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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 sy

by 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.
- trey-jones 6y ago
  Regardless of any progress that has been made, I think anecdotal evidence is important here, and pretty much anybody who has actually used the system knows that it sucks. Nobody knows what to pay and what not to pay, for one thing. There isn't any trust - as many posters here describe, paying medical bills in the US is (feels like?) a constant struggle against being defrauded by both your insurance company and your doctor. I always tell the same story in opposition to our current capitalist healthcare model: 1. When my oldest daughter was born 10 years ago with Spina Bifida we had private insurance through my employer. The premiums for this were something like $15,000/yr. At the time this was probably 1/3 of my total income. 2. Despite that, we continue to receive bills that we couldn't possibly pay for years after that. 3. Since my third child was born, the children have been covered by a state program (Georgia), and pretty much everything has been covered, no questions asked. As a consumer, this is pretty much all I care about. I recognize that the current system is bad for the service providers as well, as evidenced by this article. The doctor in question gotten all he's gonna get from insurance companies. He has no hope of collecting this money, so he may as well turn it into good PR (cynical perspective, I guess, but that's me).
  - lotsofpulp 6y ago
    While the system may suck, it's leagues better than it was before ACA for most people. Even your example shows it, since before ACA, there was no out of pocket maximums, and hence you continued to receive bills. In fact, before ACA, there was a maximum benefit amount the insurers would pay up to, and then after that, the costs would fall on you. And your GA state program is most certainly made possibly by the expanded Medicaid funding due to ACA. >There isn't any trust - as many posters here describe, paying medical bills in the US is (feels like?) a constant struggle against being defrauded by both your insurance company and your doctor. This is true, but it would help if healthcare providers would list the codes they will charge so that people can look up the cost with their insurer and aren't signing blank checks every time they enter a medical office.
- alistairSH 6y ago
  I’m claiming that insurers do not erroneously deny claims in the hopes that people give up. You keep saying "erroneously" but I'm not sure what you mean by that. My experience is that for any major change in medication (either dosage or brand, but for the same chronic condition) the insurance will initially deny the claim. This kicks off many hours of phone tag between my family, the insurance, and the doctor. Eventually the insurance company will pay up, but usually well after we've already paid out-of-pocket for the first month, which then requires another few hours on the phone to get reimbursed. This isn't a single insurance provider. This has spanned decades, 4 employers, 5 insurance companies, and at least 3 medical providers.

by kmos17 6y ago

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.

trey-jones 6y ago
Regardless of any progress that has been made, I think anecdotal evidence is important here, and pretty much anybody who has actually used the system knows that it sucks. Nobody knows what to pay and what not to pay, for one thing. There isn't any trust - as many posters here describe, paying medical bills in the US is (feels like?) a constant struggle against being defrauded by both your insurance company and your doctor. I always tell the same story in opposition to our current capitalist healthcare model: 1. When my oldest daughter was born 10 years ago with Spina Bifida we had private insurance through my employer. The premiums for this were something like $15,000/yr. At the time this was probably 1/3 of my total income. 2. Despite that, we continue to receive bills that we couldn't possibly pay for years after that. 3. Since my third child was born, the children have been covered by a state program (Georgia), and pretty much everything has been covered, no questions asked. As a consumer, this is pretty much all I care about. I recognize that the current system is bad for the service providers as well, as evidenced by this article. The doctor in question gotten all he's gonna get from insurance companies. He has no hope of collecting this money, so he may as well turn it into good PR (cynical perspective, I guess, but that's me).
- lotsofpulp 6y ago
  While the system may suck, it's leagues better than it was before ACA for most people. Even your example shows it, since before ACA, there was no out of pocket maximums, and hence you continued to receive bills. In fact, before ACA, there was a maximum benefit amount the insurers would pay up to, and then after that, the costs would fall on you. And your GA state program is most certainly made possibly by the expanded Medicaid funding due to ACA. >There isn't any trust - as many posters here describe, paying medical bills in the US is (feels like?) a constant struggle against being defrauded by both your insurance company and your doctor. This is true, but it would help if healthcare providers would list the codes they will charge so that people can look up the cost with their insurer and aren't signing blank checks every time they enter a medical office.
alistairSH 6y ago
I’m claiming that insurers do not erroneously deny claims in the hopes that people give up. You keep saying "erroneously" but I'm not sure what you mean by that. My experience is that for any major change in medication (either dosage or brand, but for the same chronic condition) the insurance will initially deny the claim. This kicks off many hours of phone tag between my family, the insurance, and the doctor. Eventually the insurance company will pay up, but usually well after we've already paid out-of-pocket for the first month, which then requires another few hours on the phone to get reimbursed. This isn't a single insurance provider. This has spanned decades, 4 employers, 5 insurance companies, and at least 3 medical providers.