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Health Insurance Claim Denied? See What Insurers Said Behind the Scenes
- jschveibinz 3y agoThis is important.
- yamtaddle 3y ago> Changing it, a Cigna employee estimated, could save more than $98,000. (Cigna spokesperson Justine Sessions said the insurer only suggests changes when clinically appropriate and that cost is never the sole determining factor. She said Cigna does not directly benefit from such savings.) Emphasis mine. Can... someone explain how that makes any sense at all?
- jrmski 3y agoLarge employers are often self-insured. But since they lack the expertise and large network of negotiated rates and providers, they typically hire a company in the insurance business to administer their plan. Thus, the employer bears the risk of the claims, and also is the party that benefits when expenditures are reduced.
- jabroni_salad 3y ago.... which leads to excellent situations where employers try to get rid of employees who have expensive health problems. Especially if a smaller employer is self-insuring because a decision maker read some blog post about it and thought it sounded neat. Sorry about the cancer!! please go die somewhere that I cant see it thanks.
- toast0 3y agoIf the employer doesn't self insure, then their insurer will raise their rates because their employees have a history of expensive health problems. Which still leads to pressure to get rid of those employees. (Unless the employer based coverage is priced like marketplace plans, where only age, sex, and smoking are available to set prices; but I don't think that's the case for most?)
- ComputerGuru 3y agoI don’t believe insurers have that kind of “dynamic pricing” where the rate you pay changes depending on who you retain and who you let go. But my experience is with a large insurer and a school with a hundred or so employees, not something on Microsoft’s scale.
- lotsofpulp 3y ago> then their insurer will raise their rates because their employees have a history of expensive health problems This is illegal since 2011 due to the Affordable Care Act. The only factors allowed to price insurance is age, location, and tobacco use. https://www.healthcare.gov/how-plans-set-your-premiums https://www.healthcare.gov/how-plans-set-your-premiums Even the age factor is bounded by the highest risk age having to be only 3x the lowest risk age (i.e. a subsidy from young to old). The lack of ability to price based on pre existing health conditions is a subsidy from healthy to sick. And for political reasons, we can afford to discriminate against tobacco use, but not sugar or alcohol or sat fats or lack of exercise.
- toast0 3y agoDoes that page apply to employer based plans? It's not clear that it's not just discussing marketplace plans.
- chimeracoder 3y ago> Does that page apply to employer based plans? It's not clear that it's not just discussing marketplace plans. It applies to all non-Medicare, non-Medicaid, non-grandfathered[0] plans for people under the age of 65. Ironically, once you turn 65, all bets are off: insurers can factor your age into your premiums, and people often get a massive rate hike then (usually prompting them to switch to Medicare). [0] A small percentage of employer-provided pre-ACA plans are grandfathered in, but they're few in number and decreasing over time. If you have a grandfathered plan, you probably know it, because it's required to be disclosed visibly in the plan documents when you enroll.
- ecommerceguy 3y agoThat is illegal and if you know of that situation I implore them to seek council and contact the DOL.
- klyrs 3y agoMy guess is that they increase premiums to cover payouts; so the cost of payout is amortized away. The indirect benefit is that their prices are more competitive the less they pay out.
- yamtaddle 3y agoMaybe. They've got payout minimums these days, too, but it seems like finding ways they could tweak payouts lower to get as close as possible to that line if they have room to is a pretty direct benefit. [EDIT] I mean I guess what I'm getting at is that if they decide to make the adjustment in treatment, it's going to be because it makes them more money, even if they can't afford to make all of those adjustments they might, or it'd push payouts too low and they'd have to give some money back—finding the option to do so doesn't increase profit immediately, but if they choose to make the change, it's surely because it'll make them more money.
- deleted 3y ago[deleted]
- gizmo686 3y agoInsurance companies must pay out at least 80% of premiums to claims. Any excess gets refunded to policy holders. This means that it is, counterintuitivly, in there interest to spend more on claims, as it makes the 20% profit they are allowed to take bigger. At least until they start to lose clients.
- toomuchtodo 3y agohttps://www.propublica.org/article/why-your-health-insurer-does-not-care-about-your-big-bills https://www.propublica.org/article/why-your-health-insurer-d... (ProPublica: Why Your Health Insurer Doesn’t Care About Your Big Bills)
- ecommerceguy 3y agoNot all plans fall under this regulation.
- lotsofpulp 3y agoAny plan worth having does. If you are offered non ACA compliant health insurance, you should value it at $0, especially since there is no penalty for not having health insurance.
- ecommerceguy 3y agoIncorrect, I know of several TPA's that offer Qualified ACA plans that operate below 80% MLR. I can provide proof for my statement, can you do the same?
- deleted 3y ago[deleted]
- deleted 3y ago[deleted]
- lotsofpulp 3y agoWhat is a TPA? You are always welcome, even encouraged, to provide proof. I am getting my information from: https://www.healthcare.gov/health-care-law-protections/rate-review/ https://www.healthcare.gov/health-care-law-protections/rate-... >Does this apply to my plan? >It depends. >For Rate Review: These requirements don’t apply to grandfathered plans. Check your plan’s materials or ask your employer or your benefits administrator to find out if your health plan is grandfathered. >For the 80/20 Rule: These rights apply to all individual, small group, and large group health plans, whether your plan is grandfathered or not. I assume grandfathered plans are not ACA compliant, and hence do not have all the provisions that make health insurance worth having (such as out of pocket maximums and zero cost preventative care and appeals processes and other things that set a floor on the quality of healthcare covered by the insurance).
- aquaphile 3y ago"She said Cigna does not directly benefit from such savings." The quote indicates that the employer group was self-insured, and Cigna was the plan administrator. This means that Cigna is not insuring the health plan. Cigna is probably paid a per member per month (PMPM) fee for third party administration (TPA). The actual medical claims and associated costs are directly paid by the self-insured entity (the employer group). Self-insurance can make actuarial sense for companies with >2,000 employees.
- yamtaddle 3y agoAh. Thanks, that makes sense.
- ecommerceguy 3y agoIn addition there is likely specific and aggregate stop loss coverage carried by a reinsurance carrier, such as AXA, Lloyds or even Cigna papers reinsurance often on their self funded plans.
- krupan 3y agoThis is some of the best hacking I've seen on Hacker News in a long time! My son broke his arm skiing a few months ago and we went to the clinic that is at the ski resort. They x-rayed him, set the bone a little (thankfully it didn't need much), put on a splint, and put his arm in a sling. Straightforward simple stuff. The clinic is not on our insurance so we filed a claim with them after the fact ourselves using the detailed receipt the clinic provided. It was out of network so they didn't pay for most of it (for some reason they did pay the $12 or whatever for the sling), but they applied the cost to our out-of-network deductible. Except not the cost the clinic charged, the cost they thought the clinic should have charged, which was of course about $150 less. What?? I'd love more insight into how all that makes sense in someone's mind.
- toomuchtodo 3y agoYour health insurance doesn't want to pay for it because they deem what the clinic charged as "too expensive" or another reason there isn't a pre negotiated contract in place between provider and insurer. The clinic can extract what it can from your because your insurance didn't cover it, sending you to collections if you don't pay [1] [2]. Many folks harp about how government insurance doesn't pay enough, and there is some validity to that argument, but without cost controls or other guardrails, the patient is always caught between the payer (private insurance) and the provider. Both are attempting to maximize their profits, the former through "cost plus" accounting, the latter at point of sale/purchase/care. This might or not be helpful, depending on circumstances: https://www.cms.gov/nosurprises/consumers/new-protections-for-you https://www.cms.gov/nosurprises/consumers/new-protections-fo... Tangentially, this is why global/nomad/world traveller health insurance typically excludes the US specifically from coverage and visitors to the US in many cases will fly home for urgent medical emergencies vs receiving care in country; the economics are simply unpalatable. [1] https://www.quora.com/Why-would-a-doctor-go-out-of-network-pertaining-to-insurance?share=1 https://www.quora.com/Why-would-a-doctor-go-out-of-network-p... [2] https://www.consumerfinance.gov/rules-policy/medical-debt/ https://www.consumerfinance.gov/rules-policy/medical-debt/ (intimately familiar with the inside mechanics of private insurance from patient advocacy work)
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- rqtwteye 3y agoHow long are people in the US going to put up with this insanity? Some we have managed to create an extremely cruel, bureaucratic, expensive and unreliable system that produces below average outcomes compared to other countries at exorbitant cost.
- ecommerceguy 3y ago[flagged]
- standardUser 3y agoHow many and for what treatments? I want details and specific numbers. And how does that compare to the number of people who go to Eastern Europe and Latin American for medical care they can't afford in the US?
- ecommerceguy 3y agoDrive into any cancer clinic in south Florida and count the number of Canadian vehicle plates (most of them are very nice cars so these are people with means). Single payer systems doesnt mean equal access. Quite the contrary actually. Don't most Canadians carry some form of private insurance? Why would they do that if healthcare is "free"?
- kmoser 3y agoDrive to any supermarket and you'll see the same Canadian plates. They don't come all the way to the US for the food. South Florida is a vacation destination for Canadians; while a few may come for medical treatment, the vast majority come for the warm weather.
- standardUser 3y agoIf you're truly committed to defending insurance companies, so be it, but you should try to offering something other than anecdotes about some cars you see. Medical debt is a huge burden in this country, not only in terms of families struggling financially, but in terms of people avoiding or postponing needed treatments due to cost. https://www.cnbc.com/2022/06/22/100-million-adults-have-health-care-debt-and-some-owe-10000-or-more.html https://www.cnbc.com/2022/06/22/100-million-adults-have-heal...
- sidewndr46 3y agoI think the most absurd case of this was getting an insurance claim denied for relatively boring treatment. I had some wounds cleaned after an accident. I call and talk to the insurance representative. I am informed that they'll resubmit it and it will be approved. No additional information needed, no evidence, etc. They literally just deny most claims outright because most individuals are not going to call them about it.
- ifyoubuildit 3y agoI'm pretty sure I've experienced this as well, and the pressure must be pretty high to do that sort of thing "accidentally". It's basically free money for them.
- sidewndr46 3y agoIs it even illegal though? Would it need to be 'accidental' or could they just make it an internal policy?
- singlow 3y agoIt doesn't have to be a policy. Large beaurocracies naturally tend toward certain behaviors due to natural incentives. You must have policies/regulations to specifically counteract these tendencies.
- ifyoubuildit 3y agoSeems like the kind of thing that is probably illegal if they're overt enough, but I don't know. It's definitely not ethical or moral or admirable in any way.
- jimt1234 3y agoI recently discovered how completely arbitrary healthcare pricing is. I got services from an out-of-network clinic, and ended up receiving a very large bill. I called my health insurer, and the conversation went like this: - What's up with this $2000 bill? - You went to an out-of-network clinic. - I didn't know it was out-of-network; my doctor recommended it to me. - [...pause...] How about $200? And that was it. My $2000 bill became $200 for a completely unknown reason. I didn't ask for a price reduction; I didn't even know that was possible. The whole situation was, and still is, bizarre to me. What is the pricing based on, if it can be dropped so drastically without explanation?
- standardUser 3y agoWe're all victims in waiting. But, just like with other arbitrary systems such as the enforcement of victimless crimes or traffic laws, most of us don't suffer too much most of the time, so the systems endure despite the inherent incoherency and unfairness. It's just the occasional poor sucker having their life ruined, but never enough to create a meaningful backlash.
- ecommerceguy 3y ago>>We're all victims in waiting. Maybe for you being a victim, that's your problem. Don't lump me into your issues. I prefer to create my own destiny. I am not a victim. I can handle myself. I have the ability to ask for help when needed. As a matter of fact I'd say most of my circle of friends colleagues and acquaintances would agree with not being a victim. Probably be offended by your statement actually.
- lotsofpulp 3y agoWhich insurer was this? It makes no sense to me that they would care about reducing the price you owe to a third party. You do not owe the insurance company $2,000, and the insurance company does not send you bills. So what is their incentive to pay the healthcare provider the $1,800, or otherwise engage with them to reduce how much the healthcare provider charged you who has no contract with them (since they are out of network)?
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- DoreenMichele 3y agoPlease pay careful attention to the section on what information to include. It takes at least three pieces of info to positively ID the correct policy for a large (national) insurance company. It's a HIPAA violation if they send you the wrong files. If you have a common name, have a relative with a similar name, etc, it's especially important to make sure to include things like policy numbers and claim numbers. I wish this sort of article were not necessary. This is not how it should work, though I don't know how to fix this mess.
- Volundr 3y agoMy sister has severe MS that has been progressing rapidly, and the most common treatments have failed to halt or slow progression. Her neurologist who specializes in MS wanted to put her on a new, but expensive drug that has shown significant promise. Her insurance denied it, insisting that she should be put on a different medication that has never so much as been studied, much less approved for treating MS. Multiple appeals, by my sister, by the doctor, and by the hospitals insurance specialists were all denied. A lawyer advised that legal action would be prohibitively expensive and have no guarantee of results. Mind you MS is a progressive disease,. causing permanent brain and neurological damage. There is no "recovering". Once the damage has been done, it's permanent, treatment only hopes to stop or slow progression, so experiment with another drug isn't something you can do, then later decide it's not working and go with something else. Permanent damage has been done, while your wasting time with treatments that have no expectations of working. The semi-good news is the insurance company did approve the drug 6 months later after she ended up in the ER and had a 4-day stay, and she believes she hasn't experienced progression since starting the drug. I cannot fathom however why we as US citizens allow this cruel practice of private industry insurance to continue.
- deleted 3y ago[deleted]
- ecommerceguy 3y agoStep therapy, did she get a second opinion? >>insisting that she should be put on a different medication that has never so much as been studied, much less approved for treating MS. I find this hard to believe and would be very interested in seeing details. Ironically, Cigna has a very good speciality Rx program for MS. >>I cannot fathom however why we as US citizens allow this cruel practice of private industry insurance to continue. Did she find a Country where she was comfortable getting the denied treatment? What do you recommend besides "Government paying for everything"? What makes you think that "Medicare for all or whatever" will get the declined drug approved? Do you realize Canadians commonly get denied for things too? God forbid you have Rectal Cancer in Germany, generally not covered by the Government plan. https://bookinghealth.com/disease/colorectal-cancer/germany https://bookinghealth.com/disease/colorectal-cancer/germany
- systemtest 3y agoThere was an article in the news today. Woman with stage 4 cancer got treatment denied by her insurance company because the treatment only had a 30% chance of succes. The operation would cost 150k out of pocket. She was, and I quote "not profitable enough". It took them 9 weeks to tell her this news. It is a death sentence to her. In the video you can hear her 5 month old baby in the background. https://twitter.com/zeg_eens_aad/status/1656194692202090498 https://twitter.com/zeg_eens_aad/status/1656194692202090498
- paulddraper 3y agoThat sucks, a terrible situation. On an objective note, stage 4 cancer and 70% chance of failure...sounds like it was mostly a death sentence from the start.
- ksaun 3y agoIt depends on the specifics of her situation. If the 30% is the chance of it being curative (as opposed to just dealing with the currently known tumors), then even if the treatment "failed," it might still allow her to live several additional years and/or be in better health for her time remaining.
- ecommerceguy 3y agoIs this in the USA or Europe? I think it's important to point out given how widespread blatantly false information is given by leftist Americans when comparing US health insurance to European Health insurance.
- polski-g 3y agoEurope has death panels. America does not, we provide coverage regardless of success chance, one reason why its so expensive. https://www.researchgate.net/publication/49843550_The_real-life_death_panel_reformed https://www.researchgate.net/publication/49843550_The_real-l...