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I recently had a procedure denied (after the fact) because the price charged was apparently "excessively above the average" price for that procedure, leaving me

by c22 2y ago

I recently had a procedure denied (after the fact) because the price charged was apparently "excessively above the average" price for that procedure, leaving me on the hook for the full amount. It felt like the opposite of being insured. I also couldn't wrap my head around why they didn't just pay whatever they thought it was worth and let me cover the rest.

xena 2y ago
Doing that would make sense, and we can't have that now, can we?
cogman10 2y ago
> I also couldn't wrap my head around why they didn't just pay whatever they thought it was worth and let me cover the rest. Because insurance would then just lowball the cost of everything. Insurance needs to either do what they say they do, cover x% of procedure cost with a maximum yearly deductible or we need to be talking about why we have insurance in the first place. We need new regulations around health and insurance. Ideally, public insurance.
- evoke4908 2y ago
  > Because insurance would then just lowball the cost of everything. They do. Many, many billable items are priced to the limit that insurance will pay. Insurance and providers have agreements on the prices they can charge for certain procedures or supplies. It used to be the norm that insurance would pay their maximum and leave the rest to you. Sometimes the provider would waive the difference, sometimes it was billed to you. The cost of healthcare is 100% an artefact of insurance price fixing and absolutely nothing else.
bfrog 2y ago
Insurance is a terrible name for what we have, its not insurance, its blackmail. You dying and zero being paid out by the insurance company is the best profit margin they can ask for, that's the entire goal of an insurance company at this point.
- s1artibartfast 2y ago
  If there are no payouts, then they have to return all premiums. They only get paid a percentage of covered care. This presents it's own set of tradeoffs, namely between decreasing premiums to attract subscribers, and what is covered, to keep subscribers happy.
  - bfrog 2y ago
    They don’t return anything, what are you talking about? Subscribers are never happy, it’s very expensive and fails to cover many things. But what choice is there? Don’t get coverage and hope you don’t get sick? Often times you don’t even get a choice… the company decides what plan and such you can get. So no, there’s no incentive to do the right thing other than the potential loss of corporate customers (which don’t have the same incentive as individuals) or potential lawsuits.
    - s1artibartfast 2y ago
      Im talking about that ACA 85/15% rule. Health insurers must spend 85% of premiums on payouts or return funds to the insured.
  - brokenmachine 2y ago
    Not American but it seems so crazy to me that you can't even realistically choose your provider, since it's combined with your job. Seems insane.
    - bdangubic 2y ago
      of course you can but it ain’t cheap. $20k for a family of 3 is what I pay
      - brokenmachine 2y ago
        That is a lot. Does your job pay you the amount they would have paid for you?
deleted 2y ago
[deleted]
lovich 2y ago
> I also couldn't wrap my head around why they didn't just pay whatever they thought it was worth and let me cover the rest. Because nothing is forcing them to do so. If you don’t like it, what are you going to do about it? Shoot their CEO or something? They have all the leverage.
- vjulian 2y ago
  I resent that the Pentagon decides who the bad guys are and that the population large accepts what it’s told.
  - lovich 2y ago
    Was this a non sequitor? Not entirely sure how it’s related to my comment
    - thedailymail 2y ago
      Not OP, but I think the logic thread goes something like: Through taxes, we pay the government to exercise various protective functions, such as equipping the law enforcement and the military to identify and respond to existential threats. However, they completely miss or ignore bad behavior on the part of some domestic actors, such as healthcare profiteers.
      - vjulian 2y ago
        Sorry. I was commenting from my phone and didn’t check to see if my post appeared properly. Overall correct on the logic.
nradov 2y ago
Was the provider in or out of your health plan's network? If the procedure was performed by a network provider then it's likely they made a billing error and submitted a claim in excess of the negotiated rate. But it does suck that patients are caught in the middle.
- c22 2y ago
  In network! I considered challenging it, but the amount was small enough to not be worth my time.

by c22 2y ago

xena 2y ago

Doing that would make sense, and we can't have that now, can we?

cogman10 2y ago

> I also couldn't wrap my head around why they didn't just pay whatever they thought it was worth and let me cover the rest. Because insurance would then just lowball the cost of everything. Insurance needs to either do what they say they do, cover x% of procedure cost with a maximum yearly deductible or we need to be talking about why we have insurance in the first place. We need new regulations around health and insurance. Ideally, public insurance.

evoke4908 2y ago
> Because insurance would then just lowball the cost of everything. They do. Many, many billable items are priced to the limit that insurance will pay. Insurance and providers have agreements on the prices they can charge for certain procedures or supplies. It used to be the norm that insurance would pay their maximum and leave the rest to you. Sometimes the provider would waive the difference, sometimes it was billed to you. The cost of healthcare is 100% an artefact of insurance price fixing and absolutely nothing else.

bfrog 2y ago

Insurance is a terrible name for what we have, its not insurance, its blackmail. You dying and zero being paid out by the insurance company is the best profit margin they can ask for, that's the entire goal of an insurance company at this point.

s1artibartfast 2y ago
If there are no payouts, then they have to return all premiums. They only get paid a percentage of covered care. This presents it's own set of tradeoffs, namely between decreasing premiums to attract subscribers, and what is covered, to keep subscribers happy.
- bfrog 2y ago
  They don’t return anything, what are you talking about? Subscribers are never happy, it’s very expensive and fails to cover many things. But what choice is there? Don’t get coverage and hope you don’t get sick? Often times you don’t even get a choice… the company decides what plan and such you can get. So no, there’s no incentive to do the right thing other than the potential loss of corporate customers (which don’t have the same incentive as individuals) or potential lawsuits.
  - s1artibartfast 2y ago
    Im talking about that ACA 85/15% rule. Health insurers must spend 85% of premiums on payouts or return funds to the insured.
- brokenmachine 2y ago
  Not American but it seems so crazy to me that you can't even realistically choose your provider, since it's combined with your job. Seems insane.
  - bdangubic 2y ago
    of course you can but it ain’t cheap. $20k for a family of 3 is what I pay
    - brokenmachine 2y ago
      That is a lot. Does your job pay you the amount they would have paid for you?

deleted 2y ago

[deleted]

lovich 2y ago

> I also couldn't wrap my head around why they didn't just pay whatever they thought it was worth and let me cover the rest. Because nothing is forcing them to do so. If you don’t like it, what are you going to do about it? Shoot their CEO or something? They have all the leverage.

vjulian 2y ago
I resent that the Pentagon decides who the bad guys are and that the population large accepts what it’s told.
- lovich 2y ago
  Was this a non sequitor? Not entirely sure how it’s related to my comment
  - thedailymail 2y ago
    Not OP, but I think the logic thread goes something like: Through taxes, we pay the government to exercise various protective functions, such as equipping the law enforcement and the military to identify and respond to existential threats. However, they completely miss or ignore bad behavior on the part of some domestic actors, such as healthcare profiteers.
    - vjulian 2y ago
      Sorry. I was commenting from my phone and didn’t check to see if my post appeared properly. Overall correct on the logic.

nradov 2y ago

Was the provider in or out of your health plan's network? If the procedure was performed by a network provider then it's likely they made a billing error and submitted a claim in excess of the negotiated rate. But it does suck that patients are caught in the middle.

c22 2y ago
In network! I considered challenging it, but the amount was small enough to not be worth my time.