4 ms·

I don't understand the comments excusing the CEO of his responsibility. I work for a scale-up insurance company, and the CEOs are pretty clear with their mandat

I don't understand the comments excusing the CEO of his responsibility. I work for a scale-up insurance company, and the CEOs are pretty clear with their mandate: customer service is paramount, we make money by streamlining our processes, negotiating hard with our network, and pricing properly our products. NOT by denying claims. This philosophy is enforced from the top all the way down, with Chinese walls between pricing and claims handling, proper training, and continuous NPS surveys

avalys 2y ago
How do you avoid losing money due to fraudulent claims, claims for services outside the scope of what you're insuring against, claims for ineffective resolutions to the claimed damages, etc.? Am I supposed to know what a "scale-up insurance company" is?
- michaeljx 2y ago
  Scale-up means youngish (10-12years old), mid-size in the countries we are operating, think 3 countries 600-800m revenue. Fraudulent claims are a tiny percentage of claims, and are rejected after human review, usually involving detectives. In the countries we operate, fraudulent claims are about 6-8% of all claims, and that's usually the level we aim to detect. Being able to absorb some false negatives is usually cheaper than going for the full 100% detection rate. It is definitely more customer oriented than rejecting due to false positives.
  - avalys 2y ago
    Is this a health insurance company or are you providing property insurance?
    - michaeljx 2y ago
      No this is general insurance (motor, property, travel etc). It is also founder-led, which is an important factor, as the reason they started it was their personal frustration with the motor insurances.
      - nradov 2y ago
        Your experience in general insurance has nearly zero relevance to US health insurance. Their main customers are large self-funded employers and they operate under a completely different legal regime. Most of their business is no longer even "insurance" in the traditional sense.
        motorest 2y ago
        OP's point is orthogonal to whatever legal regime is in effect. OP's point was that fraudulent claims are at a residual level. If anything, general insurance is expected to have higher rates of fraudulent claims than health insurance.
lern_too_spel 2y ago
UHG is notorious for Medicare Advantage fraud. Ask any cardiologist, and they'll tell you that this is still happening. It's not as bad for the patient as denying claims, but it's plenty bad for taxpayers and the healthcare system as a whole. It's not going to get fixed because some of those fraudulently acquired dollars buy legislators, and nobody who wants to fix it is going to spend anywhere near as much. https://www.justice.gov/opa/pr/united-states-intervenes-false-claims-act-lawsuit-against-unitedhealth-group-inc-mischarging https://www.justice.gov/opa/pr/united-states-intervenes-fals... https://www.justice.gov/opa/pr/united-states-intervenes-second-false-claims-act-lawsuit-alleging-unitedhealth-group-inc https://www.justice.gov/opa/pr/united-states-intervenes-seco... https://kffhealthnews.org/news/article/medicare-advantage-overbilling-diagnostic-codes-cms-killed-rule/ https://kffhealthnews.org/news/article/medicare-advantage-ov... https://medtrade.com/news/billing-reimbursement/medicare-advantage-fraud-billions-lost-in-overpayments-and-political-influence/ https://medtrade.com/news/billing-reimbursement/medicare-adv...
oskarkk 2y ago
But wouldn't denying less claims necessitate raising prices? I see stats like these: https://i.redd.it/7aa6zytdox4e1.jpeg https://i.redd.it/7aa6zytdox4e1.jpeg If the company is denying so much claims (32%), and they have quarterly profit around $6B on $100B revenue (and they had less profit in earlier quarters, even a loss in Q1), I think they would need to raise prices to stop denying most claims that they deny. And what then? Someone would kill the CEO because they can't afford the insurance?
- wholinator2 2y ago
  How did we enter a world in which the only given fact that must be held true is that "the business profit will grow unceasingly for all time, no matter the consequence" Instead of, "the human beings that we serve matter, and our duty to them comes before all else. We will profit by being the best in the market" I think monopoly and MBAification of every leadership position at every company in at least America. Some of the curriculum is disgusting, anti human propaganda. It's absolutely not a given that shareholder profits come above everything else no matter what. The buck does not stop with fiduciary duty, the buck stops with the actual human beings you're company "serves", as we've just seen. Shareholder profits didn't order that person dead. Humans did. It's insane that you can let your company perform so terribly, so catastrophicly evil for the public that it becomes impossible to know which of the millions of people who've has their lives damaged or destroyed would've actually decided to order your ceo dead rather than just gleefully commiserate about it at their mothers funeral. I think we get there by destroying the real market. I don't get to choose which insurance my job provides me! I don't know how that would work but all they have to do is pay more large companies to choose them and bam, locked in audience, disgusting parody of a free market, death for thousands of sick people and one CEO. Antitrust needs to block every merger for the next 10 years and obliterate any company that's powerful enough to capture over 20,000,000 customers while the vast majority of them _actively despise you_.
  - Ygg2 2y ago
    > How did we enter a world in which the only given fact that must be held true is that "the business profit will grow unceasingly for all time, no matter the consequence" What do you mean enter? This was always the model of capitalistic acquisition. Early industrial revolution was not known for it's blue skies, labor friendly laws and preventing children from working in the mines. The moment you have inflation, which you need to suppress wages of people living from wages (i.e. labor), is the moment you entered the magical roundabout of infinite growth. The only time capitalism had to placate labor was when communism was a credible rival.

avalys 2y ago

How do you avoid losing money due to fraudulent claims, claims for services outside the scope of what you're insuring against, claims for ineffective resolutions to the claimed damages, etc.? Am I supposed to know what a "scale-up insurance company" is?

michaeljx 2y ago
Scale-up means youngish (10-12years old), mid-size in the countries we are operating, think 3 countries 600-800m revenue. Fraudulent claims are a tiny percentage of claims, and are rejected after human review, usually involving detectives. In the countries we operate, fraudulent claims are about 6-8% of all claims, and that's usually the level we aim to detect. Being able to absorb some false negatives is usually cheaper than going for the full 100% detection rate. It is definitely more customer oriented than rejecting due to false positives.
- avalys 2y ago
  Is this a health insurance company or are you providing property insurance?
  - michaeljx 2y ago
    No this is general insurance (motor, property, travel etc). It is also founder-led, which is an important factor, as the reason they started it was their personal frustration with the motor insurances.
    - nradov 2y ago
      Your experience in general insurance has nearly zero relevance to US health insurance. Their main customers are large self-funded employers and they operate under a completely different legal regime. Most of their business is no longer even "insurance" in the traditional sense.
      - motorest 2y ago
        OP's point is orthogonal to whatever legal regime is in effect. OP's point was that fraudulent claims are at a residual level. If anything, general insurance is expected to have higher rates of fraudulent claims than health insurance.

lern_too_spel 2y ago

UHG is notorious for Medicare Advantage fraud. Ask any cardiologist, and they'll tell you that this is still happening. It's not as bad for the patient as denying claims, but it's plenty bad for taxpayers and the healthcare system as a whole. It's not going to get fixed because some of those fraudulently acquired dollars buy legislators, and nobody who wants to fix it is going to spend anywhere near as much. https://www.justice.gov/opa/pr/united-states-intervenes-false-claims-act-lawsuit-against-unitedhealth-group-inc-mischarging https://www.justice.gov/opa/pr/united-states-intervenes-fals... https://www.justice.gov/opa/pr/united-states-intervenes-second-false-claims-act-lawsuit-alleging-unitedhealth-group-inc https://www.justice.gov/opa/pr/united-states-intervenes-seco... https://kffhealthnews.org/news/article/medicare-advantage-overbilling-diagnostic-codes-cms-killed-rule/ https://kffhealthnews.org/news/article/medicare-advantage-ov... https://medtrade.com/news/billing-reimbursement/medicare-advantage-fraud-billions-lost-in-overpayments-and-political-influence/ https://medtrade.com/news/billing-reimbursement/medicare-adv...

oskarkk 2y ago

But wouldn't denying less claims necessitate raising prices? I see stats like these: https://i.redd.it/7aa6zytdox4e1.jpeg https://i.redd.it/7aa6zytdox4e1.jpeg If the company is denying so much claims (32%), and they have quarterly profit around $6B on $100B revenue (and they had less profit in earlier quarters, even a loss in Q1), I think they would need to raise prices to stop denying most claims that they deny. And what then? Someone would kill the CEO because they can't afford the insurance?

wholinator2 2y ago
How did we enter a world in which the only given fact that must be held true is that "the business profit will grow unceasingly for all time, no matter the consequence" Instead of, "the human beings that we serve matter, and our duty to them comes before all else. We will profit by being the best in the market" I think monopoly and MBAification of every leadership position at every company in at least America. Some of the curriculum is disgusting, anti human propaganda. It's absolutely not a given that shareholder profits come above everything else no matter what. The buck does not stop with fiduciary duty, the buck stops with the actual human beings you're company "serves", as we've just seen. Shareholder profits didn't order that person dead. Humans did. It's insane that you can let your company perform so terribly, so catastrophicly evil for the public that it becomes impossible to know which of the millions of people who've has their lives damaged or destroyed would've actually decided to order your ceo dead rather than just gleefully commiserate about it at their mothers funeral. I think we get there by destroying the real market. I don't get to choose which insurance my job provides me! I don't know how that would work but all they have to do is pay more large companies to choose them and bam, locked in audience, disgusting parody of a free market, death for thousands of sick people and one CEO. Antitrust needs to block every merger for the next 10 years and obliterate any company that's powerful enough to capture over 20,000,000 customers while the vast majority of them _actively despise you_.
- Ygg2 2y ago
  > How did we enter a world in which the only given fact that must be held true is that "the business profit will grow unceasingly for all time, no matter the consequence" What do you mean enter? This was always the model of capitalistic acquisition. Early industrial revolution was not known for it's blue skies, labor friendly laws and preventing children from working in the mines. The moment you have inflation, which you need to suppress wages of people living from wages (i.e. labor), is the moment you entered the magical roundabout of infinite growth. The only time capitalism had to placate labor was when communism was a credible rival.