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Nobody, not this article or any other reasonable person, thinks that claim denial is the reason healthcare is expensive. Rather, they think it is fundamentally

Nobody, not this article or any other reasonable person, thinks that claim denial is the reason healthcare is expensive. Rather, they think it is fundamentally fraudulent that someone can pay their premiums, etc. and then when they need treatment, be arbitrarily denied by an in-house doctor employed by their insurer to deny treatment. This is a story of the fraud in the health insurance industry, not the racket part of the industry.

FireBeyond 2y ago
> be arbitrarily denied by an in-house doctor employed by their insurer to deny treatment. Oftentimes by a doctor who cannot or doesn't practice in "the real world" (some physicians employed by insurers go straight to working from them after becoming licensed). Or a nurse (technically with "oversight" by a doctor who might "supervise" the decisions of dozens of nurses or more). And now these companies if not using AI directly, will present these providers "notes" along with the claim for review with an AI summary, replete with hallucinations, as bullet points "guiding" them towards the "correct" decision.
ClumsyPilot 2y ago
> is fundamentally fraudulent that someone can pay their premiums, etc. and then when they need treatment, be arbitrarily denied This -somehow the insurance industry does whatever it wants. If I get paid but refuse to provide service, multiple times, I will be a wanted man.
s1artibartfast 2y ago
Cost controls are a necessary part of the US system, and European single payer systems as well. The primary difference is that the US system puts the patient in-between the doctor and payer. Alternative systems usually sort this out by simply denying or allowing the treatment without the patient in the loop
Aunche 2y ago
Again, zeroing in on these denials is missing the forest for the trees. It's the entire claims process that is incentivized to dysfunctional. Insurers are paying for unnecessary chiropractic adjustments, name-brand prescriptions as a first resort, and the more expensive private rooms that hospitals like to build these days over shared ones. Occasionally, they'll fail to provide life saving care, but they can spin that into a win because that will give them an excuse to increase premiums even higher. Psychiatric issues, which this Propublica article is about, are already being over-treated even though it may be under-treated in other aspects. Focusing only on these cases of denial may cause under-treatment to go down, but at a cost of much higher over-treatment, which comes out of everyones premiums. I don't think anything wrong with SSRIs or stimulants being used as medication, but clearly something wrong with the way we're prescribing them when despite being the largest consumers of them, Americans suffer more poor mental health outcomes.
- ssivark 2y ago
  When judging a system using the ROC curve, you need to evaluate both the precision AND the recall. You are pointing out that the precision is low, and must be improved; the article is pointing out that recall ought to be improved. Both are true, and we cannot use just one of the two metrics to evaluate system performance. https://en.wikipedia.org/wiki/Receiver_operating_characteristic https://en.wikipedia.org/wiki/Receiver_operating_characteris...
grumpy_coder 2y ago
It's also important to realize claim denial isn't the same for all customers. When I was classed as an executive at a large blue chip company, my claims were approved quickly and easily at the company specific hotline. With the same provider, making the same claims, they are now partially denied initially and it requires long phone calls to get them to admit they should be covered and often it just isn't worth the hassle.

FireBeyond 2y ago

> be arbitrarily denied by an in-house doctor employed by their insurer to deny treatment. Oftentimes by a doctor who cannot or doesn't practice in "the real world" (some physicians employed by insurers go straight to working from them after becoming licensed). Or a nurse (technically with "oversight" by a doctor who might "supervise" the decisions of dozens of nurses or more). And now these companies if not using AI directly, will present these providers "notes" along with the claim for review with an AI summary, replete with hallucinations, as bullet points "guiding" them towards the "correct" decision.

ClumsyPilot 2y ago

> is fundamentally fraudulent that someone can pay their premiums, etc. and then when they need treatment, be arbitrarily denied This -somehow the insurance industry does whatever it wants. If I get paid but refuse to provide service, multiple times, I will be a wanted man.

s1artibartfast 2y ago

Cost controls are a necessary part of the US system, and European single payer systems as well. The primary difference is that the US system puts the patient in-between the doctor and payer. Alternative systems usually sort this out by simply denying or allowing the treatment without the patient in the loop

Aunche 2y ago

Again, zeroing in on these denials is missing the forest for the trees. It's the entire claims process that is incentivized to dysfunctional. Insurers are paying for unnecessary chiropractic adjustments, name-brand prescriptions as a first resort, and the more expensive private rooms that hospitals like to build these days over shared ones. Occasionally, they'll fail to provide life saving care, but they can spin that into a win because that will give them an excuse to increase premiums even higher. Psychiatric issues, which this Propublica article is about, are already being over-treated even though it may be under-treated in other aspects. Focusing only on these cases of denial may cause under-treatment to go down, but at a cost of much higher over-treatment, which comes out of everyones premiums. I don't think anything wrong with SSRIs or stimulants being used as medication, but clearly something wrong with the way we're prescribing them when despite being the largest consumers of them, Americans suffer more poor mental health outcomes.

ssivark 2y ago
When judging a system using the ROC curve, you need to evaluate both the precision AND the recall. You are pointing out that the precision is low, and must be improved; the article is pointing out that recall ought to be improved. Both are true, and we cannot use just one of the two metrics to evaluate system performance. https://en.wikipedia.org/wiki/Receiver_operating_characteristic https://en.wikipedia.org/wiki/Receiver_operating_characteris...

grumpy_coder 2y ago

It's also important to realize claim denial isn't the same for all customers. When I was classed as an executive at a large blue chip company, my claims were approved quickly and easily at the company specific hotline. With the same provider, making the same claims, they are now partially denied initially and it requires long phone calls to get them to admit they should be covered and often it just isn't worth the hassle.