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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 tha

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.

lotsofpulp 6y ago
>You keep saying "erroneously" but I'm not sure what you mean by that. "Erroneously" as in denying coverage for something that should be covered (per the terms of the contracts). It's unfortunate that you have to go through all of that when changing medications. I don't know the reason for it in your specific case, but I would hope it's not widespread fraud across all of those companies.
- spaetzleesser 6y ago
  “I would hope it's not widespread fraud across all of those companies.” Assume it is. It’s the normal way of doing business. Deny things and hope that most people will give up.
  - lotsofpulp 6y ago
    If it is fraud, then it's not manifesting in outsize profits for insurance company. Almost all premiums go towards paying for benefits, and they are left with ~5% or less in profit. The executives are not earning outsized compensation compared to executives at other large companies, there is no army of people with FAANG salaries, so who is the fraud benefiting? This is all public information per their SEC filings. You can drop the compensation for all the bosses down to zero and it wouldn't move the needle on how much more healthcare they could be providing the insureds.
    - alphabettsy 6y ago
      5% or less is still a massive amount of money. Cigna alone posted annual profits of $122 billion in the same year that General Motors and Ford combined made less than $7 billion.
- alistairSH 6y ago
  Sure, I won't go as far as calling it outright fraud. But, it certainly is part of the business. And as the consumer, at the time of service, I really don't care why it happens, only that it does and that it costs me time and money and delays treatment. As far as I can tell, it's a byproduct of an adversarial relationship between the 3 parties (consumer, doctor, insurer). Insurance doesn't trust the MD to do his job, so hires their own MDs to second guess. And on anything that costs more than $100, that second guessing is the default action - the insurance company's own MDs are only there to provide legitimacy to the initial denial. I say this because in ALL cases, my medical needs have eventually been covered, but not before committing more time and energy than should be necessary. At the end of the day, we pay more money (and time) for worse outcomes than most of Western Europe and the wealthier nations in Asia.
  - lotsofpulp 6y ago
    >the insurance company's own MDs are only there to provide legitimacy to the initial denial. I have first hand knowledge that this is false. Especially if the insurer is just acting as an administrator for a state Medicaid or federal Medicare or other payer, since there are big penalties for denying coverage just to save money. The insurers even have MDs and PharmDs to audit their own MDs and PharmDs to see if they are appropriately approving or denying treatment. A lot of the problem is probably coming from lack of proper EMR and supporting documentation justifying treatment, and subjectivity in justifying treatment because there are many gray areas. This same approval denial situation happens under taxpayer funded healthcare also, since no one has unlimited resources. But yes, the US implementation of it with myriad payers and rules certainly makes for an unpleasant experience and results in subpar healthcare.
    - alistairSH 6y ago
      I guess, but if so, that's a massive amount of cost to the insurer (and eventually falls back on the consumer) around paperwork/review/approval for something they're going to approve eventually. I really don't understand it. Certainly in my experience, the insurer could get rid of their internal review process and people, just rubber-stamp whatever our MDs are prescribing, and save us all a lot of money and headache.

lotsofpulp 6y ago

>You keep saying "erroneously" but I'm not sure what you mean by that. "Erroneously" as in denying coverage for something that should be covered (per the terms of the contracts). It's unfortunate that you have to go through all of that when changing medications. I don't know the reason for it in your specific case, but I would hope it's not widespread fraud across all of those companies.

spaetzleesser 6y ago
“I would hope it's not widespread fraud across all of those companies.” Assume it is. It’s the normal way of doing business. Deny things and hope that most people will give up.
- lotsofpulp 6y ago
  If it is fraud, then it's not manifesting in outsize profits for insurance company. Almost all premiums go towards paying for benefits, and they are left with ~5% or less in profit. The executives are not earning outsized compensation compared to executives at other large companies, there is no army of people with FAANG salaries, so who is the fraud benefiting? This is all public information per their SEC filings. You can drop the compensation for all the bosses down to zero and it wouldn't move the needle on how much more healthcare they could be providing the insureds.
  - alphabettsy 6y ago
    5% or less is still a massive amount of money. Cigna alone posted annual profits of $122 billion in the same year that General Motors and Ford combined made less than $7 billion.
alistairSH 6y ago
Sure, I won't go as far as calling it outright fraud. But, it certainly is part of the business. And as the consumer, at the time of service, I really don't care why it happens, only that it does and that it costs me time and money and delays treatment. As far as I can tell, it's a byproduct of an adversarial relationship between the 3 parties (consumer, doctor, insurer). Insurance doesn't trust the MD to do his job, so hires their own MDs to second guess. And on anything that costs more than $100, that second guessing is the default action - the insurance company's own MDs are only there to provide legitimacy to the initial denial. I say this because in ALL cases, my medical needs have eventually been covered, but not before committing more time and energy than should be necessary. At the end of the day, we pay more money (and time) for worse outcomes than most of Western Europe and the wealthier nations in Asia.
- lotsofpulp 6y ago
  >the insurance company's own MDs are only there to provide legitimacy to the initial denial. I have first hand knowledge that this is false. Especially if the insurer is just acting as an administrator for a state Medicaid or federal Medicare or other payer, since there are big penalties for denying coverage just to save money. The insurers even have MDs and PharmDs to audit their own MDs and PharmDs to see if they are appropriately approving or denying treatment. A lot of the problem is probably coming from lack of proper EMR and supporting documentation justifying treatment, and subjectivity in justifying treatment because there are many gray areas. This same approval denial situation happens under taxpayer funded healthcare also, since no one has unlimited resources. But yes, the US implementation of it with myriad payers and rules certainly makes for an unpleasant experience and results in subpar healthcare.
  - alistairSH 6y ago
    I guess, but if so, that's a massive amount of cost to the insurer (and eventually falls back on the consumer) around paperwork/review/approval for something they're going to approve eventually. I really don't understand it. Certainly in my experience, the insurer could get rid of their internal review process and people, just rubber-stamp whatever our MDs are prescribing, and save us all a lot of money and headache.