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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 deni

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...

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...