life destroying out of pocket costs? Because it really is constant.
    - lotsofpulp 6y ago
      There’s 330M people in the US and 365 days in a year, so you can hear about one mistake every day and it’s still an extremely minute error rate. It would be nice if someone brought data to the discussion. And specifically about health insurers erroneously denying coverage. I have first hand knowledge from a doctor at an insurance company that audits other doctors’ work at the same insurance company to ensure they are not erroneously denying claims, as there are heavy penalties from state governments and CMS. That is a separate conversation from out of pocket costs destroying someone’s life that has nothing to do with health insurers and everything to do with how much US voters are willing to have their taxes go to those with less. There is some information in this link: https://www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plans/ https://www.kff.org/private-insurance/issue-brief/claims-den... > The ACA guarantees external appeal rights to enrollees in all non-grandfathered private health plans. When issuers uphold denials at the internal appeal level, consumers have the option of requesting an independent review by an outside entity, whose decision is binding. Consumers also can bypass internal appeal and go directly to external review in emergencies and certain other circumstances. Consumers seldom avail themselves of external review.
xyproto 6y ago
Or they simply die in the process.
j4yav 6y ago
Presumably also if they can drive up stress of patients more of them will die more quickly and they will have to pay less.
francisofascii 6y ago
Exactly. Dealing with the back and forth between the insurance company and the provider today, actually. What a hassle. Only over $150 for charging me for an annual preventative care visit which should be covered by insurance. Normally I would just pay to avoid the hassle, but this I will try to fight it.
- lotsofpulp 6y ago
  I've dealt with the same nonsense. Is this your first time with that specific doctor? The doctor has to use one of the annual wellness visit codes, so if it's your first time, the doctor will charge you a new patient charge code, which is higher reimbursement than a wellness visit code, so insurers will deny it. However, I was able to tell my doctor's office that I want the wellness visit charge code only, and they did that. I don't even see a reason for the new patient visit code to exist, since they are allotted the same time and subject matter. For example: https://content.highmarkprc.com/Files/EducationManuals/GeriatricResourceBinder/gerbinder-cpt-codes.pdf https://content.highmarkprc.com/Files/EducationManuals/Geria... If a doctor bills for code 99387, that might not covered under "annual wellness visit" or "annual physical" by the insurer, so you end up having to pay the whole amount if you haven't met your deductible. If the doctor bills code 99397, then it would be. But it shouldn't be this hard. The insurer should be forced to show the codes that qualify for the free annual wellness visit, and you should be able to inform the doctor's office that you want to purchase services for that code and that code only.

tlrobinson 6y ago

Are there services that will handle this nonsense for you?

rangibaby 6y ago
In rich countries outside of the US it’s called “the government”
- ant6n 6y ago
  Other countries are slipping, though. For example, Germany does not actually have a single-payer system, but instead a "system" of public and private health insurance companies. As an employee you`re usually in the public system, which can be more expensive for higher-earners because the fees are based on your income (although the health taxes are regressive, capped above like 65K income per year). Self-employed people are often in the private system, and higher income earners can also opt into the private system. The problem is you can´t easily opt back into the public system once you´re out (especially once you´re old), so there are tens of thousands (if not hundreds), that get stuck in the private system without being able to pay the fees because they´ve become poor (possibly because of health reasons), and then they get denied coverage and thus access to medical services. Immigrants can fall through the cracks in the over-complicated system as well. The problem is not as insane as in the US, happens "at the fringes", but it still affects thousands and is mostly outside of the perception of society, since everybody just assumes they got the best system in the world.
  - yladiz 6y ago
    Please. Let’s not turn this into whataboutery. This isn’t about other countries doing things poorly, and more specifically Germany was not named by the parent commenter. This is about the US doing things significantly worse than basically any other developed country. I live in Germany, and know that the German healthcare system is not perfect, but I also know, as an American, that it is significantly better by essentially any metric than the US, and it’s unfair to pretend otherwise. I’m glad I don’t live in a society anymore in which I have to worry about taking an ambulance for an emergency because I can’t afford the fucking $500 price.
    - undecisive 6y ago
      I think all systems have their downsides. In the UK for example, we've started doing citizenship checks for anyone who looks remotely like a foreigner, which to my mind is perverse and unnecessary, and part of a governmental preoccupation with trying to become as racist as possible via the back-door. (essentially, if we can blame the foreigners, we can absolve the government) However, I think we can still say "America's system is totally screwy" and also say "and btw, as a warning, X country seems to be heading down that route too" - I don't think, phrased the way ant6n's post was, it takes away from criticism of America. Essentially, in a perfect world, nobody would be made bankrupt because they got ill, and it seems right that governments should do everything they can to prevent that. If there is a class of people who get forced into that position because of something they cannot change, then that system is broken - whether or not that broken system adversely affects you personally. For example, the American system is not broken for rich people, and especially those in perfect health. For those people, it works just right. And even if you are the only person in a country that is given the choice between feeding their family or investigating an abnormal lump, it doesn't matter how many people benefit from the upsides of that system, it doesn't matter if all your neighbours can visit their GP for a weekly checkup without penalty - without a doubt that system is broken and unjust and needs fixing. But yes, I think most developed-country-based non-Americans would rate America's system as somewhere between "more broken than mine" and "perverse and cruel". The fact that we all use America's system as the yardstick for what a bad system looks like says it all.
      - allendoerfer 6y ago
        The rest of the developed world, especially Switzerland, also has to thank the US for single-handedly ensuring the profits for its pharmaceutical industry.
        allendoerfer 6y ago
        Downvoters might read up on which country those pharma profits overwhelmingly come from and why companies like Novartis or Roche are worth what they are worth. As a European the US healthcare system gives me a failed-state vibe, but there are people close to me profiting directly from the absurd prices it pays for drugs.
  - deleted 6y ago
    [deleted]
  - schlowmo 6y ago
    > The problem is you can´t easily opt back into the public system once you´re out (especially once you´re old), so there are tens of thousands (if not hundreds), that get stuck in the private system without being able to pay the fees because they´ve become poor (possibly because of health reasons), and then they get denied coverage and thus access to medical services. Although I recognize the personal hardship this can cause, I fail to accept this as a general injustice. In the German healthcare system nobody is forced to choose a private insurance instead of the public one. Choosing a private insurance when you're allowed to (which often means because you're in a higher income bracket) is usually only cheaper if you're young and healthy. It's basically a gamble on your own health for wealthy people. And if the wealthy young and healthy population don't contribute to the public health insurance system which also pays for the not-so-wealthy and not-so-healthy (older) population, the public insurance system isn't sustainable. The real problem with this system is its division in public and private insurance. Mandatory public insurance would mean lower insurance fees for public insurance and the problem of being stuck in private insurance would no longer exist.
    - ant6n 6y ago
      The point is that there exist cracks in that many people will fall through and society at large doesn't even know that they are there; society as a whole is in denial about the problem because they can look at utterly dysfunctional systems like the US and and say "we're so much better here". Part of the problem is that many of those who are aware of the problem blame the individuals themselves for falling through the cracks in the system (like you do, based on some notion of 'choice'). One possible solution (it seems you agree with me here), is to remove the division between public and private systems. The first step ist to accept the existence of a problem instead of denying it (blaming individuals is a form of denying systemic issues).
      - schlowmo 6y ago
        I was commenting on a specific point made by the parent comment. It's pretty far fetched I'm in denial of the root issue when I even mentioned the real solution which you're agreeing with. So while I get your sentiment you're really arguing against the wrong person here. Besides that in my opinion there is a significant difference between "falling through the cracks" and making wrong decisions poorer people aren't even allowed to make - and then wanting those poorer people pay for your errors.
alphabettsy 6y ago
There’s a whole industry segment of attorneys specializing in denied medical claims.
- tlrobinson 6y ago
  I want a cheap mostly automated service that monitors medical expenses looking for irregularities etc.

lotsofpulp 6y ago

It’s not intentional. Insurance companies are better labeled “managed care organizations” (MCO). They offer services for adjudicating services and prices for self insured and non self insured clients. Self insured clients would be governments (Medicaid, Medicare, large corporations that can afford to pay for all of the healthcare). Non self insured are clients like smaller companies and people on healthcare.gov that pay insurance premiums, but are not liable for the entire amount of healthcare. In the event the MCO is administered a self funded plan, they are simply following rules laid out by the payer. The payer (usually government) can come in and audit the MCO anytime and penalize them for approving healthcare that the payer deemed outside the scope of the rules. This works out quite well for the payer, as the MCO serves as the fall guy and takes the heat of being a “bad actor” and denying people healthcare. The reality is that healthcare in the US is rationed, and MCOs are tasked with rationing it. The government gets to avoid being blamed for denying care.

k_sze 6y ago

I don't even understand how the "health care" system and the insurance industry can be both so messed up in the US. It may be just anecdata, but In Hong Kong, my family has an insurance agent whom we work very close with. We're just middle class. E.g. only my dad has a car; my sister is 42 and I'm 38, and we still don't have our own car. Whenever something related to making use of the insurance plan comes up, the insurance agent would be very helpful and ensure we get our money's worth. She would teach us what to do in order to not miss out on benefits. The claims process is also easy. We don't get this nonsense where the insurer tries to deny us and hope that we don't dispute.

lotsofpulp 6y ago
> We don't get this nonsense where the insurer tries to deny us and hope that we don't dispute. It’s also not the case in 99% of US claims. The ones you hear about are typically due to healthcare providers not providing sufficient justification for the healthcare or medications they are prescribing, which can easily cost tens of thousands, if not hundreds of thousands of dollars. The “insurers” are many times not even the payer. In many cases, the government hires insurers to adjudicate healthcare according to the government’s rules, which will specify under what scenario and documentation they will pay for certain treatments. Surely, there are mistakes made, but there is no standard operating procedure at insurance companies to deny healthcare. They employ teams of doctors and pharmacists to review cases and determine what is evidence based medicine and what conforms to the payers’ guidelines.
- faceplanted 6y ago
  > It’s also not the case in 99% of US claims. So is it just sampling bias that we hear constant stories outside the US of everything from broken legs to cancer patients being denied coverage or being covered but having life destroying out of pocket costs? Because it really is constant.
  - lotsofpulp 6y ago
    There’s 330M people in the US and 365 days in a year, so you can hear about one mistake every day and it’s still an extremely minute error rate. It would be nice if someone brought data to the discussion. And specifically about health insurers erroneously denying coverage. I have first hand knowledge from a doctor at an insurance company that audits other doctors’ work at the same insurance company to ensure they are not erroneously denying claims, as there are heavy penalties from state governments and CMS. That is a separate conversation from out of pocket costs destroying someone’s life that has nothing to do with health insurers and everything to do with how much US voters are willing to have their taxes go to those with less. There is some information in this link: https://www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plans/ https://www.kff.org/private-insurance/issue-brief/claims-den... > The ACA guarantees external appeal rights to enrollees in all non-grandfathered private health plans. When issuers uphold denials at the internal appeal level, consumers have the option of requesting an independent review by an outside entity, whose decision is binding. Consumers also can bypass internal appeal and go directly to external review in emergencies and certain other circumstances. Consumers seldom avail themselves of external review.

xyproto 6y ago

Or they simply die in the process.

j4yav 6y ago

Presumably also if they can drive up stress of patients more of them will die more quickly and they will have to pay less.

francisofascii 6y ago

Exactly. Dealing with the back and forth between the insurance company and the provider today, actually. What a hassle. Only over $150 for charging me for an annual preventative care visit which should be covered by insurance. Normally I would just pay to avoid the hassle, but this I will try to fight it.

lotsofpulp 6y ago
I've dealt with the same nonsense. Is this your first time with that specific doctor? The doctor has to use one of the annual wellness visit codes, so if it's your first time, the doctor will charge you a new patient charge code, which is higher reimbursement than a wellness visit code, so insurers will deny it. However, I was able to tell my doctor's office that I want the wellness visit charge code only, and they did that. I don't even see a reason for the new patient visit code to exist, since they are allotted the same time and subject matter. For example: https://content.highmarkprc.com/Files/EducationManuals/GeriatricResourceBinder/gerbinder-cpt-codes.pdf https://content.highmarkprc.com/Files/EducationManuals/Geria... If a doctor bills for code 99387, that might not covered under "annual wellness visit" or "annual physical" by the insurer, so you end up having to pay the whole amount if you haven't met your deductible. If the doctor bills code 99397, then it would be. But it shouldn't be this hard. The insurer should be forced to show the codes that qualify for the free annual wellness visit, and you should be able to inform the doctor's office that you want to purchase services for that code and that code only.