5 ms·

How 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 ka

How 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 ago
The 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 ago
  One 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 ago
Fraud 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.
- ethbr1 3y ago
  Setting US standards by the citizens of Florida and New Jersey is a bit outside the bell curve...
  - anigbrowl 3y ago
    I'm quite sure I could find examples from every state, I just picked the two most egregious examples that sprang to mind.
    - ethbr1 3y ago
      I'm sure you could find singular examples in any state. That's how exceptions work. In Florida, though, my experience has been that corruption is far more endemic and culturally accepted. There's a reason no president has ever come from Florida politics -- despite being the 3rd most populous state (more people than NY!) -- the skills and acceptable approaches down here don't fly in the rest of the county. F.ex. the publicly-regulated utility covering most of the state (FPL) financed a third party candidate (up to $3m) in a state senate race. That candidate didn't campaign, but did happen to have the same last name as the incumbent, who had been critical of FPL and pushed reform efforts. The incumbent lost by 32 votes. [0] Or the (again regulated-FPL-adjacent) takeover attempt of the sole remaining city-run utility company in Florida (JEA) that collapsed in a flurry of federal charges over kickbacks and undeclared secret bonus clauses. [1] And this is just "business as usual" in Florida. Shady stuff happens in other states, sure, but at least people elsewhere have the decency to be ashamed about what they're doing. [0] https://www.orlandosentinel.com/2022/07/22/operatives-working-with-fpl-plotted-primary-challenge-for-miami-senator/ https://www.orlandosentinel.com/2022/07/22/operatives-workin... [1] https://stories.usatodaynetwork.com/moneyandpower/home/ https://stories.usatodaynetwork.com/moneyandpower/home/
      - mlrtime 3y ago
        Awesome, do Chicago next.
        3y ago
ethbr1 3y ago
>> ...spending an average of 1.2 seconds on each case... > How are these guys allowed to stay in business? Afaik, that's exactly how the ACA was written -- there's a ceiling to non-care expenses that insurance companies can include in premiums. One consequence of this is pushing insurers to be hyper-efficient. One consequence of that is the average case needing to take 1.2 seconds. Granted, that likely includes a huge amount of happy path cases that flow through automated rules engines, which effectively take no time. So really, it's more like (most cases take 0 time) + (a low number of cases take non-zero time) = 1.2 seconds on average.
andrewjl 3y ago
I always felt that every insurance company should report anonymized aggregate percentages for denied claims in some fashion. Not sure how much that would help but it could shine more light on the issue.
- rqtwteye 3y ago
  An interesting number would be the number of successful appeals after denial. If that number is high it would indicate that they are denying too often.
jrockway 3y ago
I think the best analogy I can come up with is your kid touching a hot stove. You tell them not to, but they do anyway, and then when they learn that it really hurts, they stop doing it. Regulations are like that. Regulations are a SUPER hot stove. The employees at the insurance company want to touch the stove as often as possible. They get paid extra the closer they come to touching it. But, as more companies get burned by the stove for failing to meet the regulation's requirements, they learn that being in pain is bad. Then, they stop trying to touch the stove. So this ProPublica article is great; they say to someone relatively important at the insurance company, "hey, the individuals you wronged are actually well-connected enough to get journalists involved" and the companies get REALLY SCARED, because step 2 after the newspaper article is published is every junior US Attorney in the country tripping over each other to cart them off to prison as quickly as possible. (OK, it's probably a fine. But shareholders do not like your stock when you are routinely fined, and CEOs are paid in stock. See why competent people might get involved when that's at risk?) You can read this article as "evil companies are evil", but I read it as "evil companies are learning". There will be eventually a day when your entire claims packet is on the same website as your EOBs, and you can click a link to report a mistake. The companies will have to act on your reported mistakes, because a paper trail that says they did something illegal is super bad for the shareholders. It takes time, but journalism like this is what gets it started. If you feel depressed, don't. The system is slow, but the system is working. This is what we have democracy and a free press for!
- rqtwteye 3y ago
  "There will be eventually a day when your entire claims packet is on the same website as your EOBs, and you can click a link to report a mistake. The companies will have to act on your reported mistakes, because a paper trail that says they did something illegal is super bad for the shareholders. It takes time, but journalism like this is what gets it started. If you feel depressed, don't. The system is slow, but the system is working. This is what we have democracy and a free press for!" When will that be? In 100 years?

kurthr 3y ago

The 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 ago
One 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 ago

Fraud 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.

ethbr1 3y ago
Setting US standards by the citizens of Florida and New Jersey is a bit outside the bell curve...
- anigbrowl 3y ago
  I'm quite sure I could find examples from every state, I just picked the two most egregious examples that sprang to mind.
  - ethbr1 3y ago
    I'm sure you could find singular examples in any state. That's how exceptions work. In Florida, though, my experience has been that corruption is far more endemic and culturally accepted. There's a reason no president has ever come from Florida politics -- despite being the 3rd most populous state (more people than NY!) -- the skills and acceptable approaches down here don't fly in the rest of the county. F.ex. the publicly-regulated utility covering most of the state (FPL) financed a third party candidate (up to $3m) in a state senate race. That candidate didn't campaign, but did happen to have the same last name as the incumbent, who had been critical of FPL and pushed reform efforts. The incumbent lost by 32 votes. [0] Or the (again regulated-FPL-adjacent) takeover attempt of the sole remaining city-run utility company in Florida (JEA) that collapsed in a flurry of federal charges over kickbacks and undeclared secret bonus clauses. [1] And this is just "business as usual" in Florida. Shady stuff happens in other states, sure, but at least people elsewhere have the decency to be ashamed about what they're doing. [0] https://www.orlandosentinel.com/2022/07/22/operatives-working-with-fpl-plotted-primary-challenge-for-miami-senator/ https://www.orlandosentinel.com/2022/07/22/operatives-workin... [1] https://stories.usatodaynetwork.com/moneyandpower/home/ https://stories.usatodaynetwork.com/moneyandpower/home/
    - mlrtime 3y ago
      Awesome, do Chicago next.
      - 3y ago

ethbr1 3y ago

>> ...spending an average of 1.2 seconds on each case... > How are these guys allowed to stay in business? Afaik, that's exactly how the ACA was written -- there's a ceiling to non-care expenses that insurance companies can include in premiums. One consequence of this is pushing insurers to be hyper-efficient. One consequence of that is the average case needing to take 1.2 seconds. Granted, that likely includes a huge amount of happy path cases that flow through automated rules engines, which effectively take no time. So really, it's more like (most cases take 0 time) + (a low number of cases take non-zero time) = 1.2 seconds on average.

andrewjl 3y ago

I always felt that every insurance company should report anonymized aggregate percentages for denied claims in some fashion. Not sure how much that would help but it could shine more light on the issue.

rqtwteye 3y ago
An interesting number would be the number of successful appeals after denial. If that number is high it would indicate that they are denying too often.

jrockway 3y ago

I think the best analogy I can come up with is your kid touching a hot stove. You tell them not to, but they do anyway, and then when they learn that it really hurts, they stop doing it. Regulations are like that. Regulations are a SUPER hot stove. The employees at the insurance company want to touch the stove as often as possible. They get paid extra the closer they come to touching it. But, as more companies get burned by the stove for failing to meet the regulation's requirements, they learn that being in pain is bad. Then, they stop trying to touch the stove. So this ProPublica article is great; they say to someone relatively important at the insurance company, "hey, the individuals you wronged are actually well-connected enough to get journalists involved" and the companies get REALLY SCARED, because step 2 after the newspaper article is published is every junior US Attorney in the country tripping over each other to cart them off to prison as quickly as possible. (OK, it's probably a fine. But shareholders do not like your stock when you are routinely fined, and CEOs are paid in stock. See why competent people might get involved when that's at risk?) You can read this article as "evil companies are evil", but I read it as "evil companies are learning". There will be eventually a day when your entire claims packet is on the same website as your EOBs, and you can click a link to report a mistake. The companies will have to act on your reported mistakes, because a paper trail that says they did something illegal is super bad for the shareholders. It takes time, but journalism like this is what gets it started. If you feel depressed, don't. The system is slow, but the system is working. This is what we have democracy and a free press for!

rqtwteye 3y ago
"There will be eventually a day when your entire claims packet is on the same website as your EOBs, and you can click a link to report a mistake. The companies will have to act on your reported mistakes, because a paper trail that says they did something illegal is super bad for the shareholders. It takes time, but journalism like this is what gets it started. If you feel depressed, don't. The system is slow, but the system is working. This is what we have democracy and a free press for!" When will that be? In 100 years?