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Maybe they should hurry up and approve more claims. Seriously, my son’s insulin pump is sitting in “prior authorization” just so they can fuck me into paying th
by GiorgioG 2y ago
Maybe they should hurry up and approve more claims. Seriously, my son’s insulin pump is sitting in “prior authorization” just so they can fuck me into paying the full deductible come Jan 1. Fuck United Healthcare.
- mattgreenrocks 2y agoDude, that’s horrible. I’m sorry you have to deal with that.
- BadCookie 2y agoIt ought to be the law that approved claims should be backdated to when the initial claim was made. UHC pulled this exact trick on me, denying something that ought to have been approved in order to push the date into the new plan year with a reset deductible.
- mindslight 2y agoIt ought to be the law that every in-network claim must be automatically approved. In network providers have already jumped through hoops to have that contract with the "insurance" company, including the creation of documentation to satisfy the "insurance" company of their judgement. It's disingenuous for an "insurance" company to then claim to be second guessing the very professionals' judgement they've already examined and approved of.
- tptacek 2y agoRo Khanna said something similar a week or so ago. You all get that this would basically be the biggest corporate giveaway in the history of American politics, right? The reason you're getting health care denials is that providers are trying to rip your face off. I'm pleading with people on this site to go look at where the dollars in health care spending actually go. CMS, the government organization that manages Medicare (and somehow got vilified a few weeks ago when Blue Cross tried to adopt Medicare's anesthesia billing rules), tracks this stuff in a set of documents called the National Health Expenditures. They're spreadsheets, they're easy to go read, please, for the love of all that is holy, go look at them before designing policy.
- alistairSH 2y agoI can see where the money goes. That doesn’t absolve the insurance industry of being a festering sore worthy of every bit of scorn sent their direction.
- inferiorhuman 2y agoand somehow got vilified a few weeks ago when Blue Cross tried to adopt Medicare's anesthesia billing rules LOL That is absolutely fucking NOT why Blue Cross Blue Shield got vilified. Please stop making disingenuous arguments. BCBS attempted to weaponize Medicare statistics and set a hard cap on anesthesia coverage based on the average time Medicare says a procedure takes. This is NOT how Medicare reimbursement works. Medicare pays anesthesia providers for the entire time a patient is under. Full stop.
- tptacek 2y agoNo, from everything I understand about the situation, this is the opposite of the truth. Feel free to cite a source saying otherwise! I'll read it!
- inferiorhuman 2y agoYeah, go read the rules set forth by CMS. Medicare pays for the entire cost of anesthesia. So here's why I'm so dismissive of your garbage argument. From Medicare's policy manual: https://www.cms.gov/files/document/chapter2cptcodes00000-01999final11.pdf https://www.cms.gov/files/document/chapter2cptcodes00000-019... A unique characteristic of anesthesia coding is the reporting of time units. Payment for anesthesia services increases with time. In addition to reporting a base unit value for an anesthesia service, the anesthesia practitioner reports anesthesia time. Anesthesia time is defined as the period during which an anesthesia practitioner is present with the patient. It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient (i.e., when the patient may be placed safely under postoperative care). Compare this to BCBS's policy (which they've tried to scrub from the internet): https://www.asahq.org/about-asa/newsroom/news-releases/2024/11/anthem-blue-cross-blue-shield-will-not-pay-complete-duration-of-anesthesia-for-surgical-procedures https://www.asahq.org/about-asa/newsroom/news-releases/2024/... Anthem will arbitrarily pre-determine the time allowed for anesthesia care during a surgery or procedure. If an anesthesiologist submits a bill where the actual time of care is longer than Anthem's limit, Anthem will deny payment for the anesthesiologist’s care. With this new policy, Anthem will not pay anesthesiologists for delivering safe and effective anesthesia care to patients who may need extra attention because their surgery is difficult, unusual or because a complication arises. There's a vast gulf between those two approaches. Medicare pays for the time a procedure takes, BCBS does not. BCBS deserves every ounce of vitriol they got over that. Your entire argument appears to be that doctors are corrupt and cannot be trusted which is entirely orthogonal to the the issue with pre-determining the amount of time a procedure will take. Meanwhile BCBS overcharged (a.k.a. fraudulently charged) the federal government for over $100 million. Doctors are not the problem with health care in the United States. https://www.reuters.com/legal/anthem-must-face-us-government-lawsuit-alleging-medicare-advantage-fraud-2022-10-03/ https://www.reuters.com/legal/anthem-must-face-us-government... UHC? $7.5 billion (with a b) in fraudulent Medicare charges. https://www.startribune.com/report-unitedhealth-group-tops-list-of-medicare-advantage-insurers-receiving-billions-in-questionable-payments/601169613 https://www.startribune.com/report-unitedhealth-group-tops-l... Cigna? They settled their fraud cases for $200+ million. https://www.justice.gov/opa/pr/cigna-group-pay-172-million-resolve-false-claims-act-allegations https://www.justice.gov/opa/pr/cigna-group-pay-172-million-r... https://www.justice.gov/usao-sdny/pr/united-states-reaches-37-million-settlement-fraud-lawsuit-against-cigna-submitting https://www.justice.gov/usao-sdny/pr/united-states-reaches-3... Independent Health Association? $100 million. https://kffhealthnews.org/news/article/medicare-advantage-fraud-lawsuit-settlement-new-york/ https://kffhealthnews.org/news/article/medicare-advantage-fr... Private insurance is one of the biggest drivers of the obscene cost of health care in this country.
- _yb2s 2y agoThat is how Kaiser works- the doctors have internal guidelines, e.g. a set criteria for a diagnosis, and every treatment that is ordered is automatically approved. This isn't a perfect solution either though- the guidelines are often unreasonably strict, and still deny people treatments they very much need.
- tptacek 2y agoThe difference being that in the Kaiser system, the doctors work for Kaiser, and not for health provider chains.
- JumpCrisscross 2y ago> ought to be the law that every in-network claim must be automatically approved This almost certainly requires vertical integration between providers and insurers. That or shifting approval/denial to the provider level, i.e. your doctor can fall off the approval list from month to month for submitting too many claims. If not, providers will become the most profitable business on the planet right until every health insurer goes bankrupt. (We’ll probably get to blame it on PE-run hospitals, even if everyone is doing it.)
- ocschwar 2y agoProviders are liable for malpractice if they approve un-needed treatments, and all drugs have side effects. And they meanwhile have their own liability insurance to pay, as well as medical student debt. So not going to be profitable either. Unless they start prescribing Carnival Cruise therapy or stiff like that.
- JumpCrisscross 2y ago> Providers are liable for malpractice if they approve un-needed treatments There is a lot of grey area between necessary to the point of malpractice if not provided and unnecessary to the point of malpractice. Like, you’re not going to win a malpractice case because your doctor prescribed too many non-invasive tests and MRIs. And if my insurer is forced to approve every MRI, I'm probably going to ask my doctor for an MRI.
- nradov 2y agoIt is simply naive to think that the threat of malpractice discipline by state medical boards would deter bad actors from delivering wasteful or unnecessary care. The fee-for-service financial system heavily incentivizes over treatment. If you don't believe me then read "The Price We Pay" by Dr. Marty Makary. It documents many such incidents for which the providers were never punished. https://www.bloomsbury.com/us/price-we-pay-9781635575910/ https://www.bloomsbury.com/us/price-we-pay-9781635575910/
- xbar 2y agoI mean, it was fine for 50 years.
- rjbwork 2y agoFor providers with a history of high quality PA requests and high approval rates, there is something similar. See https://www.uhc.com/news-articles/newsroom/gold-card https://www.uhc.com/news-articles/newsroom/gold-card Other insurers have similar programs.
- mindslight 2y agoSounds like another layer of "gotchas" to pin more work and blame on patients, while still not providing any guarantee. "Your healthcare was denied because while you may have checked the provider was 'in network', you did not also check to see if they have earned a gold star. I can email you a list of our highest quality providers that have earned gold stars"... Then most aren't taking new patients, and the one or two that do are booking out the better part of a year for a new patient visit. I'll go out on a limb and say that the proliferation of these punt-the-problem administrative layers (in lieu of straightforwardly owning and solving problems) is one of the main things driving the medical industry's cost disease. A few years from now this "gold card" program will likely be administered by a newly spun out "third party" vendor that doesn't publish updated lists very well, but if you feel you were treated unfairly you can always file an appeal with them...
- nradov 2y agoIn terms of annual deductible, claims are always dated to the date of service regardless of when they were submitted or adjudicated. I think what you're asking for is that if a prior authorization request is submitted in one plan year then all claims linked to that request should be counted towards the deductible in that plan year regardless of the date of service. That might help some plan members but would hurt others depending on timing. Health plans covered by the CMS-0057-F final rule are generally required to issue decisions on prior auth requests within 7 days. But that rule doesn't apply to most private commercial health plans. https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f https://www.cms.gov/newsroom/fact-sheets/cms-interoperabilit...
- hsuduebc2 2y agoIt's very hard to have any compassion for architects of this company's system.
- detourdog 2y agoCongress claims this is what we the people want.
- hsuduebc2 2y agoI believe that some people really needs that. Ironically the ones which need it most.
- hsuduebc2 2y ago*really believe not need
- maeil 2y ago[flagged]
- JumpCrisscross 2y ago[flagged]
- maeil 2y agoThrowing around terms like "murderer" and "terrorism" is a pure appeal to emotion. It's just as easy to call the CEO a "murderer" and say UHC committed "terrorism". Not going to make that argument because it's pointless semantics. The idea that it's only a tiny, negligible fringe of people who are positive towards his deeds is of course also not true. The days where websites like Reddit are purely a playground for nerds with fringe belief are long, long past us. On many mainstream social networks, the dominating view has been one of support.
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- whycome 2y agoHow is this legal?
- schmidtleonard 2y agoLawmakers need campaign money and shakedowns are profitable.
- SpicyLemonZest 2y agoIt's not in many jurisdictions. The AMA tracks laws on prior authorization, and in an increasing number of states insurers must make a decision within 5 calendar days. (https://www.ama-assn.org/system/files/prior-authorization-state-law-chart.pdf https://www.ama-assn.org/system/files/prior-authorization-st...)
- pxeboot 2y agoMany of the shenanigans pulled by health insurers aren't legal, but they know a significant number of people will just pay or file bankruptcy instead of appealing or lawyering up.
- deleted 2y ago[deleted]
- IncreasePosts 2y agoHow would OP know that is the reason?
- rchaud 2y agoThink of all the times you've seen a news headline that reads "Company X settles with [regulatory body], does not admit guilt". Corporate malfeasance rarely reaches the courtroom, so their wrongdoing is not entered into public record in a way that can be cross-examined.
- dgfitz 2y agoI, as a male, have a 4.5k medical bill from a breast cancer biopsy center. I had surgery on December 8th. They billed me for the biopsy on January 3rd, and of course UHC isn’t covering it. Turns out joke is on them, I’m not paying it.
- thebruce87m 2y agoMales can/do get breast cancer, unless I am missing your point?
- dgfitz 2y agoAsk me how I know!