10 ms·

Feds help health insurers hide their dirty secret: denials on the rise

150 points by mancerayder 2y ago

andrelaszlo 2y ago
"No industry malfeasance could ever excuse murder. Period." Murdering a murderer to save many innocents could be considered ethical by some? (Not saying that's the case here, but nypost made an interesting categorical statement.)
- no_wizard 2y ago
  Given the NY Posts leanings I’m not surprised they walked that line by putting it in there. Media seems to be on an agenda setting tear to disavow the murder, but I think it’s a frankly boot licking response to what is going on here. I think this spooked a lot of executives (re: “elites” if you will) and there is pressure to ignore the nuance of what the murder means to people and why it isn’t the same as say, stabbing a tech CEO in SF like what happened last year
- tossandthrow 2y ago
  It is funny that the sentiment that nothing excuses a murder is being circulated in the US - a country that still carried out death sentences.
  - xyzzy4747 2y ago
    It's a little different when a jury of your peers convicts you of a crime which was democratically passed by a legislature, versus a lone gunman who feels he is the judge, jury, and executioner.
    - mrbungie 2y ago
      The point here is that "democratically passed legislature" is not at people's service.
      - xyzzy4747 2y ago
        It's the least bad system.
        OutOfHere 2y ago
        It's legalized corruption to the max. It's the worst implementation of the least bad system.
        xyzzy4747 2y ago
        If the U.S. is leading the world's economy with high standards of living, maybe it is only a bad implementation in some aspects but not all.
      - analog31 2y ago
        An elected legislature is a pipe dream in a country with gerrymandering.
        SauciestGNU 2y ago
        Forget gerrymandering, a representative government is impossible as long as the Senate still gives the same weight to the 15 people in North Dakota as it does the 40 million in California.
    - tossandthrow 2y ago
      Why? Apparently something excused murder in the death row case? So expressing the sentiment that nothiong excuses murder and still having a death row is just I congruent and wrong.
      - xyzzy4747 2y ago
        In the death row case, the capital punishment isn't murder if you use classic definitions. If you change the definitions then it's only murder if you equate all homicide to murder. And yes, both the will of the people and tradition can justify capital punishment.
        tossandthrow 2y ago
        That's fair. And in that vein the current killing of the ceo can not rightfully be deemed a murder as no one have been convicted of such. But then again, the society apparently defines the quality of a killing - only future history will tell if this is a murder, and thst can go back and forth a lot depending on public sentiment.
    - mdanger007 2y ago
      America is the land of stand your ground laws in which a citizen may legally take a life if they feel endangered. Let's not forget the 1000 or so police kill every year.
    - foul 2y ago
      It's justified when the committee is large enough and regulated enough?
  - deleted 2y ago
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  - jimbokun 2y ago
    I understand what you're saying. But a murder carried out by a random citizen is still worse than a death sentence after a fair trial and convicted by a jury of your peers.
    - tossandthrow 2y ago
      It was not the justification of murder I was talking about. Simply the fact that murder as a solution is absolutely accepted in the US.
      - tedivm 2y ago
        Murder isn't the same as homicide. By definition the death penalty isn't murder, because it's state sanctioned. Self defense, another example of legal killing, also isn't murder and most people who are against murder would consider a death in self defense to be justified and not murder.
        psychoslave 2y ago
        Self defense can give mitigating circumstances in some legal systems, but it’s not an ethical joker to kill whoever we self-decreed feels as representing a threat. For example, we can go into treacherous schemes that pushes our neighbors into paths where the only obvious option they can still perceive as a way to escape our shenanigans is an attempt to kill us, and as they come with this very real intention to kill us, press the button we had prepared to trigger some mortal trap.
      - philipov 2y ago
        When all the acceptable solutions are taken off the table, people start turning to unacceptable solutions. It's not good, because the erosion of social institutions will worsen the situation for everyone, but the only way to deal with this is to put the acceptable solutions back on the table. If we don't want to live and die through the inevitable consequences, our government needs to stop the corporate abuse of power that has led to this.
    - boxed 2y ago
  - TimTheTinker 2y ago
    In the 20th century, I think the death sentence was only ever applied for first-degree murder and for treason. A claim denial that results in denial of life-saving treatment could never be counted as either of those charges.
    - boxed 2y ago
      > A claim denial that results in denial of life-saving treatment could never be counted as either of those charges. First-degree murder is when you willingly, and with forethought, plans and carries out the killing of a human. Which seems to me to be 100% what you described.
      - seneca 2y ago
        Denying a claim can not kill someone. Disease and injury killing a person. Claim denial prevents financial support for intervention in resolving a disease or injury. That is not the same thing, and equivocating them is sophistry.
        wat10000 2y ago
        I’d say that not equivocating them is sophistry. In both cases, someone takes a deliberate action that they know will result in an innocent person’s death. I fail to see why the exact mechanism should be so important.
        kstrauser 2y ago
        If you’re shot, and I pull up a chair and watch you die without saying a word or helping in any way, especially if I get paid extra for refusing, I’m not sure if I’d call it murder, exactly, but I bet your family and friends would describe me as a killer.
        harimau777 2y ago
        Pulling a trigger can not kill someone. Bullets kill people. /s
  - joejohnson 2y ago
    And which is currently fighting multiple wars around the world, or justifying support of many proxy wars which are killing thousands daily.
    - drweevil 2y ago
      This. The cognitive dissonance is jarring. And no "that's different!" is no argument. Like it or not, our government leads by example. And the example is not a good one.
  - seneca 2y ago
    The act of killing a human being is not inherently murder. It specifically communicates an unlawful killing, which the death penalty inherently is not.
  - athenot 2y ago
    This is because the US is not one homogenous system of thought, but rather a mosaic of people with differing views. (This goes for any other country or population for that matter.) A more constructive observation would be to consider the overlap in groups of people who (1) hold that murder is indefensible in any case, and (2) hold that death sentences are appropriate for crimes. While not sharing that view myself, I could think of a few factors that may lead others to espouse it, such as: - an implicit trust in authority and deterrents (follow rule, "or else"); - feeling of being mostly immune to errors in the justice system ("this would never happen to me"); - a propensity to desire revenge but only when it pertains to "others" ("I'm a good person, we must punish the bad people")...
  - ahupp 2y ago
    Murder is by definition an unlawful homicide. This isn’t just pedantry; it’s the most parsimonious explanation for why someone would support the death penalty and object to something like the assassination.
    - tossandthrow 2y ago
      It becomes pedantry of the law is not right. Eg. If the law is based on an oligarchy over a democracy.
      - psychoslave 2y ago
        Until the day we can point to a country that implements a direct democracy with a fair way to obtain citizenship for whoever is involved in its society, all laws will always remain a tool of a minority to arbitrarily rule a majority. The concern is not whether laws are rights or wrongs, but which privileges and which hurts they reinforce for which classes in the society where the national myth is eager to present them as the applied rules.
        Dracophoenix 2y ago
        > Until the day we can point to a country that implements a direct democracy with a fair way to obtain citizenship for whoever is involved in its society, all laws will always remain a tool of a minority to arbitrarily rule a majority. There's Switzerland.
        psychoslave 2y ago
        Switzerland definitely shows interesting political paths, they nonetheless don’t pretend to be a direct democracy. https://www.swissinfo.ch/eng/democracy/swiss-democracy-in-an-international-context_the-perfect-democracy-does-not-exist-not-even-in-switzerland/45578888 https://www.swissinfo.ch/eng/democracy/swiss-democracy-in-an...
        2y ago
  - pessimizer 2y ago
    Not to mention that we happily do extrajudicial assassinations outside of our borders, and the news falls all over themselves to celebrate them. Everybody knows that plenty excuses a murder, we live in murderous states and in murderous times. The question is whether this murder is excusable, and one's opinion on it is probably dependent on whether one wishes they had that guy's job. Most people wouldn't do it for any price, but plenty would.
- mrbluecoat 2y ago
  If a cancer patient is denied a claim for life-saving medication because they're 'not sick enough' then dies, is it murder?
  - JohnFen 2y ago
    Yes, in my opinion. It's homicide at the very least.
- carlgreene 2y ago
  I'm trying to figure out if these deaths caused by insurance denials could actually be considered murder. I think they would definitely qualify as being premeditated, but can you consider them "killing"? They are causing death due to omission of expected care, but can the omission of something like medical care be considered the cause of death?
  - GiorgioG 2y ago
    Ask yourself this question again when it's your partner/parent/child in the casket.
  - ziddoap 2y ago
    I am not a lawyer, but I would assume that death due to omission of expected care fits pretty neatly under "negligent homicide".
    - tjpnz 2y ago
      Duty of care?
      - bee_rider 2y ago
        It is weird—I would expect only the folks who make decisions as to which procedures are medically necessary (just doctors ideally) to have a duty of care. But insurance companies are bouncing back procedures are not medically necessary, so maybe we’re due for a re-adjustment in the expectations as to who has that duty. It is surprising if insurance companies what to sign themselves up for this sort of obligation. But obviously they’ll take all the privileges of the decision making process if we don’t also hold them to the responsibilities.
  - psbp 2y ago
    There is legal precedent establishing healthcare providers' obligations in life-threatening situations. The same moral responsibility should exist when insurers deny lifesaving care, it's just hidden behind bureaucracy.
  - 2y ago
- technothrasher 2y ago
  Well, if a killing is ethically justified, it isn't murder. So yes, they're at least begging the question with that statement for sure.
  - ziddoap 2y ago
    >Well, if a killing is ethically justified, it isn't murder. Are you saying this as an opinion, or is this an established thing? I thought murder was an "unlawful killing without justification or valid excuse" (paraphrased from Wikipedia), whether one finds it ethical or not is sort of beside the point. Especially because there is no objectively correct ethics. But, I'm not a lawyer, this is just my understanding.
    - bombcar 2y ago
      I would say you have to be careful and specific - as "murder" is usually the domain of the law and "ethically justified* is the domain of ethics. It's quite easy to come up with situations where the law declares a killing as unequivocally murder yet everyone agrees it was ethically justified. The opposite can happen too.
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- amarcheschi 2y ago
  But now you have another ceo. I'm not suggesting that to fix the issue you would need to - inaudible - again and again
- lopalimpa 2y ago
  "Murdering a murderer to save many innocents could be considered ethical by some?" This is a heavy statement. More I read, heavy it gets. Kill people it never the answer. The ideia that "I" have the power is weak. People, together, have power, however they don't know what to do. In his case the easiest way to win is pressuring the government, with the people, for clear changes.
  - amarcheschi 2y ago
    Killing people is not the answer but somehow another Healthcare company backtracked on not covering anymore long anesthesia. Perhaps n = 1 is too low of a value? We should research this field more, some people may die but it's a chance I'm willing to take
    - wk_end 2y ago
      Although it should be noted that the anesthesia thing was dumb and bad. So maybe policy by mob justice isn’t a good thing. https://www.vox.com/policy/390031/anthem-blue-cross-blue-shield-anesthesia-limits-insurance https://www.vox.com/policy/390031/anthem-blue-cross-blue-shi...
      - amarcheschi 2y ago
        the article cites a study that says: "5% of practitioners reported anesthesia times greater in total than what would be expected across university, community, and specialty hospitals. Furthermore, it was found that the greatest differences in expected anesthesia times were in specialty hospitals compared with university hospitals.8 However, the authors have stressed that their findings should not be interpreted to indicate fraud because fraud involves intent, which could not be determined. Because this study was a retrospective study, the authors could not rule out the alternative but unlikely explanation that the practitioners could be rounding down. The reason for caution by the authors is that the CMS has differentiated fraud from abuse by emphasizing that fraud is intentional, whereas abuse is the result of poor medical practices.2 This differentiation is important because sometimes the rounding in digits ending in 0 or 5 minutes in anesthesia time is part of the organization culture of operating rooms in which rounding is performed systematically by the operation room circulating nurse along with the anesthesia practitioner. Sun et al8 recognized this issue as being related to institutional factors, which was one of the reasons they performed a 2-step regression analysis; long anomalous times were not sufficient to establish inappropriate discretion.8" So Anthem based on the article it might be overpaying for at worst 5% of the operations BUT the big but is that in some hospitals it is routine to round digits. So paying less workers for some rounding operations? It doesn't look as bad to me. It might be because of reasons, or might be due to media backslash. I think it's safe to assume we definitely need more research into healthcare companies rules after healthcare companies ceo related killing
- christophilus 2y ago
  Executing a murderer can be defended. “Industry malfeasance” leading to death is indefensible.
- jimbokun 2y ago
  You would need to prove that murdering a health care CEO will save many innocents, first.
  - forgetfreeman 2y ago
    K. So step 1. murder health insurance CEO (no healthcare involved there), check. Step 2. watch UnitedHealth's refusal rates closely, ongoing.
    - walls 2y ago
      It got Anthem to immediately reverse a horrible decision: https://www.nbcnews.com/health/health-care/anthem-blue-cross-blue-shield-time-limits-anesthesia-surgery-rcna183035 https://www.nbcnews.com/health/health-care/anthem-blue-cross... Violence works.
- euroderf 2y ago
  Zeitgeist graffiti, anyone? "When they wage war, we wage war."
- aaomidi 2y ago
  Consent has been manufactured that if you kill through indirect means then you’re good to go!
  - OutOfHere 2y ago
    Yes, mass media exists to manufacturer consent, and this shooter forced their hand.
- oulipo 2y ago
  Also without this murder, we could imagine that the NYPost would have never written this article to alert on the malfeasance of healthcare providers... Why wouldn't they do their part as a news org, and why did they wait for the murder to publish such an article, if that murder was not "needed" for things to change, then?
- JohnFen 2y ago
  Even if you accept that, it still doesn't excuse it being done by companies or individuals. The point is also orthogonal to what the insurance industry does.
- LiquidSky 2y ago
  You can't just shoot people and kill them in the street! That's barbaric! You need to do it from behind a desk through a corporate bureaucracy like a civilized person.
- refurb 2y ago
  One issue is that if denying medical care is murder then every healthcare system is guilty. In the US it’s insurance companies (or the government through Medicare or Medicaid) but in the UK it’s NICE, in Canada it’s CADTH and the provincial health authorities. Since there are finite resources spent on healthcare, trade offs are made all the time. If spending $10M on treatment A saved 10,000 lives and $10M on treatment B saves 1,000 lives, then treatment A gets funded and treatment B doesn’t. The difference is that patients in the US have an up close and personal experience with denial. In Canada and the UK they don’t because doctors knows what is covered and what isn’t so never bring up life saving options if they aren’t paid for. In rare circumstances like cystic fibrosis in the UK, patients become aware that they are being denied a life saving drug and protest, but generally it’s pretty rare because patients just don’t know the option exists.
  - OutOfHere 2y ago
    Your argument is completely bogus for multiple reasons. Firstly, people are paying here for insurance, a lot. Secondly, it's the FDA's job to approve treatments which it does. Thirdly, we do not have a uniform privatized determination across the country of what is approvable or not by insurance companies. They deny numerous legitimate treatments and procedures at their whim.
    - refurb 2y ago
      I’m not sure how that makes my argument bogus. Plenty of treatments are denied in other countries. Not to mention most other countries have private insurance layered on top of public and it’s the same issue - private insurers denying a treatment through their own process. If US insurers are guilty of murder than most of the worlds insurers are too.
  - wat10000 2y ago
    The difference is that patients in the US are being denied by people lining their own pockets with the savings. In sane countries, there’s at least some basis of trying to do the most good with the resources at hand, which sometimes means denying care for person A because those resources would be better spent on person B. With private insurers in the US, it means denying care for person A because they think they can get away with it and it will increase their profits.
- lubujackson 2y ago
  I guess we aren't going back in time to kill Hitler any more then? The media pearl-clutching is extremely heavy this time around, painting Luigi as an unhinged lunatic and all the rest. It feels incongruent and purposefully dismissive to equate this to something like the Oklahoma City Bombing.
- kyleblarson 2y ago
  I hate the way the press and seemingly most people are approaching this but am completely unsurprised: "You are either a heathen who supports murder or you are a virtuous supporter of the people and this man deserved to die." Two things can be correct at the same time. 1) Murder is not OK. 2) The insurance industry is completely broken as it incentivizes terrible behavior and this CEO was a scumbag who perpetuated this behavior while possibly insider trading.
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PittleyDunkin 2y ago
"No industry malfeasance could ever excuse murder." AND YET
- actionfromafar 2y ago
  If there wasn't a recent murder of a CEO, that line could be taken as directed towards insurers.
  - kstrauser 2y ago
    That is, the ones who actually convene the “death panels” some politicians pearl-clutched about.
- staticautomatic 2y ago
  Of course! But maybe …
- SauciestGNU 2y ago
  Of course not legally, but I think there's a philosophical exercise here for ethicists to debate the boundaries and efficacy of community self defense.
edwinjm 2y ago
It's time the US realizes how bad its medical system is.
- weberer 2y ago
  Everybody knows how bad it is. Everyone wants to change it. But I don't see how it can change as long as both parties are on the payroll https://www.opensecrets.org/orgs/unitedhealth-group/recipients?id=D000000348 https://www.opensecrets.org/orgs/unitedhealth-group/recipien...
  - tboyd47 2y ago
    It can change once Americans break their addiction to "health care."
    - dgfitz 2y ago
      Huh? I don't know a single person who ENJOYS going to the doctor, or needing medical treatment. What are you on about?
      - tboyd47 2y ago
        There are lots of people who get freaked out and go to the hospital for every little thing. We used to have a term for that: "hypochondriac." Now it's become socially acceptable, so you don't hear the term as much. Everyone knows Americans pay the most for medical treatment, but the life expectancy is not that high. If you know your behavior isn't good for you, but you can't stop yourself, well, that's an addiction.
        AdmiralAsshat 2y ago
        On the contrary, if the healthcare system in the US weren't such shit, more people would probably be going to primary care doctors and getting Preventative Care before it becomes an emergency, and requires a trip to the hospital. But many people don't, because visiting a primary care / walk-in clinic / urgent care is expensive, so they ignore it, until it becomes un-ignorable. Now it's an ER visit.
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Bengalilol 2y ago
IDK. What puzzles me here is that a NYPost article can be trending on HN.
- mancerayder 2y ago
  As opposed to a Medium blog? If source material and reputation is the concern. Many online papers have pay walls. There are similar articles criticizing health care denials from other sources, feel free to post them. They're not all discussion material nor even readable. And if the writer did a poor job, poke a hole in the argument.
JohnFen 2y ago
That has to be the worst kept dirty secret in the history of dirty secrets.
garciasn 2y ago
I was just denied a colonoscopy as not medically necessary by UHC, coincidentally three days before their CEO was killed, because they don't want me to have anesthesia to do it; they argue I should be awake. When I called to refute the denial, which was denied, I asked them to find the person, if it was a person, who denied it and shove a tube up their ass without anesthesia and then reassess whether it's medically necessary to have a colonoscopy without it. I'm 45. Colonoscopies are a thing. I had a friend die at 52 two years ago after he was diagnosed with stage IV during his first colonoscopy. I spent many of his last days watching him struggle to survive; I don't want that to happen to me just because UHC charges me $2000/month in premiums and denies basic service because they need to pay their executives too much money.
- bschmidt11 2y ago
  [flagged]
- tommilburn 2y ago
  that's insane! everyone should get a colonoscopy, and i believe they're recommending them for people over 40 if you meet certain risk categories signed up for an account with my real name to share a doc i've been working on for a long, long time now - i've had UC since high school, and have written an extensive guide of what i've learned, if it helps you or anyone else you know who might be getting scoped: https://docs.google.com/document/d/1bTW2rdF744woSPpFsUeSaFYauthOKQSyW4_myXUypig/edit?tab=t.0 https://docs.google.com/document/d/1bTW2rdF744woSPpFsUeSaFYa...
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  - hgomersall 2y ago
    It's estimated by CRUK there are 44,000 bowel cancer cases each year in the UK. Assuming only people over 40 get it, and that's about half the population, the incidence is something like 1 in 800 annually. The rate of "serious complications" for a colonoscopy is about 1 in 300. Given those numbers, how often should everyone get a colonoscopy? That's before we get on to the potential harm from a false diagnosis (which is much higher without additional priors). Yes, absolutely people should pay attention to their bowels and get a colonoscopy when it's indicated. Let's not all rush to get one though unless there's some reason for it.
Invictus0 2y ago
Not saying this article is wrong but it is clearly written in a sensational style and does not belong on HN.
- 65 2y ago
  The one sentence paragraph writing style drives me nuts.
toast0 2y ago
I think we need more thorough analysis. Are the denied claims denied in error? The appeals success rate probably indicates that most of the appealed denied claims were denied in error... but appealed claims are a biased sample of denied claims, so it doesn't tell us much about the overall denied claims. In my experience, I've seen some denied claims, because the provider submitted a wrong code. Then the provider submits a new claim with the correct code and it goes through. Given the proliferation of plans, and their sometimes conflicting requirements on medicial coding, I could see that being a big driver of denials increasing over time. As well as a driver of increased administrative costs for providers and insurance companies.
- OutOfHere 2y ago
  That's just code gaming. It's not necessarily an error. Also, numerous legitimate legitimate claims are denied no matter their code.
  - toast0 2y ago
    I don't doubt that numerous doubly legitimate claims are denied. What I want is a sense of what the breakdown of the denied claims. Ex: company sends a list of all denied claims. Auditor picks 100 randomly, gets the files for each and researches those denials to classify the denial as reasonable or not and whatever other categories apply.
- timmytokyo 2y ago
  "A key congressional committee asked insurance giant Cigna on Tuesday to provide corporate documents so that lawmakers can examine the company’s practice of denying health care claims without ever opening a patient file." https://www.propublica.org/article/cigna-health-insurance-denials-pxdx-congress-investigation#:~:text=The%20letter%20follows%20an%20investigation,PXDX%20system%2C%20spending%20an%20average https://www.propublica.org/article/cigna-health-insurance-de...
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dheera 2y ago
Just leaving this here for reference: In 2022 I was denied full insurance payment of a routine, preventative echocardiogram at Stanford Healthcare to monitor my heart issues. I was balance billed $5000+. The insurance company was HealthNet. The policy clearly indicated full coverage of preventative procedures, without a deductible. They said they did not recognize the procedure as preventative. Fuck them, I know better about what's preventative and what's not than them. I argued the shit out of it, dozens of e-mails, hours of phone calls, and it was eventually sent to debt collectors. I wrote back to the debt collectors that it wasn't my debt and to stop contacting me. I reported it to a couple of government agencies as well to give them more headaches. I did not pay. In 2024 it was written off as uncollectible. (a) Use a virtual mailbox with your health provider so that they don't send debt collectors to your residence. Do not give them your residential address. (b) Use a virtual phone number with your health provider so that the debt collectors can't call you. Their only option will be mail and that leaves a paper trail which you DO want. NEVER communicate with a debt collector by phone. (c) Freeze your credit reports with all 3 bureaus so that they cannot use your mailing address to find your residential address. (d) If they do somehow find your residential address, do NOT answer. Only communicate by mail. Disclaimer: IANAL, account of personal experience only
- AdmiralAsshat 2y ago
  That might have gotten them to stop bugging you, but I imagine your credit score still took a hit?
  - dheera 2y ago
    It didn't show up on my credit score at all. I also wasn't too concerned about that because (a) I believe medical debts don't affect credit scores for a long time. (b) I believe medical debts are required to have complete erasure from a credit report if cleared so if I actually needed my credit score to buy a house or whatever I could take the $5K hit to restore the credit score at that time. (c) I sent them a formal letter disputing the debt, which I assumed means they can't just take it to the credit agency, they'd have to go to court with me first. (Again IANAL, I don't know how accurate this is.) In any case I was mentally prepared to spend $10K on lawyers and court and give them a absolute hell of a time than pay $5K to pay for healthcare I shouldn't need to pay for. I made it VERY CLEAR to the debt collectors that I was ready to pay for lawyers. (d) For the forseeable future I don't think I need my credit score for anything. I don't plan to borrow money.
Miner49er 2y ago
It shouldn't even be legal for health insurance providers to deny claims. It's essentially them practicing medicine without a license, because they're making calls about what healthcare a person needs or doesn't need, only a person's doctor(s) should be able to make those decisions.
- kstrauser 2y ago
  That’s the crux of it. I didn’t visit with any of my insurer’s staff, like I did with my own doctor. How are they making treatment decisions without ever having seen the patient?
- dboreham 2y ago
  Otoh some medical providers like to over bill and over treat.
  - drewbug01 2y ago
    > Otoh some medical providers like to over bill and over treat. This is true to some extent, but the share of medical providers that over-bill and over-treat really doesn't justify the way the insurance industry does business. It's a false equivalence.
  - kstrauser 2y ago
    Crack down on them, but don’t use it to justify denying healthcare to patients.
  - harimau777 2y ago
    It seems to me that should then be handled by the legal system or perhaps the licensing boards. That is to say, the insurance companies should be forbidden from denying coverage and if they believe that something is going on then they can alert the police or take the doctor to court.
    - antisthenes 2y ago
      Will never happen. Doctors have strong lobbying of their own and they really like their second vacation homes and Porsches.
drweevil 2y ago
>"An appeal means coaxing your doctor and staff to spend hours filling out forms and making repeated phone calls to joust with an insurance company employee." The hospital where I receive my cancer treatments once told me "don't worry, our Denial Team is handling this." They have a Denial Team. That is to say, insurance companies are imposing cost overheads on providers and patients due to their illegitimate profit boosting tactics. And our government can't be bothered to enforce the ACA's basic requirement to track and report denial rates. >"No industry malfeasance could ever excuse murder. "Period." And yet, that's what it took for our media to start reporting on this? We have some real problems in this country, and a corporate news media asleep at the switch, or at worst complicit, is one of the most serious.
- dogboat 2y ago
  "industry malfeasance" is 1984-esque lanuage. IED airbags, HIV injections, babies without limbs, etc. are industry malfesance. So the phrase implies: No acts of corporate greed including profiting by killing people could ever excuse murder.
codegeek 2y ago
My solution to this mess: - Health "Insurance" middleman mafia should not be the default b/w me and my doctor - Health Insurance should only exisit for Catastrophic events (big surgery, cancer etc) - Get rid of the regular Premiums, CoPays, Deductible, CoInsurnace, In network/Out network Bullshit. - For catastrophic events, we pay a premium (much smaller than now) - All hospitals and Doctors must offer an advertised/displayed Cash Price. No exceptions. Fine heavily if they hide - Let me pay cash for a regular doc visit. - Govt can subsidize for poor people (exdtension to medicare etc ??) That's it. Problem Solved. This will remove so much BS, middleman stuff, overhead and with a competitive market, prices will drop significantly. Doctors will be happy not dealing with Insurance for everything. Tell me why I am wrong.
- __m 2y ago
  People will probably avoid going to the doctor if they have to pay cash, missing the opportunity to detect the big things early.
  - codegeek 2y ago
    I would argue that people already dread going to the doctor because you still have to deal with all the insurance garbage. Remember that even with a copay, you still could get a bill after the visit depending on deductible.
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i_love_retros 2y ago
How do we stop this?
lapcat 2y ago
Worth noting: neither major Presidential candidate, nor the news media, made health care a focus of the recent election. The issue was almost ignored. And neither major political party offers much: the Democratic establishment will defend the Affordable Care Act to the death (literally in this case), despite the fact that it's not particularly affordable, becoming more unaffordable over time, and it continues to enshrine and subsizide the ruthless for-profit insurance companies. On the other hand, the Republicans paint any kind of government involvement in health care as "Communist", despite the fact that the entire rest of the civilized world have more efficient, effective, and compassionate health care systems heavily regulated by the government. I think it's a sign of deep American corruption that we can't even have this public debate without a salacious murder occurring.
- lofenfew 2y ago
  The affordable care act is the most reasonable path from the current american system to a system on par with other first world countries. This especially given the sort of republican opposition it's liable to face. It's current form is due in substantial part to the republicans gutting it, so you can't really blame the dems for it not working very well.
  - lapcat 2y ago
    The Affordable Care Act received precisely zero Republican votes in Congress. It was entirely a Democratic product.
    - tristor 2y ago
      John McCain, a Republican, famously voted to save the ACA during a time when the Republicans had a Congressional majority, even though his health was failing. He died shortly after the vote.
      - lapcat 2y ago
        I was talking about the 2010 passage of the ACA, not the 2017 repeal attempt. The 2010 legislation was written by Democrats. Moreover, since as you mention, the Republican repeal attempt failed, it can't truly be said that Republicans have "gutted" the ACA. It is true that for some (dumb) reason the ACA gave significant power to the states, which has been abused by Republican governors and legislatures, but that was entirely the choice of the Democrats who wrote the ACA.
onionisafruit 2y ago
She says that you can’t find denial rates for specific providers then she gives denial rates for specific providers. I’m not sure if she cited a source. I’m curious where her data comes from.
amarcheschi 2y ago
I don't know what happened but this super duper upvoted post disappeared from the home of hn. perhaps moderators temporarily shadow content that is upvoted too much? Or else?
- deleted 2y ago
  [deleted]
- techdmn 2y ago
  Also curious about this. Several other posts of similar age and with fewer points are in top spots on the front page. This post is still gathering comments, but seems to be hidden.
siliconc0w 2y ago
We should just have single payer if we have to constantly police these companies.
foundart 2y ago
This is an opinion piece. Its main claim is that the ACA requires denial rates to be available to consumers but they aren't. Additionally, it reports that denial rates have increased 10x in 10 years, based on the following chain: - "UnitedHealthcare nixed 1.1%, Humana 1.9%, Aetna 1.5% in 2013, per the American Medical Association." - "By 2022, major insurers were refusing to pay, on average, 15% of claims, according to a national survey of hospitals and health-care providers by Premier, an insurance consultant." - "The figure continues to shoot upward, with some companies today denying almost _half_ of all claims, according to researchers at the Kaiser Family Foundation." Furthermore, "few people appeal, but of those that do 41% obtain a reversal", which suggests the denials may be unfair. I certainly would like to know the denial rates when selecting an insurance provider. As the article says, "You aren't really insured if your insurer can deny valid claims with impunity." Given that the ACA requires this information be provided, it certainly ought to be provided. Then we'd have a much clearer picture. It's an opinion piece on a news site known for inflammatory articles but it reports some interesting information. It would be much nicer if it included references to the research it's based on, but it seems pretty reasonable to me.
- leereeves 2y ago
  Excellent summary. I'd like to address the denials in particular. As the article says: "No industry malfeasance could ever excuse murder." With that in mind, we should remember that every death that happens because a valid lifesaving claim was denied is a kind of murder, and no amount of fraud could ever excuse denying valid lifesaving claims. The stakes are too high: all claims should be approved, then adjudicated later. Fraud should of course be punished severely (with prison, not merely returning the money), but no one should die to protect insurance companies from fraud.
  - nradov 2y ago
    I think you're mixing up terminology here. When a claim is submitted the care (lifesaving or otherwise) was already delivered. You might be thinking of prior authorization, where a provider asks an insurer for advance approval before delivering care. If a payer denies a prior authorization request then some providers will refuse to deliver care unless the patient has another form of payment. Fraud is only a small part of the systemic problems. There is an enormous amount of waste and abuse by providers who deliver treatments that are ineffective or unnecessary or excessively expensive. The dominant fee-for-service financial model incentivizes over treatment. We can argue about where to draw the line but payers (whether commercial or government) have to push back on this to keep the system from collapsing. Healthcare is already ~20% of the US economy. It can't continue expanding, we simply don't have the resources to pay any more. Every other country rations care in some way; no country delivers unlimited lifesaving care to everyone. https://peterattiamd.com/saumsutaria/ https://peterattiamd.com/saumsutaria/ https://www.npr.org/sections/health-shots/2019/10/22/767376340/the-price-we-pay-argues-rising-health-care-costs-undermine-public-trust-in-medic https://www.npr.org/sections/health-shots/2019/10/22/7673763...
johnohara 2y ago
In December 2021, the American Hospital Association issued the following statement regarding United Healthcare's plans to closely scrutinize medical claims for ER visits. [0] UHC subsequently reversed itself and delayed the plan for 6 months. That was in 2021-2022. It's now 2024-2025. Around that time many insurers, not just UHC, began implementing AI-assisted claims adjudication. It was a bumpy ride with a steep learning curve and probably took a couple of years to fine-tune the algorithms and learning models. Especially as the Covid-19 claims tsunami subsides. No matter tho', every claim paid is considered a loss by insurers. Every claim denied is considered a small step towards mitigating those losses. In the U.S., medical reimbursement is a push and shove, shove and push battle fought inch by inch with high-speed data systems. It has been that way for a long time. [0] https://www.aha.org/special-bulletin/2021-12-29-aha-expresses-concern-unitedhealthcares-coverage-criteria-change https://www.aha.org/special-bulletin/2021-12-29-aha-expresse...
- nradov 2y ago
  That's simply not how the system works. For the most part, medical insurers no longer provide much real "insurance" in the sense of bearing risk. Instead they mostly act as administrators for employer self-funded health plans. Since insurers are subject to an 85% minimum medical loss ratio, every paid claim is actually a gain because they get to take up to 15% from a larger revenue stream. The majority of the pressure to tighten coverage rules actually comes from those large employers since they're the ones ultimately paying the bills. https://www.cms.gov/marketplace/private-health-insurance/medical-loss-ratio https://www.cms.gov/marketplace/private-health-insurance/med... If anyone wants to see real reform then eliminating employer sponsored health plans is one potential way to get the incentives more properly aligned.
ethbr1 2y ago
There's an easy solution to this that the Federal Employee Program (aka FEP) [0] uses -- regular, external accuracy audits. The relevant metric to customers isn't "What percentage of claims are denied?" given the substantial amounts of medical claim fraud. It's "What percentage of claims are denied... that should have been approved?" So you regularly audit a random sampling of denials, publish the results of that audit transparently, and provide a financial incentive for insurers to keep their numbers below a certain threshold. It's worked pretty well for FEP -- to the extent that FEP insurers typically have segregated operations from the rest of the company and do much better on denial accuracy and other metrics. [0] https://en.m.wikipedia.org/wiki/Federal_Employees_Health_Benefits_Program https://en.m.wikipedia.org/wiki/Federal_Employees_Health_Ben...
- adleyjulian 2y ago
  It's a question of what we want to measure. There's a metric that represents how much a claimant sees in unexpected costs due to denied claims vs impact on care from the insurer. A denied prior auth results in no unexpected costs but perhaps a change or delay in care. A denied claim to an in network hospital may result in the provider losing revenue but nothing for the claimant.
- Eddy_Viscosity2 2y ago
  The auditors would either be captured or rendered powerless in short order. There is a great deal of money that can be used for effective lobbying.
  - ethbr1 2y ago
    Hasn't in the FEP program. Mostly because there's no incentive: doing so helps your competitors as much as you. And it's more profitable to invest those dollars in hitting KPIs.
  - SauciestGNU 2y ago
    Wrongful care denial should be considered a serious felony on par with assault with intent to do grave bodily harm. It should be a veil piercing crime that exposes every insurance company employee involved in denial to personal legal jeopardy should they wrongly deny claims. Reasons for denials must should be required to be extremely detailed and provided to the institutions requesting coverage. Upon receiving a denial, the health care institution should be able to evaluate the denial for validity and choose to refer the denial to local prosecuting attorneys if the denial is medically unsound.
mancerayder 2y ago
Let the health insurance companies deny claims. But then let the medical providers duke it out behind the scenes! Leave patients alone and don't send them bills six months later.
- refurb 2y ago
  This is actually key. The problem today is the insurers, hospitals and doctors put the patients at the center of the fight. Insurance denied? You pay patient. Insurance didn’t pay doctor enough? You pay patient. Hospital not in network? You pay patient. I think patients would see it as an improvement if hospital said upfront to go somewhere else as insurance won’t pay. If they knew insurance would pay at the right hospital than it would be better than today’s situation.
- dogboat 2y ago
  Assuming you are a coder lets see how that works for you.. Someone comes to you saying they need a website. You say "absolutely ... clearly you need one!". So you build it. The decision to pay you however comes from some 3rd party who says "denied". Now the customer keeps their site and you don't get paid. Will you stay in this coding business? The real solution is a public health system. Which has issues (apply queuing theory, because you will have to wait for the limited resources you are niw denied) overall it is better though since it can in theory be optimized as a whole.
antisthenes 2y ago
They deny claims. I deny paying my medical bills.
benterix 2y ago
It's insane that someone needs to die for a serious discussion about it to take place.
caeril 2y ago
Denial policy should be very very simple: If you're seeking coverage for lung cancer, but you chose to smoke, denied. If you're seeking coverage for type II diabetes, but you weigh 400lbs, denied. If you're seeking coverage for cancer because you got unlucky with a cosmic ray incident on your DNA, approved. If you're seeking coverage for a liver transplant because you refused to put down the bottle, denied. If you're seeking coverage for injuries from an auto accident that was not your fault, approved. I will NEVER understand why this type of blanket policy is so controversial. Cover bad luck, do NOT cover personal choices. It will fix not only costs, but the moral hazard endemic to the current system. Or, AT THE VERY LEAST, allow prejudicial adjustments to premiums for fatties, smokers, and alcoholics.
byecancer21 2y ago
The German state is also helping public health insurers hide their dirty secret: in hundreds of thousands of cases, denials were legally flawed and the cases have to be reviewed. They refuse to do so on the behest of politics as a small number of cases will turn out to be intentionally negligent homicides caused by public officials. A site properly presenting the facts is due for launch in the lead up to Germany's upcoming federal election. Until then, you can find a teaser here: https://de.wickepedia.org https://de.wickepedia.org Any claim related to outpatient treatment which outside the ordinary requires prior approval there. You cannot opt to pay in advance and seek reimbursement later. In the state of Bavaria the doctors at a government agency have been practicing without a medical license going back many years because their supervisor let this slide. I discovered her problem randomly in the course of litigation and it impacts probably a million case. The person responsible for her staff of hundreds lacking a current medical license was later hired to lead the qualifications department at the medical board. That is, after I got her fired from her position and then from a job at a hospital (a felonious psychologist is unacceptable risk for patients). Politics would prefer to see her problem covered up.
beej71 2y ago
Do these numbers include denials when a provider bills more than the negotiated rate? I see this happen all the time with my insurer.
EasyMark 2y ago
One thing that will help greatly is to regulate hospitals into having an umbrella of "services" that allows "private" operators BUT those operators have to be covered by any insurance that wants to work with the hospital rather than these 3 nurses in one pay center, this surgeon in another, assistant surgeons in a third, and the anesthesiologist so far out of network he laughs and isn't part of any HMO, PPO or anything else.

150 points by mancerayder 2y ago

"No industry malfeasance could ever excuse murder. Period." Murdering a murderer to save many innocents could be considered ethical by some? (Not saying that's the case here, but nypost made an interesting categorical statement.)

no_wizard 2y ago
Given the NY Posts leanings I’m not surprised they walked that line by putting it in there. Media seems to be on an agenda setting tear to disavow the murder, but I think it’s a frankly boot licking response to what is going on here. I think this spooked a lot of executives (re: “elites” if you will) and there is pressure to ignore the nuance of what the murder means to people and why it isn’t the same as say, stabbing a tech CEO in SF like what happened last year
tossandthrow 2y ago
It is funny that the sentiment that nothing excuses a murder is being circulated in the US - a country that still carried out death sentences.
- xyzzy4747 2y ago
  It's a little different when a jury of your peers convicts you of a crime which was democratically passed by a legislature, versus a lone gunman who feels he is the judge, jury, and executioner.
  - mrbungie 2y ago
    The point here is that "democratically passed legislature" is not at people's service.
    - xyzzy4747 2y ago
      It's the least bad system.
      - OutOfHere 2y ago
        It's legalized corruption to the max. It's the worst implementation of the least bad system.
        xyzzy4747 2y ago
        If the U.S. is leading the world's economy with high standards of living, maybe it is only a bad implementation in some aspects but not all.
    - analog31 2y ago
      An elected legislature is a pipe dream in a country with gerrymandering.
      - SauciestGNU 2y ago
        Forget gerrymandering, a representative government is impossible as long as the Senate still gives the same weight to the 15 people in North Dakota as it does the 40 million in California.
  - tossandthrow 2y ago
    Why? Apparently something excused murder in the death row case? So expressing the sentiment that nothiong excuses murder and still having a death row is just I congruent and wrong.
    - xyzzy4747 2y ago
      In the death row case, the capital punishment isn't murder if you use classic definitions. If you change the definitions then it's only murder if you equate all homicide to murder. And yes, both the will of the people and tradition can justify capital punishment.
      - tossandthrow 2y ago
        That's fair. And in that vein the current killing of the ceo can not rightfully be deemed a murder as no one have been convicted of such. But then again, the society apparently defines the quality of a killing - only future history will tell if this is a murder, and thst can go back and forth a lot depending on public sentiment.
  - mdanger007 2y ago
    America is the land of stand your ground laws in which a citizen may legally take a life if they feel endangered. Let's not forget the 1000 or so police kill every year.
  - foul 2y ago
    It's justified when the committee is large enough and regulated enough?
- deleted 2y ago
  [deleted]
- jimbokun 2y ago
  I understand what you're saying. But a murder carried out by a random citizen is still worse than a death sentence after a fair trial and convicted by a jury of your peers.
  - tossandthrow 2y ago
    It was not the justification of murder I was talking about. Simply the fact that murder as a solution is absolutely accepted in the US.
    - tedivm 2y ago
      Murder isn't the same as homicide. By definition the death penalty isn't murder, because it's state sanctioned. Self defense, another example of legal killing, also isn't murder and most people who are against murder would consider a death in self defense to be justified and not murder.
      - psychoslave 2y ago
        Self defense can give mitigating circumstances in some legal systems, but it’s not an ethical joker to kill whoever we self-decreed feels as representing a threat. For example, we can go into treacherous schemes that pushes our neighbors into paths where the only obvious option they can still perceive as a way to escape our shenanigans is an attempt to kill us, and as they come with this very real intention to kill us, press the button we had prepared to trigger some mortal trap.
    - philipov 2y ago
      When all the acceptable solutions are taken off the table, people start turning to unacceptable solutions. It's not good, because the erosion of social institutions will worsen the situation for everyone, but the only way to deal with this is to put the acceptable solutions back on the table. If we don't want to live and die through the inevitable consequences, our government needs to stop the corporate abuse of power that has led to this.
  - boxed 2y ago
- TimTheTinker 2y ago
  In the 20th century, I think the death sentence was only ever applied for first-degree murder and for treason. A claim denial that results in denial of life-saving treatment could never be counted as either of those charges.
  - boxed 2y ago
    > A claim denial that results in denial of life-saving treatment could never be counted as either of those charges. First-degree murder is when you willingly, and with forethought, plans and carries out the killing of a human. Which seems to me to be 100% what you described.
    - seneca 2y ago
      Denying a claim can not kill someone. Disease and injury killing a person. Claim denial prevents financial support for intervention in resolving a disease or injury. That is not the same thing, and equivocating them is sophistry.
      - wat10000 2y ago
        I’d say that not equivocating them is sophistry. In both cases, someone takes a deliberate action that they know will result in an innocent person’s death. I fail to see why the exact mechanism should be so important.
      - kstrauser 2y ago
        If you’re shot, and I pull up a chair and watch you die without saying a word or helping in any way, especially if I get paid extra for refusing, I’m not sure if I’d call it murder, exactly, but I bet your family and friends would describe me as a killer.
      - harimau777 2y ago
        Pulling a trigger can not kill someone. Bullets kill people. /s
- joejohnson 2y ago
  And which is currently fighting multiple wars around the world, or justifying support of many proxy wars which are killing thousands daily.
  - drweevil 2y ago
    This. The cognitive dissonance is jarring. And no "that's different!" is no argument. Like it or not, our government leads by example. And the example is not a good one.
- seneca 2y ago
  The act of killing a human being is not inherently murder. It specifically communicates an unlawful killing, which the death penalty inherently is not.
- athenot 2y ago
  This is because the US is not one homogenous system of thought, but rather a mosaic of people with differing views. (This goes for any other country or population for that matter.) A more constructive observation would be to consider the overlap in groups of people who (1) hold that murder is indefensible in any case, and (2) hold that death sentences are appropriate for crimes. While not sharing that view myself, I could think of a few factors that may lead others to espouse it, such as: - an implicit trust in authority and deterrents (follow rule, "or else"); - feeling of being mostly immune to errors in the justice system ("this would never happen to me"); - a propensity to desire revenge but only when it pertains to "others" ("I'm a good person, we must punish the bad people")...
- ahupp 2y ago
  Murder is by definition an unlawful homicide. This isn’t just pedantry; it’s the most parsimonious explanation for why someone would support the death penalty and object to something like the assassination.
  - tossandthrow 2y ago
    It becomes pedantry of the law is not right. Eg. If the law is based on an oligarchy over a democracy.
    - psychoslave 2y ago
      Until the day we can point to a country that implements a direct democracy with a fair way to obtain citizenship for whoever is involved in its society, all laws will always remain a tool of a minority to arbitrarily rule a majority. The concern is not whether laws are rights or wrongs, but which privileges and which hurts they reinforce for which classes in the society where the national myth is eager to present them as the applied rules.
      - Dracophoenix 2y ago
        > Until the day we can point to a country that implements a direct democracy with a fair way to obtain citizenship for whoever is involved in its society, all laws will always remain a tool of a minority to arbitrarily rule a majority. There's Switzerland.
        psychoslave 2y ago
        Switzerland definitely shows interesting political paths, they nonetheless don’t pretend to be a direct democracy. https://www.swissinfo.ch/eng/democracy/swiss-democracy-in-an-international-context_the-perfect-democracy-does-not-exist-not-even-in-switzerland/45578888 https://www.swissinfo.ch/eng/democracy/swiss-democracy-in-an...
        2y ago
- pessimizer 2y ago
  Not to mention that we happily do extrajudicial assassinations outside of our borders, and the news falls all over themselves to celebrate them. Everybody knows that plenty excuses a murder, we live in murderous states and in murderous times. The question is whether this murder is excusable, and one's opinion on it is probably dependent on whether one wishes they had that guy's job. Most people wouldn't do it for any price, but plenty would.
mrbluecoat 2y ago
If a cancer patient is denied a claim for life-saving medication because they're 'not sick enough' then dies, is it murder?
- JohnFen 2y ago
  Yes, in my opinion. It's homicide at the very least.
carlgreene 2y ago
I'm trying to figure out if these deaths caused by insurance denials could actually be considered murder. I think they would definitely qualify as being premeditated, but can you consider them "killing"? They are causing death due to omission of expected care, but can the omission of something like medical care be considered the cause of death?
- GiorgioG 2y ago
  Ask yourself this question again when it's your partner/parent/child in the casket.
- ziddoap 2y ago
  I am not a lawyer, but I would assume that death due to omission of expected care fits pretty neatly under "negligent homicide".
  - tjpnz 2y ago
    Duty of care?
    - bee_rider 2y ago
      It is weird—I would expect only the folks who make decisions as to which procedures are medically necessary (just doctors ideally) to have a duty of care. But insurance companies are bouncing back procedures are not medically necessary, so maybe we’re due for a re-adjustment in the expectations as to who has that duty. It is surprising if insurance companies what to sign themselves up for this sort of obligation. But obviously they’ll take all the privileges of the decision making process if we don’t also hold them to the responsibilities.
- psbp 2y ago
  There is legal precedent establishing healthcare providers' obligations in life-threatening situations. The same moral responsibility should exist when insurers deny lifesaving care, it's just hidden behind bureaucracy.
- 2y ago
technothrasher 2y ago
Well, if a killing is ethically justified, it isn't murder. So yes, they're at least begging the question with that statement for sure.
- ziddoap 2y ago
  >Well, if a killing is ethically justified, it isn't murder. Are you saying this as an opinion, or is this an established thing? I thought murder was an "unlawful killing without justification or valid excuse" (paraphrased from Wikipedia), whether one finds it ethical or not is sort of beside the point. Especially because there is no objectively correct ethics. But, I'm not a lawyer, this is just my understanding.
  - bombcar 2y ago
    I would say you have to be careful and specific - as "murder" is usually the domain of the law and "ethically justified* is the domain of ethics. It's quite easy to come up with situations where the law declares a killing as unequivocally murder yet everyone agrees it was ethically justified. The opposite can happen too.
    - deleted 2y ago
      [deleted]
amarcheschi 2y ago
But now you have another ceo. I'm not suggesting that to fix the issue you would need to - inaudible - again and again
lopalimpa 2y ago
"Murdering a murderer to save many innocents could be considered ethical by some?" This is a heavy statement. More I read, heavy it gets. Kill people it never the answer. The ideia that "I" have the power is weak. People, together, have power, however they don't know what to do. In his case the easiest way to win is pressuring the government, with the people, for clear changes.
- amarcheschi 2y ago
  Killing people is not the answer but somehow another Healthcare company backtracked on not covering anymore long anesthesia. Perhaps n = 1 is too low of a value? We should research this field more, some people may die but it's a chance I'm willing to take
  - wk_end 2y ago
    Although it should be noted that the anesthesia thing was dumb and bad. So maybe policy by mob justice isn’t a good thing. https://www.vox.com/policy/390031/anthem-blue-cross-blue-shield-anesthesia-limits-insurance https://www.vox.com/policy/390031/anthem-blue-cross-blue-shi...
    - amarcheschi 2y ago
      the article cites a study that says: "5% of practitioners reported anesthesia times greater in total than what would be expected across university, community, and specialty hospitals. Furthermore, it was found that the greatest differences in expected anesthesia times were in specialty hospitals compared with university hospitals.8 However, the authors have stressed that their findings should not be interpreted to indicate fraud because fraud involves intent, which could not be determined. Because this study was a retrospective study, the authors could not rule out the alternative but unlikely explanation that the practitioners could be rounding down. The reason for caution by the authors is that the CMS has differentiated fraud from abuse by emphasizing that fraud is intentional, whereas abuse is the result of poor medical practices.2 This differentiation is important because sometimes the rounding in digits ending in 0 or 5 minutes in anesthesia time is part of the organization culture of operating rooms in which rounding is performed systematically by the operation room circulating nurse along with the anesthesia practitioner. Sun et al8 recognized this issue as being related to institutional factors, which was one of the reasons they performed a 2-step regression analysis; long anomalous times were not sufficient to establish inappropriate discretion.8" So Anthem based on the article it might be overpaying for at worst 5% of the operations BUT the big but is that in some hospitals it is routine to round digits. So paying less workers for some rounding operations? It doesn't look as bad to me. It might be because of reasons, or might be due to media backslash. I think it's safe to assume we definitely need more research into healthcare companies rules after healthcare companies ceo related killing
christophilus 2y ago
Executing a murderer can be defended. “Industry malfeasance” leading to death is indefensible.
jimbokun 2y ago
You would need to prove that murdering a health care CEO will save many innocents, first.
- forgetfreeman 2y ago
  K. So step 1. murder health insurance CEO (no healthcare involved there), check. Step 2. watch UnitedHealth's refusal rates closely, ongoing.
  - walls 2y ago
    It got Anthem to immediately reverse a horrible decision: https://www.nbcnews.com/health/health-care/anthem-blue-cross-blue-shield-time-limits-anesthesia-surgery-rcna183035 https://www.nbcnews.com/health/health-care/anthem-blue-cross... Violence works.
euroderf 2y ago
Zeitgeist graffiti, anyone? "When they wage war, we wage war."
aaomidi 2y ago
Consent has been manufactured that if you kill through indirect means then you’re good to go!
- OutOfHere 2y ago
  Yes, mass media exists to manufacturer consent, and this shooter forced their hand.
oulipo 2y ago
Also without this murder, we could imagine that the NYPost would have never written this article to alert on the malfeasance of healthcare providers... Why wouldn't they do their part as a news org, and why did they wait for the murder to publish such an article, if that murder was not "needed" for things to change, then?
JohnFen 2y ago
Even if you accept that, it still doesn't excuse it being done by companies or individuals. The point is also orthogonal to what the insurance industry does.
LiquidSky 2y ago
You can't just shoot people and kill them in the street! That's barbaric! You need to do it from behind a desk through a corporate bureaucracy like a civilized person.
refurb 2y ago
One issue is that if denying medical care is murder then every healthcare system is guilty. In the US it’s insurance companies (or the government through Medicare or Medicaid) but in the UK it’s NICE, in Canada it’s CADTH and the provincial health authorities. Since there are finite resources spent on healthcare, trade offs are made all the time. If spending $10M on treatment A saved 10,000 lives and $10M on treatment B saves 1,000 lives, then treatment A gets funded and treatment B doesn’t. The difference is that patients in the US have an up close and personal experience with denial. In Canada and the UK they don’t because doctors knows what is covered and what isn’t so never bring up life saving options if they aren’t paid for. In rare circumstances like cystic fibrosis in the UK, patients become aware that they are being denied a life saving drug and protest, but generally it’s pretty rare because patients just don’t know the option exists.
- OutOfHere 2y ago
  Your argument is completely bogus for multiple reasons. Firstly, people are paying here for insurance, a lot. Secondly, it's the FDA's job to approve treatments which it does. Thirdly, we do not have a uniform privatized determination across the country of what is approvable or not by insurance companies. They deny numerous legitimate treatments and procedures at their whim.
  - refurb 2y ago
    I’m not sure how that makes my argument bogus. Plenty of treatments are denied in other countries. Not to mention most other countries have private insurance layered on top of public and it’s the same issue - private insurers denying a treatment through their own process. If US insurers are guilty of murder than most of the worlds insurers are too.
- wat10000 2y ago
  The difference is that patients in the US are being denied by people lining their own pockets with the savings. In sane countries, there’s at least some basis of trying to do the most good with the resources at hand, which sometimes means denying care for person A because those resources would be better spent on person B. With private insurers in the US, it means denying care for person A because they think they can get away with it and it will increase their profits.
lubujackson 2y ago
I guess we aren't going back in time to kill Hitler any more then? The media pearl-clutching is extremely heavy this time around, painting Luigi as an unhinged lunatic and all the rest. It feels incongruent and purposefully dismissive to equate this to something like the Oklahoma City Bombing.
kyleblarson 2y ago
I hate the way the press and seemingly most people are approaching this but am completely unsurprised: "You are either a heathen who supports murder or you are a virtuous supporter of the people and this man deserved to die." Two things can be correct at the same time. 1) Murder is not OK. 2) The insurance industry is completely broken as it incentivizes terrible behavior and this CEO was a scumbag who perpetuated this behavior while possibly insider trading.
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PittleyDunkin 2y ago

"No industry malfeasance could ever excuse murder." AND YET

actionfromafar 2y ago
If there wasn't a recent murder of a CEO, that line could be taken as directed towards insurers.
- kstrauser 2y ago
  That is, the ones who actually convene the “death panels” some politicians pearl-clutched about.
staticautomatic 2y ago
Of course! But maybe …
SauciestGNU 2y ago
Of course not legally, but I think there's a philosophical exercise here for ethicists to debate the boundaries and efficacy of community self defense.

edwinjm 2y ago

It's time the US realizes how bad its medical system is.

weberer 2y ago
Everybody knows how bad it is. Everyone wants to change it. But I don't see how it can change as long as both parties are on the payroll https://www.opensecrets.org/orgs/unitedhealth-group/recipients?id=D000000348 https://www.opensecrets.org/orgs/unitedhealth-group/recipien...
- tboyd47 2y ago
  It can change once Americans break their addiction to "health care."
  - dgfitz 2y ago
    Huh? I don't know a single person who ENJOYS going to the doctor, or needing medical treatment. What are you on about?
    - tboyd47 2y ago
      There are lots of people who get freaked out and go to the hospital for every little thing. We used to have a term for that: "hypochondriac." Now it's become socially acceptable, so you don't hear the term as much. Everyone knows Americans pay the most for medical treatment, but the life expectancy is not that high. If you know your behavior isn't good for you, but you can't stop yourself, well, that's an addiction.
      - AdmiralAsshat 2y ago
        On the contrary, if the healthcare system in the US weren't such shit, more people would probably be going to primary care doctors and getting Preventative Care before it becomes an emergency, and requires a trip to the hospital. But many people don't, because visiting a primary care / walk-in clinic / urgent care is expensive, so they ignore it, until it becomes un-ignorable. Now it's an ER visit.

deleted 2y ago

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Bengalilol 2y ago

IDK. What puzzles me here is that a NYPost article can be trending on HN.

mancerayder 2y ago
As opposed to a Medium blog? If source material and reputation is the concern. Many online papers have pay walls. There are similar articles criticizing health care denials from other sources, feel free to post them. They're not all discussion material nor even readable. And if the writer did a poor job, poke a hole in the argument.

JohnFen 2y ago

That has to be the worst kept dirty secret in the history of dirty secrets.

garciasn 2y ago

I was just denied a colonoscopy as not medically necessary by UHC, coincidentally three days before their CEO was killed, because they don't want me to have anesthesia to do it; they argue I should be awake. When I called to refute the denial, which was denied, I asked them to find the person, if it was a person, who denied it and shove a tube up their ass without anesthesia and then reassess whether it's medically necessary to have a colonoscopy without it. I'm 45. Colonoscopies are a thing. I had a friend die at 52 two years ago after he was diagnosed with stage IV during his first colonoscopy. I spent many of his last days watching him struggle to survive; I don't want that to happen to me just because UHC charges me $2000/month in premiums and denies basic service because they need to pay their executives too much money.

bschmidt11 2y ago
[flagged]
tommilburn 2y ago
that's insane! everyone should get a colonoscopy, and i believe they're recommending them for people over 40 if you meet certain risk categories signed up for an account with my real name to share a doc i've been working on for a long, long time now - i've had UC since high school, and have written an extensive guide of what i've learned, if it helps you or anyone else you know who might be getting scoped: https://docs.google.com/document/d/1bTW2rdF744woSPpFsUeSaFYauthOKQSyW4_myXUypig/edit?tab=t.0 https://docs.google.com/document/d/1bTW2rdF744woSPpFsUeSaFYa...
- deleted 2y ago
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- hgomersall 2y ago
  It's estimated by CRUK there are 44,000 bowel cancer cases each year in the UK. Assuming only people over 40 get it, and that's about half the population, the incidence is something like 1 in 800 annually. The rate of "serious complications" for a colonoscopy is about 1 in 300. Given those numbers, how often should everyone get a colonoscopy? That's before we get on to the potential harm from a false diagnosis (which is much higher without additional priors). Yes, absolutely people should pay attention to their bowels and get a colonoscopy when it's indicated. Let's not all rush to get one though unless there's some reason for it.

Invictus0 2y ago

Not saying this article is wrong but it is clearly written in a sensational style and does not belong on HN.

65 2y ago
The one sentence paragraph writing style drives me nuts.

toast0 2y ago

I think we need more thorough analysis. Are the denied claims denied in error? The appeals success rate probably indicates that most of the appealed denied claims were denied in error... but appealed claims are a biased sample of denied claims, so it doesn't tell us much about the overall denied claims. In my experience, I've seen some denied claims, because the provider submitted a wrong code. Then the provider submits a new claim with the correct code and it goes through. Given the proliferation of plans, and their sometimes conflicting requirements on medicial coding, I could see that being a big driver of denials increasing over time. As well as a driver of increased administrative costs for providers and insurance companies.

OutOfHere 2y ago
That's just code gaming. It's not necessarily an error. Also, numerous legitimate legitimate claims are denied no matter their code.
- toast0 2y ago
  I don't doubt that numerous doubly legitimate claims are denied. What I want is a sense of what the breakdown of the denied claims. Ex: company sends a list of all denied claims. Auditor picks 100 randomly, gets the files for each and researches those denials to classify the denial as reasonable or not and whatever other categories apply.
timmytokyo 2y ago
"A key congressional committee asked insurance giant Cigna on Tuesday to provide corporate documents so that lawmakers can examine the company’s practice of denying health care claims without ever opening a patient file." https://www.propublica.org/article/cigna-health-insurance-denials-pxdx-congress-investigation#:~:text=The%20letter%20follows%20an%20investigation,PXDX%20system%2C%20spending%20an%20average https://www.propublica.org/article/cigna-health-insurance-de...
- deleted 2y ago
  [deleted]

dheera 2y ago

Just leaving this here for reference: In 2022 I was denied full insurance payment of a routine, preventative echocardiogram at Stanford Healthcare to monitor my heart issues. I was balance billed $5000+. The insurance company was HealthNet. The policy clearly indicated full coverage of preventative procedures, without a deductible. They said they did not recognize the procedure as preventative. Fuck them, I know better about what's preventative and what's not than them. I argued the shit out of it, dozens of e-mails, hours of phone calls, and it was eventually sent to debt collectors. I wrote back to the debt collectors that it wasn't my debt and to stop contacting me. I reported it to a couple of government agencies as well to give them more headaches. I did not pay. In 2024 it was written off as uncollectible. (a) Use a virtual mailbox with your health provider so that they don't send debt collectors to your residence. Do not give them your residential address. (b) Use a virtual phone number with your health provider so that the debt collectors can't call you. Their only option will be mail and that leaves a paper trail which you DO want. NEVER communicate with a debt collector by phone. (c) Freeze your credit reports with all 3 bureaus so that they cannot use your mailing address to find your residential address. (d) If they do somehow find your residential address, do NOT answer. Only communicate by mail. Disclaimer: IANAL, account of personal experience only

AdmiralAsshat 2y ago
That might have gotten them to stop bugging you, but I imagine your credit score still took a hit?
- dheera 2y ago
  It didn't show up on my credit score at all. I also wasn't too concerned about that because (a) I believe medical debts don't affect credit scores for a long time. (b) I believe medical debts are required to have complete erasure from a credit report if cleared so if I actually needed my credit score to buy a house or whatever I could take the $5K hit to restore the credit score at that time. (c) I sent them a formal letter disputing the debt, which I assumed means they can't just take it to the credit agency, they'd have to go to court with me first. (Again IANAL, I don't know how accurate this is.) In any case I was mentally prepared to spend $10K on lawyers and court and give them a absolute hell of a time than pay $5K to pay for healthcare I shouldn't need to pay for. I made it VERY CLEAR to the debt collectors that I was ready to pay for lawyers. (d) For the forseeable future I don't think I need my credit score for anything. I don't plan to borrow money.

Miner49er 2y ago

It shouldn't even be legal for health insurance providers to deny claims. It's essentially them practicing medicine without a license, because they're making calls about what healthcare a person needs or doesn't need, only a person's doctor(s) should be able to make those decisions.

kstrauser 2y ago
That’s the crux of it. I didn’t visit with any of my insurer’s staff, like I did with my own doctor. How are they making treatment decisions without ever having seen the patient?
dboreham 2y ago
Otoh some medical providers like to over bill and over treat.
- drewbug01 2y ago
  > Otoh some medical providers like to over bill and over treat. This is true to some extent, but the share of medical providers that over-bill and over-treat really doesn't justify the way the insurance industry does business. It's a false equivalence.
- kstrauser 2y ago
  Crack down on them, but don’t use it to justify denying healthcare to patients.
- harimau777 2y ago
  It seems to me that should then be handled by the legal system or perhaps the licensing boards. That is to say, the insurance companies should be forbidden from denying coverage and if they believe that something is going on then they can alert the police or take the doctor to court.
  - antisthenes 2y ago
    Will never happen. Doctors have strong lobbying of their own and they really like their second vacation homes and Porsches.

drweevil 2y ago

>"An appeal means coaxing your doctor and staff to spend hours filling out forms and making repeated phone calls to joust with an insurance company employee." The hospital where I receive my cancer treatments once told me "don't worry, our Denial Team is handling this." They have a Denial Team. That is to say, insurance companies are imposing cost overheads on providers and patients due to their illegitimate profit boosting tactics. And our government can't be bothered to enforce the ACA's basic requirement to track and report denial rates. >"No industry malfeasance could ever excuse murder. "Period." And yet, that's what it took for our media to start reporting on this? We have some real problems in this country, and a corporate news media asleep at the switch, or at worst complicit, is one of the most serious.

dogboat 2y ago
"industry malfeasance" is 1984-esque lanuage. IED airbags, HIV injections, babies without limbs, etc. are industry malfesance. So the phrase implies: No acts of corporate greed including profiting by killing people could ever excuse murder.

codegeek 2y ago

My solution to this mess: - Health "Insurance" middleman mafia should not be the default b/w me and my doctor - Health Insurance should only exisit for Catastrophic events (big surgery, cancer etc) - Get rid of the regular Premiums, CoPays, Deductible, CoInsurnace, In network/Out network Bullshit. - For catastrophic events, we pay a premium (much smaller than now) - All hospitals and Doctors must offer an advertised/displayed Cash Price. No exceptions. Fine heavily if they hide - Let me pay cash for a regular doc visit. - Govt can subsidize for poor people (exdtension to medicare etc ??) That's it. Problem Solved. This will remove so much BS, middleman stuff, overhead and with a competitive market, prices will drop significantly. Doctors will be happy not dealing with Insurance for everything. Tell me why I am wrong.

__m 2y ago
People will probably avoid going to the doctor if they have to pay cash, missing the opportunity to detect the big things early.
- codegeek 2y ago
  I would argue that people already dread going to the doctor because you still have to deal with all the insurance garbage. Remember that even with a copay, you still could get a bill after the visit depending on deductible.

deleted 2y ago

[deleted]

i_love_retros 2y ago

How do we stop this?

lapcat 2y ago

Worth noting: neither major Presidential candidate, nor the news media, made health care a focus of the recent election. The issue was almost ignored. And neither major political party offers much: the Democratic establishment will defend the Affordable Care Act to the death (literally in this case), despite the fact that it's not particularly affordable, becoming more unaffordable over time, and it continues to enshrine and subsizide the ruthless for-profit insurance companies. On the other hand, the Republicans paint any kind of government involvement in health care as "Communist", despite the fact that the entire rest of the civilized world have more efficient, effective, and compassionate health care systems heavily regulated by the government. I think it's a sign of deep American corruption that we can't even have this public debate without a salacious murder occurring.

lofenfew 2y ago
The affordable care act is the most reasonable path from the current american system to a system on par with other first world countries. This especially given the sort of republican opposition it's liable to face. It's current form is due in substantial part to the republicans gutting it, so you can't really blame the dems for it not working very well.
- lapcat 2y ago
  The Affordable Care Act received precisely zero Republican votes in Congress. It was entirely a Democratic product.
  - tristor 2y ago
    John McCain, a Republican, famously voted to save the ACA during a time when the Republicans had a Congressional majority, even though his health was failing. He died shortly after the vote.
    - lapcat 2y ago
      I was talking about the 2010 passage of the ACA, not the 2017 repeal attempt. The 2010 legislation was written by Democrats. Moreover, since as you mention, the Republican repeal attempt failed, it can't truly be said that Republicans have "gutted" the ACA. It is true that for some (dumb) reason the ACA gave significant power to the states, which has been abused by Republican governors and legislatures, but that was entirely the choice of the Democrats who wrote the ACA.

onionisafruit 2y ago

She says that you can’t find denial rates for specific providers then she gives denial rates for specific providers. I’m not sure if she cited a source. I’m curious where her data comes from.

amarcheschi 2y ago

I don't know what happened but this super duper upvoted post disappeared from the home of hn. perhaps moderators temporarily shadow content that is upvoted too much? Or else?

deleted 2y ago
[deleted]
techdmn 2y ago
Also curious about this. Several other posts of similar age and with fewer points are in top spots on the front page. This post is still gathering comments, but seems to be hidden.

siliconc0w 2y ago

We should just have single payer if we have to constantly police these companies.

foundart 2y ago

This is an opinion piece. Its main claim is that the ACA requires denial rates to be available to consumers but they aren't. Additionally, it reports that denial rates have increased 10x in 10 years, based on the following chain: - "UnitedHealthcare nixed 1.1%, Humana 1.9%, Aetna 1.5% in 2013, per the American Medical Association." - "By 2022, major insurers were refusing to pay, on average, 15% of claims, according to a national survey of hospitals and health-care providers by Premier, an insurance consultant." - "The figure continues to shoot upward, with some companies today denying almost _half_ of all claims, according to researchers at the Kaiser Family Foundation." Furthermore, "few people appeal, but of those that do 41% obtain a reversal", which suggests the denials may be unfair. I certainly would like to know the denial rates when selecting an insurance provider. As the article says, "You aren't really insured if your insurer can deny valid claims with impunity." Given that the ACA requires this information be provided, it certainly ought to be provided. Then we'd have a much clearer picture. It's an opinion piece on a news site known for inflammatory articles but it reports some interesting information. It would be much nicer if it included references to the research it's based on, but it seems pretty reasonable to me.

leereeves 2y ago
Excellent summary. I'd like to address the denials in particular. As the article says: "No industry malfeasance could ever excuse murder." With that in mind, we should remember that every death that happens because a valid lifesaving claim was denied is a kind of murder, and no amount of fraud could ever excuse denying valid lifesaving claims. The stakes are too high: all claims should be approved, then adjudicated later. Fraud should of course be punished severely (with prison, not merely returning the money), but no one should die to protect insurance companies from fraud.
- nradov 2y ago
  I think you're mixing up terminology here. When a claim is submitted the care (lifesaving or otherwise) was already delivered. You might be thinking of prior authorization, where a provider asks an insurer for advance approval before delivering care. If a payer denies a prior authorization request then some providers will refuse to deliver care unless the patient has another form of payment. Fraud is only a small part of the systemic problems. There is an enormous amount of waste and abuse by providers who deliver treatments that are ineffective or unnecessary or excessively expensive. The dominant fee-for-service financial model incentivizes over treatment. We can argue about where to draw the line but payers (whether commercial or government) have to push back on this to keep the system from collapsing. Healthcare is already ~20% of the US economy. It can't continue expanding, we simply don't have the resources to pay any more. Every other country rations care in some way; no country delivers unlimited lifesaving care to everyone. https://peterattiamd.com/saumsutaria/ https://peterattiamd.com/saumsutaria/ https://www.npr.org/sections/health-shots/2019/10/22/767376340/the-price-we-pay-argues-rising-health-care-costs-undermine-public-trust-in-medic https://www.npr.org/sections/health-shots/2019/10/22/7673763...

johnohara 2y ago

In December 2021, the American Hospital Association issued the following statement regarding United Healthcare's plans to closely scrutinize medical claims for ER visits. [0] UHC subsequently reversed itself and delayed the plan for 6 months. That was in 2021-2022. It's now 2024-2025. Around that time many insurers, not just UHC, began implementing AI-assisted claims adjudication. It was a bumpy ride with a steep learning curve and probably took a couple of years to fine-tune the algorithms and learning models. Especially as the Covid-19 claims tsunami subsides. No matter tho', every claim paid is considered a loss by insurers. Every claim denied is considered a small step towards mitigating those losses. In the U.S., medical reimbursement is a push and shove, shove and push battle fought inch by inch with high-speed data systems. It has been that way for a long time. [0] https://www.aha.org/special-bulletin/2021-12-29-aha-expresses-concern-unitedhealthcares-coverage-criteria-change https://www.aha.org/special-bulletin/2021-12-29-aha-expresse...

nradov 2y ago
That's simply not how the system works. For the most part, medical insurers no longer provide much real "insurance" in the sense of bearing risk. Instead they mostly act as administrators for employer self-funded health plans. Since insurers are subject to an 85% minimum medical loss ratio, every paid claim is actually a gain because they get to take up to 15% from a larger revenue stream. The majority of the pressure to tighten coverage rules actually comes from those large employers since they're the ones ultimately paying the bills. https://www.cms.gov/marketplace/private-health-insurance/medical-loss-ratio https://www.cms.gov/marketplace/private-health-insurance/med... If anyone wants to see real reform then eliminating employer sponsored health plans is one potential way to get the incentives more properly aligned.

ethbr1 2y ago

There's an easy solution to this that the Federal Employee Program (aka FEP) [0] uses -- regular, external accuracy audits. The relevant metric to customers isn't "What percentage of claims are denied?" given the substantial amounts of medical claim fraud. It's "What percentage of claims are denied... that should have been approved?" So you regularly audit a random sampling of denials, publish the results of that audit transparently, and provide a financial incentive for insurers to keep their numbers below a certain threshold. It's worked pretty well for FEP -- to the extent that FEP insurers typically have segregated operations from the rest of the company and do much better on denial accuracy and other metrics. [0] https://en.m.wikipedia.org/wiki/Federal_Employees_Health_Benefits_Program https://en.m.wikipedia.org/wiki/Federal_Employees_Health_Ben...

adleyjulian 2y ago
It's a question of what we want to measure. There's a metric that represents how much a claimant sees in unexpected costs due to denied claims vs impact on care from the insurer. A denied prior auth results in no unexpected costs but perhaps a change or delay in care. A denied claim to an in network hospital may result in the provider losing revenue but nothing for the claimant.
Eddy_Viscosity2 2y ago
The auditors would either be captured or rendered powerless in short order. There is a great deal of money that can be used for effective lobbying.
- ethbr1 2y ago
  Hasn't in the FEP program. Mostly because there's no incentive: doing so helps your competitors as much as you. And it's more profitable to invest those dollars in hitting KPIs.
- SauciestGNU 2y ago
  Wrongful care denial should be considered a serious felony on par with assault with intent to do grave bodily harm. It should be a veil piercing crime that exposes every insurance company employee involved in denial to personal legal jeopardy should they wrongly deny claims. Reasons for denials must should be required to be extremely detailed and provided to the institutions requesting coverage. Upon receiving a denial, the health care institution should be able to evaluate the denial for validity and choose to refer the denial to local prosecuting attorneys if the denial is medically unsound.

mancerayder 2y ago

Let the health insurance companies deny claims. But then let the medical providers duke it out behind the scenes! Leave patients alone and don't send them bills six months later.

refurb 2y ago
This is actually key. The problem today is the insurers, hospitals and doctors put the patients at the center of the fight. Insurance denied? You pay patient. Insurance didn’t pay doctor enough? You pay patient. Hospital not in network? You pay patient. I think patients would see it as an improvement if hospital said upfront to go somewhere else as insurance won’t pay. If they knew insurance would pay at the right hospital than it would be better than today’s situation.
dogboat 2y ago
Assuming you are a coder lets see how that works for you.. Someone comes to you saying they need a website. You say "absolutely ... clearly you need one!". So you build it. The decision to pay you however comes from some 3rd party who says "denied". Now the customer keeps their site and you don't get paid. Will you stay in this coding business? The real solution is a public health system. Which has issues (apply queuing theory, because you will have to wait for the limited resources you are niw denied) overall it is better though since it can in theory be optimized as a whole.

antisthenes 2y ago

They deny claims. I deny paying my medical bills.

benterix 2y ago

It's insane that someone needs to die for a serious discussion about it to take place.

caeril 2y ago

Denial policy should be very very simple: If you're seeking coverage for lung cancer, but you chose to smoke, denied. If you're seeking coverage for type II diabetes, but you weigh 400lbs, denied. If you're seeking coverage for cancer because you got unlucky with a cosmic ray incident on your DNA, approved. If you're seeking coverage for a liver transplant because you refused to put down the bottle, denied. If you're seeking coverage for injuries from an auto accident that was not your fault, approved. I will NEVER understand why this type of blanket policy is so controversial. Cover bad luck, do NOT cover personal choices. It will fix not only costs, but the moral hazard endemic to the current system. Or, AT THE VERY LEAST, allow prejudicial adjustments to premiums for fatties, smokers, and alcoholics.

byecancer21 2y ago

The German state is also helping public health insurers hide their dirty secret: in hundreds of thousands of cases, denials were legally flawed and the cases have to be reviewed. They refuse to do so on the behest of politics as a small number of cases will turn out to be intentionally negligent homicides caused by public officials. A site properly presenting the facts is due for launch in the lead up to Germany's upcoming federal election. Until then, you can find a teaser here: https://de.wickepedia.org https://de.wickepedia.org Any claim related to outpatient treatment which outside the ordinary requires prior approval there. You cannot opt to pay in advance and seek reimbursement later. In the state of Bavaria the doctors at a government agency have been practicing without a medical license going back many years because their supervisor let this slide. I discovered her problem randomly in the course of litigation and it impacts probably a million case. The person responsible for her staff of hundreds lacking a current medical license was later hired to lead the qualifications department at the medical board. That is, after I got her fired from her position and then from a job at a hospital (a felonious psychologist is unacceptable risk for patients). Politics would prefer to see her problem covered up.

beej71 2y ago

Do these numbers include denials when a provider bills more than the negotiated rate? I see this happen all the time with my insurer.

EasyMark 2y ago

One thing that will help greatly is to regulate hospitals into having an umbrella of "services" that allows "private" operators BUT those operators have to be covered by any insurance that wants to work with the hospital rather than these 3 nurses in one pay center, this surgeon in another, assistant surgeons in a third, and the anesthesiologist so far out of network he laughs and isn't part of any HMO, PPO or anything else.