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"Not Medically Necessary": Helping America's Health Insurers Deny Coverage
- cyanydeez 6mo agoMedically speak, I'm sure we can all find several businesses that arn't necessary.
- voicedYoda 6mo ago[flagged]
- thinkingtoilet 6mo agoyes... sarcasm... Totally unrelated. In traditional stories, as anyone ever been upset when the knight slays the dragon at the end because the dragon was hoarding all the gold and killing the townspeople? I was never upset when the dragon got slayed. EDIT: Yeesh. I guess people here really like it when the dragon wins. Oh well. I guess people have to die so the dragon can hoard the wealth.
- butvacuum 6mo agohave they managed to wrangle a jury yet?
- cucumber3732842 6mo agoNot even. Just look at it by the numbers. If one in every 10k, 20k, IDK but surely you don't even need 1:1k, life alteringly aggrieved people threw what was left of their lives away getting even instead of just taking it the sheer economics would make most of the bad stuff stop. This applies to just about everything, not just medical. The suffering in society always reaches equilibrium with the pushback and modern people are very, very, very docile so we're made to suffer a lot.
- vanc_cefepime 6mo ago“The algorithm cannot say no, however. If it finds problems, it sends the request for review to a team of in-house nurses and doctors who consult company medical guidelines. Only doctors can issue a final denial.” As a physician, I’ve had to speak to these so called “peers” in a peer to peer denials with both my clinic and hospital setting. They are usually people who aren’t physicians as a first line of their defense, ie therapist, nurses, etc. This weeds out the providers who either don’t care about the patient denial and blindly accept the denial, or patient has to take matters in their own hands just to get the care they need/deserve. Or worse, in the hospital that means the patient gets hit with a huge bill (already an insane number in the US even with insurance, so don’t get me started on this) or it gets delegated to another provider who has to deal with it. Quite often patients get denied medical and rehab services, esp after something debilitating like a stroke, trauma/accident, etc. and at that point the peer to peer is to weed the provider out. Usually someone will tell the patient you’ve been denied, either go home without the services they need or you fight it. I fight it. Can’t count the number of times I’ve spoken to someone not in the field of medicine or if they are, not my field of medicine (both Family/Hospital Medicine). Often I’m fighting with an MD or “practitioner” who is some other field like a gynecologist about hospital medicine services or rehab. I’ve even had the pleasure of talking to a physical therapist and didn’t let me get a word in as we began the peer to peer. I now start of by asking for their credentials and field of speciality and demand a peer of my field to do the denying if they are so adamant about it “not being medically necessary”. I have so much to say and could write a book about it. I just wish I had the money and connections to actually change the state of US of Corporate Medicine.
- OptionOfT 6mo agoAs someone who needs expensive medication, thank you. I appreciate it. 2 questions: * This time, is it paid? Is it billable? Is it part of the visit I pay for? * What can I - as a patient - do to make this process easier?
- ceejayoz 6mo agoIt's unpaid time, but that'll just get factored into the rates charged for billable things like appointments and procedures.
- d_burfoot 6mo agoAmerica cannot, as a country, discover a reasonable approach to managing health care costs because Americans do not have a sufficient core set of shared political values. The solution is to end regulation at the federal level, and allow the states to determine what regulations they may deem appropriate. As a New Hampshire libertarian, I do not want Californian progressives telling me how our state must manage health care spending, and I am sure they feel the same way about me.
- selectodude 6mo agoAs long as you accept the outcome of “drop dead” when something happens to you. Problem is you’ll go right to the emergency room when you have a heart attack.
- expedition32 6mo agoYep they will move to California the moment they get cancer. Never trust a libertarian.
- f33d5173 6mo agoI think the vast majority of people agree on the generalities and care enough about solving the issue to be able to come to an agreement on the particulars. The problem is that the people who get rich off the current system won't agree to any solution that reduces their profits, and have thus far managed to fillibuster attempts at such a solution through a combination of buying politicians and propagandizing certain segments of the population into rejecting solutions that would benefit them.
- jmspamerton 6mo agoso, your answer is OMG, they are making money!11! It's not a money probelm, it's a resources problem. We simply don't have enought hospital resources to serve everyone in the us. it's not making money, it's not having enough beds and skilled people to do the work. Get an MD and help out, then you'll discover how you really DONT want the government to tell you which patients to serve.
- CalChris 6mo agoMedicare has a similar issue. When you sign up at 65, you have to make a first big decision, Traditional Medicare (yay!) or private Medicare Advantage (boo!). Traditional Medicare consists of Part A (hospitals), Part B (doctors) and Part D (drugs). Part A+B don't cover everything so you have a Medigap plan. I have Plan G which has very little paperwork. All up, I spend about $400/mo and I'm very happy with A+B+G+D. With Medicare Advantage you sign over your Medicare rights+benefits to a private insurer. This may save you some money, especially early on. In fairness, not really a lot and the $0/mo plans are a scam. With Medicare Advantage, you will then have to argue with an insurance company for the rest of your life. You'll have to deal with preauthorizations and a restricted network. With Traditional Medicare, what's covered is spelled out pretty clearly ahead of time. Docs know it. You know it. There's literally an app for that. With Medicare Advantage, medically necessary is at the discretion of the private insurance company. Here is the scenario from a relative: he had a heart event which ended up needing a stent. He had to argue with Kaiser while this was going on. Kaiser is 240,000 people. He is one. Medicare Advantage is very profitable. It is possible to switch back from MA to TM which really revolves around your Medigap plan. You are guaranteed issue for Medigap plans for about 3 months before/after you turn 65. After that, you will have to undergo medical underwriting.
- wrs 6mo agoThe theory behind Medicare Advantage is that it would cost the government less than traditional Medicare because the private insurer would be more efficient. Guess what happened.
- rwarren63 6mo agoI think the logic of running a more efficient company is true - they are making more money operating them than the government can/is. The insurers are such behemoths and so largely vertically integrated it is controlling the system instead of improving it. Notice how there is rarely ever any new competition in the health insurance space to drive down pricing.
- missedthecue 6mo agoWell the only ways to make any sort of insurance pool (whether it's run by the government or a private organization, for or non profit) more efficient is to deny more payouts or aggressively select for a less risky risk-pool. Medicare insures everyone over age 65, so the second option doesn't work. You can't just leave half the elderly uninsured because they're fat and likely to run up $100,000 in knee replacements. So you have to deny more claims. Insurance is brutally simple. Money in, money out. Trying to make your back office more lean with tech and automation has extremely limited returns, because the back office is such a small portion of the total cost structure. 95-100% of costs in any given insurance operation are claims. So everything to do making things more efficient and reducing costs has to do with reducing claims.
- spankibalt 6mo agoGeiz-ist-geil-healthcare is, according to many election results anyway, what most US citizens want; everything else is communism/socialism/woke/leftist/[...].
- khriss 6mo agoThe worst part, simultaneously soul crushing and apocalyptic rage inducing is that we get these outcomes after spending more per capita on healthcare than pretty much any country on the planet.
- ceejayoz 6mo agoWorse, we spend more in tax dollars on it than any other country total, and then add on the private spending on top. We do the worst of both worlds. https://commons.wikimedia.org/wiki/File:OECD_health_expenditure_per_capita_by_country.svg https://commons.wikimedia.org/wiki/File:OECD_health_expendit... (And we’re middling in outcomes!)
- jmux 6mo agoEvilcore is a fitting name. > Connecticut’s Insurance Department recently reviewed EviCore and Carelon. It found no problems with Carelon. EviCore was fined $16,000 this year for more than 77 violations found in a review of 196 files. $16k is such a low fine that it’d be funny if it wasn’t so sad. fines should be increased to actually represent a threat to the company - maybe as a % of yearly profit? our system is so fucked dude
- markvdb 6mo agoMultiplier times price of necessary care denied? One can dream. How do you get accountable people in charge of healthcare policy?
- pixl97 6mo agoBy playing Super Mario brothers with those that are not?
- dzdt 6mo agoYes trying to read that article my brain refused to parse "EviCore" as anything but "EvilCorp". Every time.
- deleted 6mo ago[deleted]
- ro_bit 6mo ago> In 2022, Carelon settled a lawsuit for $13 million that alleged the company, then called AIM, had used a variety of techniques to avoid approving coverage requests. Among them: The company set its fax machines to receive only 5 to 10 pages. Who are the people who sleep at night after designing these policies?
- pixl97 6mo agoThey sleep very soundly on a bed made of money. There is an unlimited pool of people without empathy. Never forget that.
- ChrisMarshallNY 6mo agoI am a member of a community that had an extremely high rate of HIV infection, and watched dozens of people die, in the 1990s. It was pretty awful. I found out that many insurance companies deliberately delayed approving procedures, in the hope that it would kill the patient. back then, there was no AI. The decisions were made by humans. Sometimes, people suck.
- randycupertino 6mo agoThere's entire companies (example: MedExpert) whose clients are health insurance companies whose job it is to re-route physician and patient requests for expensive necessary treatment to cheaper alternatives: https://www.medexpert.com/results/ https://www.medexpert.com/results/ When they can't completely deny they delay and/or set up burdensome hoops for the patient to jump through before they will qualify for treatment. It's literally their business model. They even brag about it on their website! > Reduced inpatient hospital admissions by 15% > Reduced use of skilled nursing facilities by 15% (because we won't approve them for nursing care!) > MedExpert clearly reduces rates of unnecessary elective surgery. If you want entertainment go to their glassdoor reviews and sort by lowest ratings: https://www.glassdoor.com/Reviews/MedExpert-Reviews-E777566.htm?sort.sortType=OR&sort.ascending=true https://www.glassdoor.com/Reviews/MedExpert-Reviews-E777566....
- lewdev 6mo agoIf insurance companies are for profit then they are incentivized to deny coverage. This fucking sucks.
- toast0 6mo agoNot exactly. ACA imposes minimum Medical Loss Ratios. If they deny everything, the MLR would be zero and they would have to refund premiums. The more care that's allowed, the more dollars they can keep. It's a complex optimization though; people like to pay less premiums, so an insurance company wants to price coverage low enough to attract customers and then allow enough care to keep the premiums without allowing so much as to reduce their margin.
- LorenPechtel 6mo agoThe problem here is one of balance. As with so many situations where you have unreasonable corporate behavior the problem is the economics favors making wrong decisions. Thus there will be little attempt to prevent those wrong decisions. The only real fix is to make wrong decisions cost--look at airlines. You end up with more passengers that seats, you pay. It went a long way towards addressing the problem. (But it should have been higher and it should be indexed to inflation.) But note the insurance is not always the bad guy. Patients want things that aren't medically warranted, especially when the right answer is "do nothing". And doctors like to run up the bill. And note this article is focusing on things other than medical decisions--but describing a system that could only be a problem if they are making wrong medical decisions. How they decide what claims to examine is irrelevant, what matters is if they are making wrong medical decisions. It very much needs to be considered the practice of medicine and a denial should only come from someone of at least the same specialization as the doctor making the request. And "not medically necessary" should require an evaluation of why, you don't get to just say "no".
- JohnMakin 6mo agoI am perplexed by the type of people that are able to stomach working in these kind of positions - how do they rationalize it? Do they really just not care? Like, in some industries that are not doing great things, or bordering on evil things, I can see sometimes how one could convince themselves they were actually doing good. But this denial stuff is nearly like, "press this button to make money, knowing you may be denying someone critical care that could kill them or cause them harm" and you're comfortable just mashing that button? How do they sleep at night? Or are there just a lot of really gung ho believers that hate provider billing with a passion and believe most of it is waste and they truly know better? Is it a bunch of sociopaths? How this can exist as an industry is crazy to me, I wouldn't even know how to hire, I'd expect the vast majority of applicants upon finding out would say "ew, no" but I guess I have a rosier view of humanity that does not align with reality.
- yks 6mo agoI recommend reading essays from: https://news.ycombinator.com/item?id=48090321 https://news.ycombinator.com/item?id=48090321. Tangentially related to your question. TLDR is that it’s a job that can pay enough to keep one housed, and sometimes there are no alternatives. I’d redirect the outrage away from the grunts denying care, and towards the leadership that set up those incentives. And even further, when the shareholders demand more profit because the line must go up, what to do?
- ahepp 6mo agoWhat are you saying here? Do you just think it's unnecessary to audit the way 18% of US GDP is being spent? You think there is no waste, or it's so small to be negligible? Despite the fact that it's well established the US spends more and gets less benefit?
- JohnMakin 6mo agoThis isn't an audit, and drives up prices. But I guess this response kind of answers my question.
- 6mo ago
- delfinom 6mo agoEviCore looks like EvilCore and knowing some richfucks that got into various businesses, that may be more intentional than coincidence.
- eaf7e281 6mo agoWhen life is controlled by algorithms.
- thatmf 6mo ago[flagged]
- righthand 6mo agoMy IT guy spends his days pushing problems that come across his desk into an LLM and generating reports/responses. He then pushes the generated material out to people in slack channels and says “hey this is what we need to do”. New AI tool? “Lets integrate, this AI report says it’s a good idea”. The C-Suite are so brain dead and unskilled at leadership that they just rubber stamp anything. When asking questions and poking holes in the generated material in order to establish some sort of vetted guidance and leadership direction, the IT and Leadership push back “Well what does your team think we should do?” Yo! I’m literally asking you that question. I’m the implementer employee you’re the specialists and leaders. Did you read the report? Does it make sense? Did you see anything that seems off? “What do you think we should do?” This is how this stuff devovles. All nepotist C-Suites should be hollowed out and fired and we should rebuild our institutions without these useless people that can’t even remember how to run a business or make a decision 6 years into LLMs.
- anarticle 6mo agoI think in the case of Optum + UnitedHealthCare being the Scylla and Charybdis of a healthcare situation, we should break up this style of business. Owning both sides of the equation means there is no competition if you are unlucky enough to find this combination. Feels like two wolves negotiating on how much of the sheep (the sheep is you) they get to eat. Dare I ask, who is for the "consumer"? If we should even use those words in this system, which in my mind should be for a nation keeping its citizens alive and well both of their own sake and the state's sake.
- nradov 6mo agoThat same basic "payvider" business model has been around since Kaiser Permanente pioneered it in the 1940s. The problem isn't with the business model per se, but with consolidation that has effectively eliminated competition in some regions.
- anarticle 6mo agoHow is the payvider model better for customers? I see why it can reduce costs in a runaway cartel based system, but how does it prevent the two wolf scenario? (It's the same wolf in this scheme.)
- pumanoir 6mo agoMark Cuban has a neat startup to appeal health insurance denials www.getclaimable.com/
- nradov 6mo agoThe CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) is driving some industry improvements in this area and there's a lot of opportunity for technologists to help implement it. While the rule mostly only applies to Medicare Advantage health plans, many payers are voluntarily implementing the same HL7 Da Vinci Project Prior Authorization Burden Reduction APIs across all lines of business. These APIs give providers standard ways to check whether prior authorization is required for a plan of treatment, find out exactly what documentation the health plan requires, and then submit the prior auth request. This won't solve the problem of improper denials but will at least reduce delays and errors. https://www.cms.gov/priorities/burden-reduction/overview/interoperability/policies-regulations/cms-interoperability-prior-authorization-final-rule-cms-0057-f https://www.cms.gov/priorities/burden-reduction/overview/int...
- bparsons 6mo agoThought I would remind people here of this simple, but mostly unknown fact about American healthcare: American taxpayers invest more public dollars per capita in healthcare than anyone in the world. This before a single cent is paid into the private insurance system. Through Medicare, Medicaid, VA and other public health programs, you pay about 40% more public dollars per-capita than the most socialist, gold plated single payer system anywhere else. You are not only getting ripped off by your insurer, but you are getting ripped off a public system, which has more than enough money to provide every man, woman and child with a lifetime of world-class, free at the point of service universal healthcare.
- ceejayoz 6mo agoExactly. In chart form: https://commons.wikimedia.org/wiki/File:OECD_health_expenditure_per_capita_by_country.svg https://commons.wikimedia.org/wiki/File:OECD_health_expendit...
- ath3nd 6mo ago[dead]
- ahepp 6mo agoI understand that nobody likes to talk about setting this threshold, but it's not some kind of unique feature of the American healthcare system. I think the article raised some reasonable concerns about EviCore, but it would be a lot stronger if it did more to contextualize denials in terms of the other quadrants (correct approval, correct denial, incorrect approval, incorrect denial). It would also be interesting to compare those statistics across types of insurers (for-profit, not-for-profit, and government).
- ceejayoz 6mo agoThe threshold is not unique. Having several layers of private, for-profit companies incentivized to deny deciding that threshold is fairly unique.
- Nomadeon 6mo agoEven if you get an approval for an expensive specialty drug, good luck. I had the insurance written approval in my hand while the pharmacist told me it was being rejected for needing prior approval. The insurance phone rep said they could find no record of any REQUEST, let alone approval, for the drug. So I go to the state insurance regulator. That does at least light a fire under their arse. They can't claim it's not medically necessary when I already have their approval. During the complaint process I learn: - Front line reps don't have any access to any pre-auths. You need to talk to a supervisor. They ADMITTED the system is by design obstructive. - The person who entered my approval did it wrong and did not follow the SOP to run a test transaction that would have caught the error. They then submit their reply to the regulator leaving out all of the above and blaming the pharmacy instead. I follow up with the regulator pointing this out. I have voice recordings. Regulator closed it as resolved. I'd class action their butts if I wasn't still exhausted by the experience two years later.
- fiej 6mo agoI worked at one of the companies mentioned in this article for a brief period of time as a junior employee. The entire framing on the inside is about helping the industry adhere to evidence-based medicine and reign in the skyrocketing costs of healthcare. The analysts would periodically share results of their anomaly detection, finding physicians who order MRIs at rates multiple standard deviations above the average physician, and further find that these physicians own their machines. There are a lot of examples of this kind of fraud. There’s also bloat and over prescription as doctors are terrified of malpractice and have patients demanding tests or procedures they read about online. When I was working in the company, I really felt like I was helping reign in unnecessary costs. We had many people reading medical literature, consulting with other physicians, scientists and others to create guidelines that form the basis of the pre-approval decisions. It felt like we were centralizing all of that knowledge and “providing it” as a service to society. One day, a brave junior employee asked the company CFO at a lunch and learn, “If we’re doing such a great service for patients, why is it the insurance companies paying us, instead of patients?” The CFO gave one of those replies that is only memorable because of how fumbled it sounded. I realized quickly after that what purpose the company really served and how the incentives created a serious conflict of interest. But my time at the company has convinced me to this day that there are no “innocent” parties in the payer-provider-patient triangle. Every party involved has their own set adverse incentives against each other and the balance of power swings like a pendulum with every merger, acquisition, or regulation passed.
- sethammons 6mo ago> are no “innocent” parties in the payer-provider-patient triangle not the patient?
- LorenPechtel 6mo agoNo. Lots of problems with patients wanting things they've heard of. Think all that drug advertising is for nothing??
- fiej 6mo agoOver utilization, especially after deductibles are met. Demanding tests and treatments that aren’t warranted, and physicians have huge pressure to comply because they’re very heavily goaled on patient happiness (rather than quality outcomes). Patients have zero incentive to shop around on price, so if an academic research hospital MRI costs $6,000 and an independent lab has the same machine and charges $600, most patients don’t care or even know the price difference and let insurance foot the bill. There’s also a small but expensive population of people who are uninsured and go to the ER very frequently and stay for a while (faking illness, requesting drugs, or simply a warm bed and meal). Clearly a societal problem, but hospitals foot the bill for those stays and raise prices for everyone. A lot of the structure of insurance plans (deductibles, co-pays, co-insurance, HMO/PPO, enrollment periods) emerged to provide a counterbalance to patient behavior, characterized by adverse selection and moral hazard primarily
- logankeenan 6mo agoPatrick Rucker, one of the authors, spent time at our company, Claimable, last fall so he could investigate this issue further. Claimable is a startup where we leverage AI to help people appeal their health insurance denials. Ask me anything, I work in this space every day. https://www.getclaimable.com/ https://www.getclaimable.com/
- silexia 6mo agoThe root problem is not health insurers, they are just a happy beating dummy. The root problem is the government restrictions on the numbers of new doctors that existing doctors have passed to restrict supply and keep their salaries astronomically high.