4 ms·

Horrifying. 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 ago
  Taking 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.
    - OfficialTurkey 3y ago
      We have a system where doctors and nurses review medications and treatment options for patients. It's called _the medical system_. You know, the one where I can go see my doctor, talk to them about what's going on, and work with them to create a treatment plan that suits my problems and my goals. Why do we need to bolt on a secondary system that sucks up an untold wealth of time and money?
      - lotsofpulp 3y ago
        https://www.beckersspine.com/orthopedic/54193-fake-orthopedic-companies-involved-in-48m-billing-fraud-money-laundering-scheme.html https://www.beckersspine.com/orthopedic/54193-fake-orthopedi... https://www.pbs.org/newshour/health/feds-break-up-1-2b-medicare-orthopedic-brace-scam https://www.pbs.org/newshour/health/feds-break-up-1-2b-medic... https://www.fbi.gov/contact-us/field-offices/dallas/news/press-releases/federal-grand-jury-indicts-dallas-anesthesiologist-on-health-care-fraud-offenses https://www.fbi.gov/contact-us/field-offices/dallas/news/pre... https://www.cnn.com/2023/06/28/politics/doj-health-care-fraud-scheme/index.html https://www.cnn.com/2023/06/28/politics/doj-health-care-frau...
        ceejayoz 3y ago
        Small potatoes. https://www.axios.com/2023/06/14/medicare-advantage-overpayments-estimated-study https://www.axios.com/2023/06/14/medicare-advantage-overpaym... > Overpayments to insurers administering Medicare Advantage plans now exceed $75 billion a year due to aggressive coding of patients' health conditions and easily-achieved bonus payments tied to quality, researchers with the USC Schaeffer Center for Health Policy & Economics found.
        lotsofpulp 3y ago
        Insurers are not the ones coding, it is the healthcare providers. And the government is the one deciding to pay. If anything, that would mean more claims should be denied. Looking at the study, it seems like the government made some erroneous assumptions about who would be taking advantage of the policies the government created, resulting in the extra costs. (Third paragraph of “policy context” section). https://healthpolicy.usc.edu/research/ma-enrolls-lower-spending-people-leading-to-large-overpayments/ https://healthpolicy.usc.edu/research/ma-enrolls-lower-spend...
    - iamjackg 3y ago
      If a business can't handle its own scale without negatively affecting its customers, it should probably stop growing. It's the same issue we see with Google accounts being seemingly randomly terminated. Since that probably won't happen, heuristic usage should at least come with penalties attached, otherwise the incentives are lopsided. If an airline's overbooking heuristics fail and get you bumped, you either get put on another flight and/or receive financial compensation. If an insurance company's "heuristics" fail and deny a legitimate claim, there should be a penalty. If Google terminates your account because of a mistake, they should pay a fine. They shouldn't be allowed to have their cake and eat it too.
      - JumpCrisscross 3y ago
        > If a business can't handle its own scale without negatively affecting its customers The scale probably helps. The point is if every billable decision is medically reviewed for more than a few seconds, a material fraction of the healthcare workforce needs to be diverted from patients to review. There is simply no solution, given the current industrial structure, to avoid some combination of non-expert, high-speed review without making even stupider trade-offs.
        NoraCodes 3y ago
        Sounds like we need to replace the structure, given that it's not fit for purpose.
        JumpCrisscross 3y ago
        > Sounds like we need to replace the structure, given that it's not fit for purpose We soundly agree. Health insurance, where risk is pooled, makes sense. Health "insurance," where payments are pooled with a bunch of needless intermediation, is unnecessary.
        ethbr1 3y ago
        *(catastrophic) risk pooling
  - trogdor 3y ago
    That is not necessarily true. As another commenter pointed out, average review time is likely a misleading figure, since the overwhelming majority of decisions are made automatically, using predetermined rules engines. So nearly all decisions take zero seconds, and a small minority take much longer, leading to an average of 1.2 seconds, when in reality, those claims that are reviewed manually take far more than 1.2 seconds to review. As the other commenter put it: “(most cases take 0 time) + (a low number of cases take non-zero time) = 1.2 seconds on average.”
- sohex 3y ago
  I think you could make fundamentally the same argument for a great number of the issues in the world today. It's a huge web of banal evils. That doesn't mean that it excuses the behavior of any given cog in that machine though. If we allow blame to be passed on indefinitely because everything is broken then nothing will ever be fixed.
  - JumpCrisscross 3y ago
    > If we allow blame to be passed on indefinitely because everything is broken then nothing will ever be fixed Or we can skip scapegoating and fix the system. This is a fundamental lesson from aviation crash analysis: the goal should be a better system, not assigning blame.
    - ceejayoz 3y ago
      I suspect the Germanwings Flight 9525 crash investigation assigns some blame to someone. There's a difference between accidents and deliberate action by motivated actors.
      - JumpCrisscross 3y ago
        > suspect the Germanwings Flight 9525 crash investigation assigns some blame to someone Read the synopsis [1]. Blaming the co-pilot would be fruitless. He's dead. There's no chance for retributive justice. And if he's the problem, the problem's solved: he's dead. Nothing more to do. Except, of course, there is. Blaming him is simply an unproductive emotional comfort. Instead, the report examines the crash's root causes. The "co-pilot’s probable fear of losing his right to fly as a professional pilot if he had reported his decrease in medical fitness to an AME." The "financial consequences generated by the lack of specific insurance covering the risks of loss of income in case of unfitness to fly." The "lack of clear guidelines" on when conditions need to be reported. Addressing these factors helps prevent the next problem. Blaming the co-pilot actually does the opposite. [1] https://bea.aero/uploads/tx_elydbrapports/BEA2015-0125.en-LR.pdf https://bea.aero/uploads/tx_elydbrapports/BEA2015-0125.en-LR...
- kurthr 3y ago
  Remember, the insurance companies are HAPPY to pay higher prices (in fact they have forced many small ObGyn into more expensive hospital practice) as long as their competitors do too! Health Insurance companies grow their bottom line by growing the topline cost of healthcare since they're margins are limited.
- cycomanic 3y ago
  United healthcare in 2022 had $324 billion revenue (up from $75 billion in 2007) and profits of $20 billion (both up >15% year on year). There is absolutely no risk that they become insolvent. https://www.statista.com/statistics/214504/total-revenue-of-unitedhealth/ https://www.statista.com/statistics/214504/total-revenue-of-... https://www.healthcaredive.com/news/unitedhealth-2022-earnings-optum-unitedhealthcare-momentum/640320/ https://www.healthcaredive.com/news/unitedhealth-2022-earnin...
- anigbrowl 3y ago
  The thing is the insurers aren't writing nasty letters to/suing dishonest providers and CCing the patient, they're dumping the problem on the patient.

> 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 ago
Taking 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.
  - OfficialTurkey 3y ago
    We have a system where doctors and nurses review medications and treatment options for patients. It's called _the medical system_. You know, the one where I can go see my doctor, talk to them about what's going on, and work with them to create a treatment plan that suits my problems and my goals. Why do we need to bolt on a secondary system that sucks up an untold wealth of time and money?
    - lotsofpulp 3y ago
      https://www.beckersspine.com/orthopedic/54193-fake-orthopedic-companies-involved-in-48m-billing-fraud-money-laundering-scheme.html https://www.beckersspine.com/orthopedic/54193-fake-orthopedi... https://www.pbs.org/newshour/health/feds-break-up-1-2b-medicare-orthopedic-brace-scam https://www.pbs.org/newshour/health/feds-break-up-1-2b-medic... https://www.fbi.gov/contact-us/field-offices/dallas/news/press-releases/federal-grand-jury-indicts-dallas-anesthesiologist-on-health-care-fraud-offenses https://www.fbi.gov/contact-us/field-offices/dallas/news/pre... https://www.cnn.com/2023/06/28/politics/doj-health-care-fraud-scheme/index.html https://www.cnn.com/2023/06/28/politics/doj-health-care-frau...
      - ceejayoz 3y ago
        Small potatoes. https://www.axios.com/2023/06/14/medicare-advantage-overpayments-estimated-study https://www.axios.com/2023/06/14/medicare-advantage-overpaym... > Overpayments to insurers administering Medicare Advantage plans now exceed $75 billion a year due to aggressive coding of patients' health conditions and easily-achieved bonus payments tied to quality, researchers with the USC Schaeffer Center for Health Policy & Economics found.
        lotsofpulp 3y ago
        Insurers are not the ones coding, it is the healthcare providers. And the government is the one deciding to pay. If anything, that would mean more claims should be denied. Looking at the study, it seems like the government made some erroneous assumptions about who would be taking advantage of the policies the government created, resulting in the extra costs. (Third paragraph of “policy context” section). https://healthpolicy.usc.edu/research/ma-enrolls-lower-spending-people-leading-to-large-overpayments/ https://healthpolicy.usc.edu/research/ma-enrolls-lower-spend...
  - iamjackg 3y ago
    If a business can't handle its own scale without negatively affecting its customers, it should probably stop growing. It's the same issue we see with Google accounts being seemingly randomly terminated. Since that probably won't happen, heuristic usage should at least come with penalties attached, otherwise the incentives are lopsided. If an airline's overbooking heuristics fail and get you bumped, you either get put on another flight and/or receive financial compensation. If an insurance company's "heuristics" fail and deny a legitimate claim, there should be a penalty. If Google terminates your account because of a mistake, they should pay a fine. They shouldn't be allowed to have their cake and eat it too.
    - JumpCrisscross 3y ago
      > If a business can't handle its own scale without negatively affecting its customers The scale probably helps. The point is if every billable decision is medically reviewed for more than a few seconds, a material fraction of the healthcare workforce needs to be diverted from patients to review. There is simply no solution, given the current industrial structure, to avoid some combination of non-expert, high-speed review without making even stupider trade-offs.
      - NoraCodes 3y ago
        Sounds like we need to replace the structure, given that it's not fit for purpose.
        JumpCrisscross 3y ago
        > Sounds like we need to replace the structure, given that it's not fit for purpose We soundly agree. Health insurance, where risk is pooled, makes sense. Health "insurance," where payments are pooled with a bunch of needless intermediation, is unnecessary.
        ethbr1 3y ago
        *(catastrophic) risk pooling
- trogdor 3y ago
  That is not necessarily true. As another commenter pointed out, average review time is likely a misleading figure, since the overwhelming majority of decisions are made automatically, using predetermined rules engines. So nearly all decisions take zero seconds, and a small minority take much longer, leading to an average of 1.2 seconds, when in reality, those claims that are reviewed manually take far more than 1.2 seconds to review. As the other commenter put it: “(most cases take 0 time) + (a low number of cases take non-zero time) = 1.2 seconds on average.”
sohex 3y ago
I think you could make fundamentally the same argument for a great number of the issues in the world today. It's a huge web of banal evils. That doesn't mean that it excuses the behavior of any given cog in that machine though. If we allow blame to be passed on indefinitely because everything is broken then nothing will ever be fixed.
- JumpCrisscross 3y ago
  > If we allow blame to be passed on indefinitely because everything is broken then nothing will ever be fixed Or we can skip scapegoating and fix the system. This is a fundamental lesson from aviation crash analysis: the goal should be a better system, not assigning blame.
  - ceejayoz 3y ago
    I suspect the Germanwings Flight 9525 crash investigation assigns some blame to someone. There's a difference between accidents and deliberate action by motivated actors.
    - JumpCrisscross 3y ago
      > suspect the Germanwings Flight 9525 crash investigation assigns some blame to someone Read the synopsis [1]. Blaming the co-pilot would be fruitless. He's dead. There's no chance for retributive justice. And if he's the problem, the problem's solved: he's dead. Nothing more to do. Except, of course, there is. Blaming him is simply an unproductive emotional comfort. Instead, the report examines the crash's root causes. The "co-pilot’s probable fear of losing his right to fly as a professional pilot if he had reported his decrease in medical fitness to an AME." The "financial consequences generated by the lack of specific insurance covering the risks of loss of income in case of unfitness to fly." The "lack of clear guidelines" on when conditions need to be reported. Addressing these factors helps prevent the next problem. Blaming the co-pilot actually does the opposite. [1] https://bea.aero/uploads/tx_elydbrapports/BEA2015-0125.en-LR.pdf https://bea.aero/uploads/tx_elydbrapports/BEA2015-0125.en-LR...
kurthr 3y ago
Remember, the insurance companies are HAPPY to pay higher prices (in fact they have forced many small ObGyn into more expensive hospital practice) as long as their competitors do too! Health Insurance companies grow their bottom line by growing the topline cost of healthcare since they're margins are limited.
cycomanic 3y ago
United healthcare in 2022 had $324 billion revenue (up from $75 billion in 2007) and profits of $20 billion (both up >15% year on year). There is absolutely no risk that they become insolvent. https://www.statista.com/statistics/214504/total-revenue-of-unitedhealth/ https://www.statista.com/statistics/214504/total-revenue-of-... https://www.healthcaredive.com/news/unitedhealth-2022-earnings-optum-unitedhealthcare-momentum/640320/ https://www.healthcaredive.com/news/unitedhealth-2022-earnin...
anigbrowl 3y ago
The thing is the insurers aren't writing nasty letters to/suing dishonest providers and CCing the patient, they're dumping the problem on the patient.