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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,

by 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.
    - guitarbill 6y ago
      There aren't 330M insured people, and many people don't need visit a doctor in a year. (Also, there are ~740M people in Europe, and yet...) Even that link you provided doesn't really back up what you said: "denial rates ranged from 1% to more than 40% across insurers"
      - lotsofpulp 6y ago
        The point was there’s a lot of people with a lot of transactions in healthcare happening, so “hearing” about it constantly doesn’t mean anything. And yes, I know the link doesn’t have statistics in erroneous denials of coverage (I couldn’t find it anywhere quickly), but it did note that the law requires insurers to abide by an external reviewer’s decision. Surely if there were that many erroneous denials of coverage, there would be lots of people clamoring to get it overturned via the external reviews. It’s probably just the case that most denials are justified (in the legal sense) that the requested healthcare lacked sufficient documentation, did not have efficacy data, was using brand name medicine instead of generic, etc.
- ruined 6y ago
  > It’s also not the case in 99% of US claims. [...] Surely, there are mistakes made, but there is no standard operating procedure at insurance companies to deny healthcare. This is so out of sync with the experience of everyone i know that i wonder if you've interacted with the healthcare system at all beyond checkups and occasional antibiotics.
  - lotsofpulp 6y ago
    If it was true that insurers are routinely erroneously denying care, then people would be taking advantage of the ACA law that mandates external review of all claims and subjects insurers to the external’s reviewers’ decision.
    - DangitBobby 6y ago
      You seriously over-estimate how much people know about their rights and the time they are willing to spend exercising them. But you are right that they should. https://www.npr.org/sections/health-shots/2014/04/14/302547851/patients-often-win-if-they-appeal-a-denied-health-claim https://www.npr.org/sections/health-shots/2014/04/14/3025478...
      - lotsofpulp 6y ago
        That's actually very interesting. Although the article is from Apr 2014, it has some statistics that may be relevant to insurers erroneously denying coverage: https://www.capradio.org/articles/2014/04/01/patients-win-about-half-the-time-they-challenge-denied-health-care-services/ https://www.capradio.org/articles/2014/04/01/patients-win-ab... >Insurers say only about three percent of claims are denied. >California data show about half the time a patient challenges a denied health care service through a third party, the patient wins and gets the health service. If we assume that denied claims that were overturned were erroneously denied coverage by the insurance company, then half is a huge error proportion, one that would make me think the insurance company is doing it intentionally, or at least intentionally not doing it right. But maybe the ones that got appealed are closer to being decisions that could go either way and the ones that don't get appealed are black and white cases that were clearly covered or not covered.
- kmos17 6y ago
  Where is your data to backup this claim? Maybe you are right that claims are approved most of the time but in my experience the problem with our health care system is not just denial of claims, but about the cost of medical services and medicine. In my anecdotal experience I have had insurance deny claims on medicine prescribed by my doctors frequently, in one case they would not cover a medicine costing $50 over the counter, but instead had me switch to an alternative with a $10 copay which turned out to be billed at $170 to the insurance company once i got the detailed statement!! how does that even make sense? It makes sense to them because the insurance company benefits from higher cost of delivering health benefits as it justifies higher premiums. Since they are by law limited to earn a capped percentage on premiums minus costs (at least in my state), the only way they can deliver increased returns to shareholders is by increasing our costs and hence our premiums.
  - lotsofpulp 6y ago
    > Where is your data to backup this claim? I’m claiming that insurers do not erroneously deny claims in the hopes that people give up. I don’t have data for it, but I’ve also never seen data that shows insurers deny coverage just to dissuade people (post ACA). > experience the problem with our health care system is not just denial of claims, but about the cost of medical services and medicine. Yes, I agree here about the cost of healthcare, but that is a separate issue from insurance companies erroneously denying coverage. > how does that even make sense? Prices for medications are extremely obfuscated, and you will never know the true price paid due to various rebates and fees on the backend between manufacturers, insurance companies, and retailers. There are various reimbursement rules from CMS (centers for Medicare and Medicare services), state Medicaid, various employers, and it’s a very, very inefficient method of price discrimination. > Since they are by law limited to earn a capped percentage on premiums minus costs (at least in my state), ACA caps health insurer profit margins federally, so it applies to all states. Assuming there are multiple competing health insurers, then unless they collided, they would not be able to arbitrarily raise prices to increase the absolute value of their profit margin. The problem was the political compromise that had to be made in order to pass ACA, which is that it allowed employers to maintain their silo’d group of employees. So you have a whole bunch of healthy white collar lives taken out of the healthcare.gov market, which leaves it with all the sick and poorer lives, making it less viable for multiple health insurers to exist. If everyone had been forced onto healthcare.gov, then it’s feasible for multiple health insurance companies to exist and compete. Also, there should be no state boundaries, since some states’ populations are so small that they can’t afford to spread around the healthcare costs.
- hshshs2 6y ago
  I have valid claims denied multiple times a year (3 out of 8 total claims last year). If it’s not standard practice they’re really bad at their jobs. They also won’t fix it for you, I end up having to call billing departments for billing codes and look up state laws on coverage, etc...
- bcrosby95 6y ago
  When my wife had surgery and insurance denied part of our claim, hospital billing said it was normal, and it usually doesn't get resolved until one of their lawyers sends a strongly worded letter.
  - lotsofpulp 6y ago
    Is it possible the hospital also has a tendency to over charge? For example, the data for Synagis indicates it only works to prevent RSV in a very narrow set of cases. It's a very expensive medicine. And it's vastly over prescribed based on the efficacy data, so a parent who is already emotional over their premature baby is going to be frustrated if/when the insurance company denies it. The doctor isn't going to into detail and explain that the data doesn't support its use. They're incentivized to "do something", even if it's a shot in the dark.
    - bcrosby95 6y ago
      For my wife's surgery (gall bladder removal - supposedly one of the most common in the country) insurance paid the surgeon, and initially denied the hospital bill and anesthesiologist bill as medically unnecessary. After 8 months of back and forth and dozens of multi-hour-long phone calls insurance finally covered it all. I don't really care whose fault it is, I shouldn't have to play phone tag with two powerful entities over the course of 8 months as they try to figure out if they're going to fuck me over or not. It's a huge waste of time.
      - deleted 6y ago
        [deleted]
      - lotsofpulp 6y ago
        Yes, that’s why Kaiser is a nice model if we can’t get to taxpayer funded healthcare. It’s vertically integrated insurers and provider so there’s no in network and out of network and covered or not covered BS.
- spaetzleesser 6y ago
  “It’s also not the case in 99% of US claims.” From what I observe with people I know the number is way higher. If you have a serious disease like cancer you there is a very good chance that you will spend a lot of time fighting providers and insurance. It can turn into a full time job.

by k_sze 6y ago

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.
  - guitarbill 6y ago
    There aren't 330M insured people, and many people don't need visit a doctor in a year. (Also, there are ~740M people in Europe, and yet...) Even that link you provided doesn't really back up what you said: "denial rates ranged from 1% to more than 40% across insurers"
    - lotsofpulp 6y ago
      The point was there’s a lot of people with a lot of transactions in healthcare happening, so “hearing” about it constantly doesn’t mean anything. And yes, I know the link doesn’t have statistics in erroneous denials of coverage (I couldn’t find it anywhere quickly), but it did note that the law requires insurers to abide by an external reviewer’s decision. Surely if there were that many erroneous denials of coverage, there would be lots of people clamoring to get it overturned via the external reviews. It’s probably just the case that most denials are justified (in the legal sense) that the requested healthcare lacked sufficient documentation, did not have efficacy data, was using brand name medicine instead of generic, etc.
ruined 6y ago
> It’s also not the case in 99% of US claims. [...] Surely, there are mistakes made, but there is no standard operating procedure at insurance companies to deny healthcare. This is so out of sync with the experience of everyone i know that i wonder if you've interacted with the healthcare system at all beyond checkups and occasional antibiotics.
- lotsofpulp 6y ago
  If it was true that insurers are routinely erroneously denying care, then people would be taking advantage of the ACA law that mandates external review of all claims and subjects insurers to the external’s reviewers’ decision.
  - DangitBobby 6y ago
    You seriously over-estimate how much people know about their rights and the time they are willing to spend exercising them. But you are right that they should. https://www.npr.org/sections/health-shots/2014/04/14/302547851/patients-often-win-if-they-appeal-a-denied-health-claim https://www.npr.org/sections/health-shots/2014/04/14/3025478...
    - lotsofpulp 6y ago
      That's actually very interesting. Although the article is from Apr 2014, it has some statistics that may be relevant to insurers erroneously denying coverage: https://www.capradio.org/articles/2014/04/01/patients-win-about-half-the-time-they-challenge-denied-health-care-services/ https://www.capradio.org/articles/2014/04/01/patients-win-ab... >Insurers say only about three percent of claims are denied. >California data show about half the time a patient challenges a denied health care service through a third party, the patient wins and gets the health service. If we assume that denied claims that were overturned were erroneously denied coverage by the insurance company, then half is a huge error proportion, one that would make me think the insurance company is doing it intentionally, or at least intentionally not doing it right. But maybe the ones that got appealed are closer to being decisions that could go either way and the ones that don't get appealed are black and white cases that were clearly covered or not covered.
kmos17 6y ago
Where is your data to backup this claim? Maybe you are right that claims are approved most of the time but in my experience the problem with our health care system is not just denial of claims, but about the cost of medical services and medicine. In my anecdotal experience I have had insurance deny claims on medicine prescribed by my doctors frequently, in one case they would not cover a medicine costing $50 over the counter, but instead had me switch to an alternative with a $10 copay which turned out to be billed at $170 to the insurance company once i got the detailed statement!! how does that even make sense? It makes sense to them because the insurance company benefits from higher cost of delivering health benefits as it justifies higher premiums. Since they are by law limited to earn a capped percentage on premiums minus costs (at least in my state), the only way they can deliver increased returns to shareholders is by increasing our costs and hence our premiums.
- lotsofpulp 6y ago
  > Where is your data to backup this claim? I’m claiming that insurers do not erroneously deny claims in the hopes that people give up. I don’t have data for it, but I’ve also never seen data that shows insurers deny coverage just to dissuade people (post ACA). > experience the problem with our health care system is not just denial of claims, but about the cost of medical services and medicine. Yes, I agree here about the cost of healthcare, but that is a separate issue from insurance companies erroneously denying coverage. > how does that even make sense? Prices for medications are extremely obfuscated, and you will never know the true price paid due to various rebates and fees on the backend between manufacturers, insurance companies, and retailers. There are various reimbursement rules from CMS (centers for Medicare and Medicare services), state Medicaid, various employers, and it’s a very, very inefficient method of price discrimination. > Since they are by law limited to earn a capped percentage on premiums minus costs (at least in my state), ACA caps health insurer profit margins federally, so it applies to all states. Assuming there are multiple competing health insurers, then unless they collided, they would not be able to arbitrarily raise prices to increase the absolute value of their profit margin. The problem was the political compromise that had to be made in order to pass ACA, which is that it allowed employers to maintain their silo’d group of employees. So you have a whole bunch of healthy white collar lives taken out of the healthcare.gov market, which leaves it with all the sick and poorer lives, making it less viable for multiple health insurers to exist. If everyone had been forced onto healthcare.gov, then it’s feasible for multiple health insurance companies to exist and compete. Also, there should be no state boundaries, since some states’ populations are so small that they can’t afford to spread around the healthcare costs.
hshshs2 6y ago
I have valid claims denied multiple times a year (3 out of 8 total claims last year). If it’s not standard practice they’re really bad at their jobs. They also won’t fix it for you, I end up having to call billing departments for billing codes and look up state laws on coverage, etc...
bcrosby95 6y ago
When my wife had surgery and insurance denied part of our claim, hospital billing said it was normal, and it usually doesn't get resolved until one of their lawyers sends a strongly worded letter.
- lotsofpulp 6y ago
  Is it possible the hospital also has a tendency to over charge? For example, the data for Synagis indicates it only works to prevent RSV in a very narrow set of cases. It's a very expensive medicine. And it's vastly over prescribed based on the efficacy data, so a parent who is already emotional over their premature baby is going to be frustrated if/when the insurance company denies it. The doctor isn't going to into detail and explain that the data doesn't support its use. They're incentivized to "do something", even if it's a shot in the dark.
  - bcrosby95 6y ago
    For my wife's surgery (gall bladder removal - supposedly one of the most common in the country) insurance paid the surgeon, and initially denied the hospital bill and anesthesiologist bill as medically unnecessary. After 8 months of back and forth and dozens of multi-hour-long phone calls insurance finally covered it all. I don't really care whose fault it is, I shouldn't have to play phone tag with two powerful entities over the course of 8 months as they try to figure out if they're going to fuck me over or not. It's a huge waste of time.
    - deleted 6y ago
      [deleted]
    - lotsofpulp 6y ago
      Yes, that’s why Kaiser is a nice model if we can’t get to taxpayer funded healthcare. It’s vertically integrated insurers and provider so there’s no in network and out of network and covered or not covered BS.
spaetzleesser 6y ago
“It’s also not the case in 99% of US claims.” From what I observe with people I know the number is way higher. If you have a serious disease like cancer you there is a very good chance that you will spend a lot of time fighting providers and insurance. It can turn into a full time job.