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You have a right to know why a health insurer denied your claim
- deathemperor 3y agoI'm a software engineer working in the insurance industry in Vietnam. The company provides claims service (TPA) for insurers. I find the conversation super interesting as our healthcare and insurance system share the same problems with the US (everywhere else too I think). I'm super excited that my work piece by piece improve the industry one way or another.
- convolvatron 3y agoisn't that kind of pointless? they are denying your claim because its their goal to reduce costs. any justification is just going to point to some made up excuse or insanely complicated internal policy designed for obfuscation. you could demand they publish those policies, but how are you going to guarantee that they are finite and parsable by humans? look a the text of voting referendums for an example, or cell phone contracts.
- quadrifoliate 3y ago> any justification is just going to point to some made up excuse or insanely complicated internal policy designed for obfuscation. I don't see how you can claim that without seeing all the records in question. Maybe it was deliberately obfuscated, maybe someone just screwed up. Guess what, human error is a thing. In fact, the article itself showcases a bunch of human errors -- those of people not knowing that their employer is required by law to provide claim files within 30 days.
- Zigurd 3y agoThere might also be a teakettle on the far side of the Moon.
- whoomp12341 3y agoyou haven't fought a claim yet, have you. Its beyond infuriating, especially when you are on the hook for a large bill
- dboreham 3y agoBeyond infuriating is when the Dr requests pre-approval then does the procedure and then they deny it. And keep denying they approved it even after the hospital has revealed they record all calls with insurance companies, and they have the recording where the procedure was pre-approved.
- CocaKoala 3y agoEh, we're currently fighting to get some claims covered. Before a certain date, all the claims are denied; after a certain date, all the claims are approved. The claims are all for the same thing, related to the same procedure (physical therapy after a joint replacement). Could the claims have been rejected due to a simple human error? Sure, it's plausible. Was there another human error that caused the claims to be rejected after we appealed? Maybe, but probably not. Could a third human error cause the claims to be rejected again after our second appeal? Seems pretty unlikely.
- quadrifoliate 3y agoYeah, in your case it seems reasonable that the denials are malicious. I guess I'm not seeing why the poster I was replying to declared that getting access to the claims file was useless. Wouldn't getting access to that file make it easier to prove that claims were wrongfully denied?
- nerdjon 3y agook great, so I should get to know why things get denied. Maybe... they just can't deny without a reasonable alternative that your doctor agrees with? Like fine deny name brand prescription for generic. The idea that your Doctor... who actually knows what is going on wants to do something and your Insurance can just say no is ridiculous. If we are so worried about Doctors doing unnecessary things to get money from Insurance than lets tackle that also.
- vondur 3y agoMy childhood doctor in the late 70's hated insurance companies over this. I'd hear him on the phone arguing with the insurance company reps asking if they had a MD Degree and would like explain the denial to him. Interesting to hear back in the day.
- nerdjon 3y agoI have to imagine many do, it sucks since what the hell are their options. I would like to think that most doctors at least care somewhat. I can't imagine how they feel if they think someone truly needs something and insurance just says no. I know my sister at one point was having some critical medication for her denied so the doctor just kept giving her sample packs. I went through an issue with a medication for me and it was still never resolved.
- nradov 3y agoIn many cases that issue can be resolved through an appeals process. But this takes extra time for providers, and they don't get paid for that. Insurers may also require step therapy. Try a cheaper treatment first, then if the patient fails to respond they will authorize a more expensive option.
- nerdjon 3y agoI call bullshit. I went through multiple appeal processes, my doctor tried to file multiple on my behalf, I called, and nothing. They don't care.
- spondylosaurus 3y agoOne thing that's bit me in the ass repeatedly with insurance claims is that the people approving/denying claims aren't doctors, and the people you have to fight to appeal a denied claim are definitely not doctors. So even if you know the grounds for denial, sometimes the reason is bullshit and flies in the face of the insurer's own policies. I spent months fighting a claim for mesalamine DR tablets (and getting nowhere) only to discover that the insurance personnel were treating it as a different claim for mesalamine EC capsules—a totally distinct formulation. Any doctor or pharmacist could tell you that they're not equivalent. But they had different approval criteria in the insurance system, and even though I met the criteria for the former (the drug I wanted) they kept denying me for not meeting the criteria of the latter (the drug I did not want). But those are both oral forms. I think if they'd tried to run the claim as the suppository version, the error would've been more obvious.
- ceejayoz 3y agoEven when they are a doctor, it doesn't matter. https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims https://www.propublica.org/article/cigna-pxdx-medical-health... > Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method, spending an average of 1.2 seconds on each case, the documents show.
- spondylosaurus 3y ago1.2 seconds! Well they're sure putting that med school knowledge to use, huh.
- ceejayoz 3y agoYep. Don't worry, though; if they slip up and do fund your expensive treatments, all of a sudden they have lots of time to focus on you. https://www.propublica.org/article/unitedhealth-healthcare-insurance-denial-ulcerative-colitis https://www.propublica.org/article/unitedhealth-healthcare-i... > At one point, court records show, United inaccurately reported to Penn State and the family that McNaughton’s doctor had agreed to lower the doses of his medication. Another time, a doctor paid by United concluded that denying payments for McNaughton’s treatment could put his health at risk, but the company buried his report and did not consider its findings. The insurer did, however, consider a report submitted by a company doctor who rubber-stamped the recommendation of a United nurse to reject paying for the treatment. > But the records reviewed by ProPublica show that United had another, equally urgent goal in dealing with McNaughton. In emails, officials calculated what McNaughton was costing them to keep his crippling disease at bay and how much they would save if they forced him to undergo a cheaper treatment that had already failed him. As the family pressed the company to back down, first through Penn State and then through a lawsuit, the United officials handling the case bristled.
- whoomp12341 3y agoIt would be really nice to know IF my claim was denied. Health billing is so messed up.
- munk-a 3y agoIf it's an expensive procedure and you want to know what the cost will be you'll usually want to submit for prior authorization before the procedure. In an emergency this isn't an option but for any other treatment this can give you a lot of clarity about what your out of pocket will be - doctors (or their offices) should be able to handle this if you ask.
- eric_the_read 3y agoI had a doctor once recommend a temporary treatment that would be provided by a third party. I called the third party and asked how much it would cost; they had no idea. I called my insurance company and asked how much it would cost; they had no idea. I called my doctor and asked how much it would cost; they had no idea. Literally nobody involved in the entire chain of providers had any idea how much it would cost. The best advice anybody could give me was to get the treatment, then look at the bill afterwards. (Oh, and nobody had any idea when I might get a bill either-- my wife is still receiving bills from the birth of our most recent child, 18 months ago.)
- evancordell 3y ago> my wife is still receiving bills from the birth of our most recent child, 18 months ago I've been dealing with this as well, and the uncertainty has been the most frustrating thing. Medical bills from the same institution should be required to be high watermarks - i.e. if you give me a bill in March, you can't send me a bill in April that has charges from February that _weren't on the bill from March_. It feels like fraud (and maybe it is, but who has time to figure that out?)
- callalex 3y agoPrior authorization does not come with any binding guarantees, insurance companies can and do reneg on their promises all the time.
- NikolaNovak 3y agoI know this is a low-quality comment, but this may be the #1 thing Hacker News has taught me over the last decade: USA health/insurance system is an Orwelian nightmare multiplied by a hundred. No straight-up evil guy with a vision and mission statement could imagine and successfully implement something as brutal as apparently we've systemically created ourselves through a million small steps. I'm a bright guy but I don't know how I'd live with the cognitive workload, stress and uncertainty over having to deal with all of this (the networks, the uncertainty over price and bills, the bills coming for weeks and months after care, the myriad involved parties, the rules and limits and interpretations and just... everything). More to the point, I don't understand how anybody, on any party or political spectrum, can say "Yup... this is a reasonable system that helps people and needs no change".
- deleted 3y ago[deleted]
- linuxftw 3y agoThankfully, the ACA made insurance mandatory for everyone. Not only do we have a garbage system, we're obliged to participate in it.
- vkou 3y ago1. You have always participated in it, regardless of whether or not you pay an insurer. 2. There are no penalties for not having insurance, that part of the ACA has been torpedoed. 3. The people who torpedoed it have no intentions of fixing a damn thing about this country's medical system.
- EvanAnderson 3y agoThis is sarcasm, right? The individual mandate was struck down. In my opinion, this was a brilliant strategic move by those opposed because it guarantees the eventual financial inviability of all of the ACA. Decreasing the size of the risk pool by allowing people to opt out will guarantee that it won't work long-term.
- TuringNYC 3y ago
- munk-a 3y agoThis problem is going to get even more fun as AI driven Prior Authorization denials get more prevalent.
- TuringNYC 3y agoI had my FSA provider PayFlex deny a medical co-pay as "Not Medically necessary." Isnt it lovely when a Private Equity firm decides what is or isnt medically necessary? They were obviously using some automated system to try and deny claims, to hell with false positives. The best thing is to just repeatedly submit the legitimate claim until it goes thru. There seems to be some non-determinism in these systems and the same thing will sometimes be accepted and sometimes rejected. Bless my wife for taking care of this insanity.
- JJMcJ 3y agoNot quite the same thing but many people report when a hospital bill seems high, and they ask for an itemized bill, magically the charges get reduced.
- coredog64 3y agoPotentially useful context: If you’re not covered by a small employer, your claims are typically being self-insured by your employer. Your employer uses Cigna or BCBS for administrative functions, but they set the tone for the amount they’re willing to pay. That’s why you’ll see differences in coverage even though you ostensibly have the same insurance provider in the same state.
- oldandboring 3y agoAnd, importantly, these "ERISA" plans are exempt from state laws and regulations (although they do have to abide by federal laws and regulations).
- power 3y agoA lesson learned from hard experience and unfortunately too late: get your own illness benefit insurance. If you have it through your employer you can't sue the insurance company since you're not a party to the contract. They don't even need to talk to you, only your employer.
- linsomniac 3y agoI was preparing to possibly have to do this, but it looks like I've narrowly avoided it. My family has a procedure scheduled Dec 4, and my work insurance is changing plans Dec 1. Got pre-approved with previous plan, previous insurance company is exiting health insurance totally. New plan needs 15 business days to approve it, and can't start that until we get group numbers, and there's a holiday in here. But, the doctor has been able to get us in due to a cancellation, before the insurance expires.
- deleted 3y ago[deleted]
- LocalH 3y agoInsurance companies should not be able to override a patient's doctor in making a determination of what's not "medically necessary".
- mbauman 3y agoIn my experience, knowing why a health insurer denied a claim isn't useful; it just becomes a maze of medical billing codes and definitions that always ends at "insurer wins."
- aesesfull 3y agoyeah I've personally chased the "why did you deny me?" line for over two years before they just came back with "we don't believe you nor your doctor that you have narcolepsy and nothing will change that (even though we're currently covering your less expensive narcolepsy medications)". hanged fire until I hit my 26th birthday and then they were off the hook entirely
- dboreham 3y agoPresumably this means "know their excuse". We already know the reason : so they can make more profit.
- bawana 3y agoAs a physician, my patients are continually stymied by the preauthorization requirement for CT scans and procedures by some insurors. This ridiculous hurdle adds weeks of delay sometimes. And there is no real quality assurance or data assessment regarding the necessity of the procedure. I have to call, go through a phone tree, the delays are frustrating and unecessary. I didnt go to school and residency for 10 years to justify a job deemed necessary by some corporate second guesser. This is just a process added by an MBA that adds no value to the patient care. It is the result of trying to apply Adam Smith's precepts of a free market economy to a. market where the consumers have no choice. No one chooses the illness they have. A capitalist model serves this market poorly. And the whole idea of making a profit off of someone's illness to pay shareholders is wrong.
- iancmceachern 3y agoI'm currently fighting this exact fight with Blue Shield I was getting nowhere until I started connecting with and then publicly shaming their executive leadership on LinkedIn. If you do that, you get transfered to their "executive relations team" who still are unable to get things done, but it's at least a different department you can file grievances that go nowhere with.
- InCityDreams 3y agoThanks for the heads up. Time to give my money to someone else...that is probably just as bad, but hey "I'm doing my part".
- iancmceachern 3y agoGladly! Another funny anecdote. They have a 1.1 star yelp review. The San Francisco DMV has 1.8. 1.1 is a statistically significant difference thsn 1.8. They have almost 800 1 star reviews on yelp, as a non profit!
- mlrtime 3y agoMy wife is very effective contacting insurance companies and getting our claims approved. She spends hours on the phone but we usually get our way. This requires understanding our benefts, the CPT codes and denial reasons. She used to do this working for a high net wealth family office for the entire family's medical expenses. We were trying to think of a way that she could offer this skill as a service for people. It would require some difficulties with HIPAA, but I think there is a opportunity here to help people.
- iancmceachern 3y agoThis is awesome. Totally understand the HIPPA challenges. I'd totally pay her to teach me how to do it for myself. Perhaps she could do it as a coaching or online course type model? I need this skillset in my life and don't know how to acquire it. I would pay someone to teach me how to acquire it.
- jmyeet 3y agoWe are arranging deck chairs on the Titanic with the dystopian US health system. Like who here legitimiately believes this is a good system? The entire system is an exercise how capitalism fails where there's inelastic demand. Health insurance companies exist to extract wealth from consumers and governments by not providing health care to increase profits. It's that simple. There is a direct link between denying prior authorizations and increasing profits [1]. Fun fact: Obamacare (ie the ACA) snuck in a ban on physician-owned hospitals [2] thanks to lobbying efforts. Just more artificial barriers and rent-seeking to increase profits. Health insurance companies continue to consolidate (eg requiring prescriptions are filled by their PBM-approved pharmacists, buying up medical providers). It is utterly insane to me that anyone can defend this system who isn't a major shareholder in United healthcare. Yet ordinary people do, which usually comes down to "I don't want to lose my insurance", which is so insanely short-sighted and selfish, it blows my mind. [1]: https://www.healthleadersmedia.com/revenue-cycle/cost-denials-saw-67-increase-2022 https://www.healthleadersmedia.com/revenue-cycle/cost-denial... [2]: https://www.fiercehealthcare.com/providers/hospital-groups-aim-blunt-effort-reverse-aca-ban-physician-owned-hospitals https://www.fiercehealthcare.com/providers/hospital-groups-a...
- nikanj 3y agoWhy? Because fuck you, that's why. Sue us, see whose legal budget runs out first -Every insurance company
- Khelavaster 3y agoSurprised disabled people don't do citizens' arrests on insurance company account administrators and executives, using heavy assault weapons when necessary to leverage force with their disabilities..
- ongytenes 3y agoBack in 2005 I was working for Dupont and had a mandatory hearing test. I asked for the results and was told that was the property of the company and I couldn't have access to it. I felt at the time it unethical to withhold information regarding my health. Now I'm wondering if it was illegal too.
- yardie 3y agoWell more recently I had a urine drug screening for a job. I passed obviously but I was curious about the results and the drug testing company also told me it was the property of the company.
- jackallis 3y agoyou might be interested in whole series https://www.propublica.org/series/uncovered https://www.propublica.org/series/uncovered
- amatecha 3y agoI wish articles like this would clearly indicate what country's laws they are referring to. This article appears to only be directly relevant to the United States.
- deleted 3y ago[deleted]
- 3seashells 3y agoIs there a way to filter out these misery parades via keyword? I know heartless Europeans, but besides bureaucratic tips, there seems little to hack and it's all in all a daily downer to see sentient being beeing mutilated and thrown away cause it's cheaper. And then the whole population treats it like some selfflaggelating religious thing. Yes I brought it on my self for clicking.