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This is a fascinating insight. Can you walk me through, at what point the HR department has the power to delay and deny claims for medical care covered under t

This is a fascinating insight. Can you walk me through, at what point the HR department has the power to delay and deny claims for medical care covered under the insurance contract? It is my understanding the hatred doesn't extend so much in the denial of claims but rather the denial of claims for covered events.

nradov 2y ago
HR departments generally have no authority over individual claims. Rather they work with insurers and independent employee benefits consultants to construct a health plan with certain benefits and coverage rules which they think will minimize costs (based on predictive analytics) without hurting employee retention too much. Large insurers offer employers a menu of options with various provider networks (narrow versus wide), negotiated rates, deductible / co-insurance / co-payment amounts, carve outs, special extra benefits, etc. Once the plan rules are set at the beginning of the year, the insurer just enforces the rules as written and passes the claim charges on to the employer. Of course, sometimes health plans just make errors in claim processing and deny a claim that should have been approved. Or the provider makes an error and submits a claim with incorrect codes or lacking the necessary documentation to establish medical necessity as per coverage rules. Or there are gray areas where it's not always clear whether a certain service should be covered or not, and it comes down to a judgment call by a nurse or doctor employed by the insurer (medicine is still more art than science and the best treatment plan isn't always clear). This can be a huge hassle for patients dealing with serious medical conditions.
- capybaraStorm 2y ago
  I think this gets to part of the issue at UHC. People are filing claims, thinking it is covered, but it gets denied. I have read anecdotal reports that people working in government roles with UHC insurance have switched to identical plans in the private sector and got much worse denial rates with UHC plans offering the same coverage. This fuels a completely speculative view that UHC might shift the 85% required healthcare costs towards favoring places where they may gain more market share and really shafting hard in other parts of the market. They can shit-can something like 15% of premiums so unequal allocation of that could lead disproportionately to some very pissed off people, even working within a system where profit is bounded by accepted claims. All of this would fit in well with a profit optimization strategy.
  - nradov 2y ago
    I'm not an expert on this but my understanding is that CMS enforces the MLR for each insurer on a per-state basis. So insurers don't have much opportunity to chase market share by shifting claim costs around between plans. Regular federal government employees are all on private insurance plans, unless they're in the military or old enough to be covered by Medicare. So your comment about "switched to identical plans in the private sector" makes no sense. But the different private insurance plans offered to federal employees do have different benefits and different claim processing policies.

nradov 2y ago

HR departments generally have no authority over individual claims. Rather they work with insurers and independent employee benefits consultants to construct a health plan with certain benefits and coverage rules which they think will minimize costs (based on predictive analytics) without hurting employee retention too much. Large insurers offer employers a menu of options with various provider networks (narrow versus wide), negotiated rates, deductible / co-insurance / co-payment amounts, carve outs, special extra benefits, etc. Once the plan rules are set at the beginning of the year, the insurer just enforces the rules as written and passes the claim charges on to the employer. Of course, sometimes health plans just make errors in claim processing and deny a claim that should have been approved. Or the provider makes an error and submits a claim with incorrect codes or lacking the necessary documentation to establish medical necessity as per coverage rules. Or there are gray areas where it's not always clear whether a certain service should be covered or not, and it comes down to a judgment call by a nurse or doctor employed by the insurer (medicine is still more art than science and the best treatment plan isn't always clear). This can be a huge hassle for patients dealing with serious medical conditions.

capybaraStorm 2y ago
I think this gets to part of the issue at UHC. People are filing claims, thinking it is covered, but it gets denied. I have read anecdotal reports that people working in government roles with UHC insurance have switched to identical plans in the private sector and got much worse denial rates with UHC plans offering the same coverage. This fuels a completely speculative view that UHC might shift the 85% required healthcare costs towards favoring places where they may gain more market share and really shafting hard in other parts of the market. They can shit-can something like 15% of premiums so unequal allocation of that could lead disproportionately to some very pissed off people, even working within a system where profit is bounded by accepted claims. All of this would fit in well with a profit optimization strategy.
- nradov 2y ago
  I'm not an expert on this but my understanding is that CMS enforces the MLR for each insurer on a per-state basis. So insurers don't have much opportunity to chase market share by shifting claim costs around between plans. Regular federal government employees are all on private insurance plans, unless they're in the military or old enough to be covered by Medicare. So your comment about "switched to identical plans in the private sector" makes no sense. But the different private insurance plans offered to federal employees do have different benefits and different claim processing policies.