4 ms·

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 ca

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.
    - joquarky 2y ago
      So are we to just do nothing and die in the crossfire between these two entities?
    - consteval 2y ago
      Most doctors are not very rich at all, upper middle class. I make more than many doctors I know as a software engineer, and this doesn't even take into account their debt. Care is expensive because of insurance. Hospitals needs hundreds of administrators and billing specialists. Very little of that money goes to the doctor.
      - SauciestGNU 2y ago
        Doctors deserve to be rich. They do incredibly specialized work where the outcomes are extremely critical, to put it mildly. I don't want doctors performing unnecessary treatments to line their pockets, but I don't think we're actually in danger of that. The difference between a rich doctor and a rich insurance exec is that the doctor helps people, and the insurance exec makes their money withholding necessary care from people, in effect torturing and killing them.
        consteval 2y ago
        This is the problem with insurance in general. The incentive of insurance is at direct odds with patients and doctors. It's a tug of war, and even if insurance "loses", it doesn't matter, because you lost trillions of dollars in that tug of war. It's artificial inefficiency caused by privatization, very much a Dark Night burning a mountain of money situation.
        2y ago
- ubnvfft 2y ago
  Stop speciously muddying the waters by either intentionally or accidentally making spurious arguments for these unethical sociopaths. I’ve seen this argument made on this website a lot, and it always conveniently omits the vertical integration of these insurers wherein they are the providers too. The DOJ is literally, actively, suing to block a merger between united healthcare and a provider. https://www.justice.gov/opa/pr/justice-department-sues-block-unitedhealth-groups-acquisition-home-health-and-hospice https://www.justice.gov/opa/pr/justice-department-sues-block...
  - nradov 2y ago
    It's not clear that vertical integration is necessarily bad for consumers. For example, Kaiser-Permanente is a huge, vertically-integrated "payvider" which both sells insurance plans and also delivers most of the treatment for plan members. They generally do a pretty good job at a competitive price. Both the payer and provider sides of the healthcare industry have been consolidating for years. Insurers merged to gain more negotiating power with providers and drive down costs. Providers responded by merging (or selling to private equity funds) to gain more negotiating power with insurers and maintain high rates. Government mandates on back office technology also incentivized provider consolidation due to economies of scale. In some areas now a few major provider organizations effectively control the market and payers are essentially forced to pay high rates in order to maintain sufficient networks. So, the logical next step is for payers to mimic KP by building their own captive health systems. Every major payer is pursuing this strategy to varying levels; it's not just UHC.
- fny 2y ago
  Yes, insurance companies deny claims, but this is mostly because they don't have the money to pay for things most of their money is spent on care in the first place: they're forced to optimize and people get hurt in the process. Providers do far more damage. UHCs profit margins are only 6%, their operating costs are extremely low[0], and if you look across G7 insurers in the US pay more than the government does in every country but France![1] Compare this to HCA which makes an average margin of 10% with far higher administrative costs. The CEO of HCA makes $20M, Brian Thompson made $10M by contrast. This is not to say we (and insurance companies) don't spend astronomically more than other countries: providers are to blame for this, and I have seen their nonsense first hand: - They keep people alive overnight to charge insurance more - Some hospitals use ML (!) to optimize ICD codes for billing. Most do this by hand: there's literally a job and training to be an ICD coder. - They allow people to deteriorate (e.g. dialysis) to charge more (no preventative care.) I have seen a hospital only provide preemptive care to patients at risk of dialysis because they were part of their own insurance pool - Their administraive expenses are far higher. - They test and provide unnecessary care. - Physician shortage is in part caused by limited residency spots, a dumb bachelors requirement, and high tuition costs. These barriers to entry are imposed by physicians. - Uneccesary tech and equipment upgrades (e.g. we need to replace your knee with a new knee) - Having to deal with tons of different insurance companies: not their fault but they don't know how to handle this efficiently. [0]: https://www.reddit.com/r/dataisbeautiful/comments/194wucn/oc_unitedhealth_group_just_released_its_income/?rdt=52541 https://www.reddit.com/r/dataisbeautiful/comments/194wucn/oc... [1]: https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fbb8e5dae-6e36-410d-9ce8-47fb6166f21a_1020x720.jpeg https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_pr...
  - ethbr1 2y ago
    Underappreciated reality. Because customer-insurer relationships are the only side of the healthcare system that most people see, they're oblivious to what are actually pass-through insurer-provider issues. As you said, the reality is that insurers operate with pretty reasonable margins and incredibly meager per-claim overhead costs. They're stuck trying to make 2 + 1 = 2. If the finger should be pointed at root causes in the US health system, it should be at: - Providers overbilling (particular in certain specialties) - Medical schools, for charging too much and under-expanding capacity - The federal government/Congress, for failing to expand residency funding to increase supply (especially in generalist provider categories)
- mancerayder 2y ago
  Yes, but in my opinion it falls to the patient to figure out the details and absorb the risk. That's the messed up part. That insurance providers and medical services might disagree on pricing or whatnot is an inevitability. What's not fair is throwing ordinary people under the bus to deal with it, which for many reasons is risky and can ruin lives.
DennisP 2y ago
Agreed. France, Germany, and Japan have health systems similar to the ACA, with the following differences: insurance is nonprofit with an effective mandate, there's a national price list for medical services, and claim denials are prohibited for anything on the list. Germany has an especially effective digital system that guarantees payment within a week. All three systems get better health results than the US, by measures like survival time after diagnosis of major disease. And all three spend a significantly lower percentage of their GDP on healthcare. Source: The Healing of America by T.R. Reid.
- deleted 2y ago
  [deleted]
- nradov 2y ago
  The other side of that is that some expensive services and drugs are simply unavailable in other countries, or are very tightly rationed. The USA has higher 5-year survival rates for most types of cancer than France, Germany, and Japan. I'm not saying that the US system is better overall, but it does do some things extremely well. We should make sure that any reforms don't sacrifice our unique advantages. https://doi.org/10.1016/S0140-6736(17)33326-3 https://doi.org/10.1016/S0140-6736(17)33326-3
  - skeaker 2y ago
    This obviously goes without saying. In fact, I'm not sure how implementing a system like Germany or Japan has would impact this at all.
    - nradov 2y ago
      I'm not sure how implementing a system like Germany or Japan wouldn't impact those things at all. Why aren't Germany or Japan equal to the USA in 5-year cancer survival rates? Their systems optimize for different priorities, and those involve trade-offs. So no, it obviously doesn't go without saying. If we want to cut overall health system costs or improve access then we might have to accept some reduction in service quality, at least for the most expensive stuff.
josh_cutler 2y ago
All large health insurers employ many physicians. You're not wrong that they may not have all of the evidence but there is a lot of licensed medical knowledge available to all Payors.
deleted 2y ago
[deleted]
ASalazarMX 2y ago
I'm glad to see this phrased this way, because that was something I felt but hadn't articulated consciously. It's literally private accountants making healthcare decisions.
refurb 2y ago
This makes no sense. Plenty of healthcare is not covered by insurance. Cosmetic procedures are healthcare and not covered. Not to mention errors in claims, claims that include care well outside guidelines, etc. You’d expect a pretty consistent level of denials even if all medically necessary claims are approved.

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.
  - joquarky 2y ago
    So are we to just do nothing and die in the crossfire between these two entities?
  - consteval 2y ago
    Most doctors are not very rich at all, upper middle class. I make more than many doctors I know as a software engineer, and this doesn't even take into account their debt. Care is expensive because of insurance. Hospitals needs hundreds of administrators and billing specialists. Very little of that money goes to the doctor.
    - SauciestGNU 2y ago
      Doctors deserve to be rich. They do incredibly specialized work where the outcomes are extremely critical, to put it mildly. I don't want doctors performing unnecessary treatments to line their pockets, but I don't think we're actually in danger of that. The difference between a rich doctor and a rich insurance exec is that the doctor helps people, and the insurance exec makes their money withholding necessary care from people, in effect torturing and killing them.
      - consteval 2y ago
        This is the problem with insurance in general. The incentive of insurance is at direct odds with patients and doctors. It's a tug of war, and even if insurance "loses", it doesn't matter, because you lost trillions of dollars in that tug of war. It's artificial inefficiency caused by privatization, very much a Dark Night burning a mountain of money situation.
        2y ago
ubnvfft 2y ago
Stop speciously muddying the waters by either intentionally or accidentally making spurious arguments for these unethical sociopaths. I’ve seen this argument made on this website a lot, and it always conveniently omits the vertical integration of these insurers wherein they are the providers too. The DOJ is literally, actively, suing to block a merger between united healthcare and a provider. https://www.justice.gov/opa/pr/justice-department-sues-block-unitedhealth-groups-acquisition-home-health-and-hospice https://www.justice.gov/opa/pr/justice-department-sues-block...
- nradov 2y ago
  It's not clear that vertical integration is necessarily bad for consumers. For example, Kaiser-Permanente is a huge, vertically-integrated "payvider" which both sells insurance plans and also delivers most of the treatment for plan members. They generally do a pretty good job at a competitive price. Both the payer and provider sides of the healthcare industry have been consolidating for years. Insurers merged to gain more negotiating power with providers and drive down costs. Providers responded by merging (or selling to private equity funds) to gain more negotiating power with insurers and maintain high rates. Government mandates on back office technology also incentivized provider consolidation due to economies of scale. In some areas now a few major provider organizations effectively control the market and payers are essentially forced to pay high rates in order to maintain sufficient networks. So, the logical next step is for payers to mimic KP by building their own captive health systems. Every major payer is pursuing this strategy to varying levels; it's not just UHC.
fny 2y ago
Yes, insurance companies deny claims, but this is mostly because they don't have the money to pay for things most of their money is spent on care in the first place: they're forced to optimize and people get hurt in the process. Providers do far more damage. UHCs profit margins are only 6%, their operating costs are extremely low[0], and if you look across G7 insurers in the US pay more than the government does in every country but France![1] Compare this to HCA which makes an average margin of 10% with far higher administrative costs. The CEO of HCA makes $20M, Brian Thompson made $10M by contrast. This is not to say we (and insurance companies) don't spend astronomically more than other countries: providers are to blame for this, and I have seen their nonsense first hand: - They keep people alive overnight to charge insurance more - Some hospitals use ML (!) to optimize ICD codes for billing. Most do this by hand: there's literally a job and training to be an ICD coder. - They allow people to deteriorate (e.g. dialysis) to charge more (no preventative care.) I have seen a hospital only provide preemptive care to patients at risk of dialysis because they were part of their own insurance pool - Their administraive expenses are far higher. - They test and provide unnecessary care. - Physician shortage is in part caused by limited residency spots, a dumb bachelors requirement, and high tuition costs. These barriers to entry are imposed by physicians. - Uneccesary tech and equipment upgrades (e.g. we need to replace your knee with a new knee) - Having to deal with tons of different insurance companies: not their fault but they don't know how to handle this efficiently. [0]: https://www.reddit.com/r/dataisbeautiful/comments/194wucn/oc_unitedhealth_group_just_released_its_income/?rdt=52541 https://www.reddit.com/r/dataisbeautiful/comments/194wucn/oc... [1]: https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fbb8e5dae-6e36-410d-9ce8-47fb6166f21a_1020x720.jpeg https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_pr...
- ethbr1 2y ago
  Underappreciated reality. Because customer-insurer relationships are the only side of the healthcare system that most people see, they're oblivious to what are actually pass-through insurer-provider issues. As you said, the reality is that insurers operate with pretty reasonable margins and incredibly meager per-claim overhead costs. They're stuck trying to make 2 + 1 = 2. If the finger should be pointed at root causes in the US health system, it should be at: - Providers overbilling (particular in certain specialties) - Medical schools, for charging too much and under-expanding capacity - The federal government/Congress, for failing to expand residency funding to increase supply (especially in generalist provider categories)
mancerayder 2y ago
Yes, but in my opinion it falls to the patient to figure out the details and absorb the risk. That's the messed up part. That insurance providers and medical services might disagree on pricing or whatnot is an inevitability. What's not fair is throwing ordinary people under the bus to deal with it, which for many reasons is risky and can ruin lives.

DennisP 2y ago

Agreed. France, Germany, and Japan have health systems similar to the ACA, with the following differences: insurance is nonprofit with an effective mandate, there's a national price list for medical services, and claim denials are prohibited for anything on the list. Germany has an especially effective digital system that guarantees payment within a week. All three systems get better health results than the US, by measures like survival time after diagnosis of major disease. And all three spend a significantly lower percentage of their GDP on healthcare. Source: The Healing of America by T.R. Reid.

deleted 2y ago
[deleted]
nradov 2y ago
The other side of that is that some expensive services and drugs are simply unavailable in other countries, or are very tightly rationed. The USA has higher 5-year survival rates for most types of cancer than France, Germany, and Japan. I'm not saying that the US system is better overall, but it does do some things extremely well. We should make sure that any reforms don't sacrifice our unique advantages. https://doi.org/10.1016/S0140-6736(17)33326-3 https://doi.org/10.1016/S0140-6736(17)33326-3
- skeaker 2y ago
  This obviously goes without saying. In fact, I'm not sure how implementing a system like Germany or Japan has would impact this at all.
  - nradov 2y ago
    I'm not sure how implementing a system like Germany or Japan wouldn't impact those things at all. Why aren't Germany or Japan equal to the USA in 5-year cancer survival rates? Their systems optimize for different priorities, and those involve trade-offs. So no, it obviously doesn't go without saying. If we want to cut overall health system costs or improve access then we might have to accept some reduction in service quality, at least for the most expensive stuff.

josh_cutler 2y ago

All large health insurers employ many physicians. You're not wrong that they may not have all of the evidence but there is a lot of licensed medical knowledge available to all Payors.

deleted 2y ago

[deleted]

ASalazarMX 2y ago

I'm glad to see this phrased this way, because that was something I felt but hadn't articulated consciously. It's literally private accountants making healthcare decisions.

refurb 2y ago

This makes no sense. Plenty of healthcare is not covered by insurance. Cosmetic procedures are healthcare and not covered. Not to mention errors in claims, claims that include care well outside guidelines, etc. You’d expect a pretty consistent level of denials even if all medically necessary claims are approved.