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One 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
by spondylosaurus 3y ago
One 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.
- NickC25 3y agoHorrifying. Those "insurers" are absolute scumbags. Poor guy, I feel awful for him.
- JumpCrisscross 3y ago> Those "insurers" are absolute scumbags It’s complicated. On the other hand are fraudsters and private-equity owned hospitals maxing the bill button. If the insurer is lax with payouts, it depletes its capital and could be left insolvent. It’s a scummy system more than a system of scumbags. (To be clear, there are scumbag insurers. But it’s reductive to cite that generally, or designate it as the source of the system’s troubles.)
- justinclift 3y agoTaking 1.2 seconds to review claims means they are without any question "doing something wrong". "Remaining solvent" doesn't seem to be the goal, rather "maximising quarterly bonuses regardless of lives destroyed" seems a more fit description.
- JumpCrisscross 3y ago> Taking 1.2 seconds to review claims means they are without any question "doing something wrong" Nobody said they aren’t. The point is, given the volume of claims, to do a proper analysis, we’d need a material fraction of doctors doing insurance reviews (instead of seeing patients). So we get a reliance on heuristics. If you’re lenient, you get targeted by fraudsters. So we get a bias towards denial. (Nobody is getting a material quarterly bonus for denying a few more claims. That nonsense occurs at the level of PBMs and other scale operations.)
- justinclift 3y ago> If you’re lenient, you get targeted by fraudsters. So in this scenario, it sounds like the fraudsters are the medical insurance companies, and the group being lenient are the regulators. A place taking (on average) 1.2 seconds to review each claim shouldn't be in business.
- gustavus 3y agoI'm assuming that the drs who end up as insruance claim evaluation drs are the Dr. Murphy's of the world who everyone decided it would be better if they weren't actually practicing medicine.
- ceejayoz 3y agoYes. Which makes it darkly ironic that the end result is them practicing medicine on tens of thousands of people a month each.
- yborg 3y agoIn many cases these doctors aren't practicing physicians, iirc the reviewer in the article hadn't practiced for 25 years. They just need someone with an MD to sign off on the denials.
- carbocation 3y agoMy view is that these people and companies are practicing medicine and should start being held to the standard of care.
- MichaelZuo 3y agoSince you have some experience in the field, How do you see your views becoming reality?
- carbocation 3y agoSadly the practicing side and the regulatory side are different enough that I basically don't have much insight into why my views are wrong. (I mean, presumably if my views were right, some enterprising lawyer would have applied the theory already.) E.g., if there is legislation that is acting as a barrier, we could get our representatives to change it. If these folks remain boarded and are practicing outside of the norms and scope, then we could get our medical licensing boards to take action as well.
- ethbr1 3y agoAfaik, medical review professionals are acting more as expert witnesses (with a crushing case load).
- DangitBobby 3y agoThey get privileged access to your medical information and directly impact the treatment plan you get. They are practicing medicine.
- gustavus 3y agoYa there is a Grisham novel about this exact thing. I hope the people involved in Cigna all have their spouses leave them, their children disown them, and then get their car towed.
- smnrchrds 3y agoWhat's the name of the novel?
- hotpotamus 3y agoWhat if their spouses and children like having food and health insurance of their own?
- rqtwteye 3y agoHow are these guys allowed to stay in business? Hospitals and insurances make many "mistakes" in their favor and leave it up to the patient to navigate this kafkaeske bureaucracy. I understand making some honest mistakes but this stuff is just plain fraud.
- kurthr 3y agoThe combination of paying of pocket or face horrific medical consequences along with ERISA limiting legal claims makes it unlikely the insurance companies face any consequences to their actions. Unless you're a wealthy litigation attorney who has friends that will rack up enormous bills as insurance takes it to federal appeals court. https://www.propublica.org/article/blue-cross-proton-therapy-cancer-lawyer-denial https://www.propublica.org/article/blue-cross-proton-therapy...
- scythe 3y agoOne thing that's especially egregious about the situation in RadOnc is that there are plenty of situations where the doctors and physicists have already planned a treatment, billing $xxx per hour, and only then it is denied by insurance, so the hospital counts this as a loss and plans another inferior treatment, increasing the cost, in order to offer a "cheaper" procedure as demanded by the insurance company. The losses are of course amortized to drive up the cost of all treatments while the patients are given inferior care. It's absolutely infuriating. A friend who is a therapy physicist left the country and went back to work in Canada taking a 40% pay cut because he couldn't stand it anymore.
- anigbrowl 3y agoFraud is an American norm, that's why lobbyists make big bucks. One of the US Senators for Florida was CEO of a company that was convicted of 14 counts of defrauding Medicare and had to pay $1.7 billion in fines, but he just said he knew nothing about it and went on to become Governor and later Senator for his state. https://en.wikipedia.org/wiki/Rick_Scott https://en.wikipedia.org/wiki/Rick_Scott Meanwhile a Democratic Senator from New Jersey is credibly accused of taking bribes from Egypt (evidence included literal bars of gold discovered in his home pursuant to a search warrant), but he refuses to resign. Corruption is endemic in the US, it just has good lawyers and PR people.
- stemlord 3y agoI've had doctors who automatically refile the claim multiple times in a row because of this. I'd get a letter from insurance saying it's denied then 2 weeks later another saying it's approved.
- autokad 3y agoI think the solution to most problems is make the c-suite criminally responsible for errors. Things will resolve themselves
- spondylosaurus 3y agoEnthusiastically agree, but considering how much political lobbying comes from health insurance giants I have no hope of it happening in my lifetime.
- NickC25 3y agoI think an even better solution is for our society to just admit that health insurance companies can't exist as for-profit entities that have to answer to Wall Street first and foremost. Think about it. A health care company collects money under the premise that "these premiums you're paying will cover you if something bad happens". If that something bad does happen (and for most people, it never will), that money should be available to pay for whatever happened. The insurer, now concerned about their margins and profits more than providing you the service that you've already paid them to do, just gets to trot out some poorly paid rep with no medical knowledge to override the medical advice of a trained medical professional. Now, you're not only injured, you're paying out of pocket for a service that won't actually do what you've paid it to do. The only winner here is the insurer's C-Suite and stockholders who get to brag on quarterly earnings calls that they've denied tens of thousands of claims (and they even get fiscally rewarded for it!). In a more modern and honest society we would call for-profit insurers what they actually are: a racketeering organization operating under the guise of fraud.
- deleted 3y ago[deleted]
- bugglebeetle 3y agoI agree if you stop at “health insurance companies can’t exist.” Being a nonprofit doesn’t stop you from being parasitic or malevolent.
- lotsofpulp 3y ago
- amalcon 3y agoI had an instance where the hospital had coded my spouse's eye issue as "routine" -- so it was not covered by medical insurance, because your vision insurance is supposed to cover that. Our vision insurance wouldn't cover it, because they only permit one visit per calendar year. The doctor that treated my spouse literally published a paper about the case, so uh... not routine. I got super lucky with the insurance person, though -- she actually called the hospital for me and got them to re-code it.
- justinram11 3y agoHad literally the exact same issue with my spouse, but without the luck of finding an insurance person who cared. At the end of the day, it wasn't worth the $200 to continue fighting it (had already invested ~5 hours into phone calls back and forth between the clinic and insurance company). Infuriating to say the least.
- Natsu 3y ago> I think if they'd tried to run the claim as the suppository version, the error would've been more obvious. Gotta tell the insurance company where to stick it? :)
- wnevets 3y ago> 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. This is a feature health insurance companies, not a bug. Their entire purpose is to collect as much premiums as possible while paying out a little as possible.
- Obscurity4340 3y agoIt'd be funny if they rubber-stamped all suppository claims. Like, we'll just cover it if it has anything to do with your ass.
- spondylosaurus 3y agoIronically I did want to try this steroid suppository foam in the throes of a bad IBD flare but my doctor said not to bother because insurance companies never cover it.
- Obscurity4340 3y agoThats why you ask for an exception and appeal the denial or get a specialist and try it with them. I don't think mine have ever been denied but I also have a long rapsheet of tried meds. If you rattle off a list of 2 or more previously tried meds, I'd be surprised if they can sustain a denial. You just might have to appeal or try something to add to the list of what to bring up as evidence to try something different (uncovered)
- Obscurity4340 3y agoThe world would be a much nicer place if the default for the insurance company was to cover your ass lol
- eweise 3y agoI recently sued my health insurance company in small claims court and won. They claimed my out of network costs were above the norm. The insurance company tried all kinds of tricks trying to get the case thrown and delaying. Took me four trips down to the courthouse but finally got them in front of a judge who knew they were full of shit and sided with me.
- sumtechguy 3y agoInteresting one I heard once from my dad. 'your policy is denied you are not covered for this because only your spouse is' 'thats interesting that is not how I wrote my OWN policy' 'uhhh we will get back to you' They approved it. But not before denying it. He sold these policies for a living. He mostly quit exactly because of this sort of noise.
- Khelavaster 3y agoThe people who denied your insurance claims were literal criminal who need to be arrested and jailed. If their local municipalities don't prosecute on your own, you're [almost certainly] legally entitled to make a citzen's arrest with as much force as necessary to bring the criminal fraudsters denying your assets to justice..
- nradov 3y agoIt would be interesting to see exactly what was coded on the electronic claim in order to understand where the fault lies. Insurers certainly make some errors when processing claims and don't always follow their own coverage rules correctly. But equally providers (including pharmacies) sometimes make data entry errors. There are distinct NDC codes for every minor variation of a drug, and sometimes only a subset are covered. Unfortunately when either side makes an error the patient gets stuck trying to fix it.
- m463 3y agoThere was a lawsuit years ago where someone sued some hospital administration or insurance company for practicing medicine without a license for denying some claim. I think this set a precedent, so if a doctor is not involved, there's a problem. EDIT: can't find the case