5 ms·
Health insurance claim denial rates range from 13% to 35% by insurer
- vkou 4mo agoGood thing the moral hazard of getting unnecessary healthcare that your doctor ordered for you is controlled for. Perhaps someone should also control the moral hazard of the people owning and running this racket getting unnecessary amounts of money, or an unnecessary seat at the table.
- fnordpiglet 4mo agoThe moral hazard is making a product with nearly totally inelastic demand a multi layered adversarial free market with structural price opacity. Thanks Reagan!
- thomasdziedzic 4mo agoReagan hasn't been president for close to 40 years and died more than 20 years ago. At what point do we accept responsibility for this instead of blaming dead presidents?
- nz 4mo agoYou might be surprised just how durable the effects of 40-year-old decisions are. You can actually see changes to the very degree completion-rates, when partitioned by field of study. Particularly, education and physics fields (as classified by NCES), have absolutely cratered from the mid 70s to the mid 80s, while business fields became dominant. And if you need data, I actually published an entire (and entirely too long) essay, analyzing the NCES data from 1970 to 2011 (a sequel post for 2011 to present is planned), yesterday[0][1]. Healthcare tends to boom and bust[2] in cycles, and those cycles are _inversely_ correlated with engineering, informatics (the most elegant term for what we call "computer and information sciences"), and business. [0]: https://galacticbeyond.com/two-percent-programmer/ https://galacticbeyond.com/two-percent-programmer/ [1]: https://web.archive.org/web/20260620162923/https://galacticbeyond.com/two-percent-programmer/ https://web.archive.org/web/20260620162923/https://galacticb... [2]: In both the economic sense, and in the completion-rate sense, because those two things are correlated. And they have been correlated since the 1980s, because a lot of the healthcare industry became de-regulated and more profitable as a result, since at least 1978 (when hospitals were de-forbidden from making profits).
- fnordpiglet 4mo agoReagan didn’t do it alone, and the philosophy that created this monstrosity inexplicably keeps marching along as if all it needs is more patches and it’s the fault of the demand side and supply side for their philosophical view that “free markets are magic” under every scenario, trundling through the wreckage holding hope as a strategy. As the only country with this problem, maybe the philosophy is wrong. I blamed Reagan because he managed to effect the philosophy in law and regulation, and therefore create the inertia. I can blame him for his role until the end of time, just as I can blame Julius Caesar for ending the Roman republic long after his death (even that happened shortly after his actions!) But it’s ok - the current slow motion disaster unfolding will make the hellscape of reaganomics look like a brilliant insight as we play out early stage idiocracy.
- deleted 4mo ago[deleted]
- IncreasePosts 4mo agoEveryone is in on the grift in the industry. Obama wanted to go single payer but realized 10% of america would be out of a job if we streamlined the bureaucracy
- vkou 4mo agoNah, the problem was that the blue dog democrat congresscritters (holding usually red districts) would have been out of a job. So instead of single payer, everyone got the ACA, and then the blue dog dems lost their jobs anyways.
- dghlsakjg 4mo agoObama proposed and pushed for single payer and it was voted down in the senate. Specifically, if you want to blame someone, it was Joe Lieberman who would have been the deciding vote, and he killed it. Joe Lieberman realized that he was from a state with massive moneymaking insurance operations. Had nothing to do with Obama streamlining bureaucracy.
- mullingitover 4mo ago> Specifically, if you want to blame someone, it was Joe Lieberman who would have been the deciding vote, and he killed it. I too believed that Joe Lieberman sucked, and sure, he did. However: there's a pattern of parties creating convenient designated villains within the party (usually someone not up for re-election) who can take the blame for doing the thing the party insiders planned to do all along. It's been especially noticeable in the current Congress. When the designated villain sticks it to us next time, notice how there are zero consequences for them.
- dghlsakjg 4mo agoMaybe it’s a massive insider conspiracy to have the party ruin its own landmark legislation of the era and all of the coconspirators have kept their mouth shut on a major scandal for more than a decade. Maybe it was the 1.1 million dollars in donations from the healthcare industry to Joe Lieberman. We may never know.
- aetch 4mo agoHad me in the first half there
- deleted 4mo ago[deleted]
- xnx 4mo agoI like the US healthcare system as much as anyone, but this analysis seems to border on useless. Even examining by the type of claim does not control for validity of those claims.
- bluefirebrand 4mo ago> I like the US healthcare system as much as anyone I can't tell if you're being serious. I'm not American but all of my American friends tell me the US healthcare system is an absolute nightmare
- Insanity 4mo agoIt’s definitely a sarcastic comment lol.
- room271 4mo ago'as much as anyone' = they don't like it
- xnx 4mo agoThat phrasing may not translate well. "as much as anyone" means "Most people don't like it, and I don't like it either.". My criticism of the analysis is not a defense of US healthcare.
- airstrike 4mo agos/like/dislike would have made it easier to understand at the expense of missing out on the (possibly accidental) sarcasm which makes the comment more rewarding to those who did understand it
- strictnein 4mo agoPeople like to complain about things and have very unrealistic perceptions of what other systems are like. It's also really unpopular online to say good things about the US healthcare system. It definitely has some issues, but it also does some things really, really well. These are, of course, anecdotes, but here some things from my life: - Next day MRI for my wife after she injured her back at the gym. Had it been more serious she would have been seen the same day. - Friend's kid was diagnosed with leukemia. They were admitted to the cancer ward the next day, where they stayed for months. The room was large, with a pull out double bed for my friend and his wife to sleep on. The same thing happened with my cousin when she was diagnosed with a brain tumor. - Our kids were both born at one of the "poor" hospitals in the largest city in our state. We were the only ones on the floor who shared the same last name, and most patients did not speak English. It was excellent. We had our own room (with bathroom, shower, small bed for me to sleep on), great staff, etc. - Urgent care available 7 days a week at numerous locations within a 5-10 minute drive from my home. Typically a 15-20 minute wait for things like stitches, burns, dislocated fingers, etc. - Nice pharmacies all over the place, which also provide things like vaccinations. Lots of our medications are now just shipped to our house directly - The small surgeries I've needed have been done within 2-3 weeks of meeting with my primary care doctor. If they would have been more serious, the timeline would have been significantly shorter, within a day or two. Things like colonoscopies are also available within a number of weeks. - The hospital system we use has done a really good job embracing technology. The app/website they offer can be used to view all of your test results, message the doctors or nurses, schedule appointments, etc
- s0ibeanz 4mo agoWhat we have today isn't insurance in any meaningful sense. Traditional insurance is about pricing risk: healthier people pay less, higher-risk people pay more, and the pool works because premiums reflect actuarial reality. The Affordable Care Act largely banned that. Insurers can no longer use health status or pre-existing conditions to set rates (via "community rating" and guaranteed issue rules). The result is that everyone effectively pays into a giant, heavily regulated pool. There's a finite amount of money in that pool, so someone has to ration care. That job now falls to the insurance companies, who deny or delay procedures, medications, and treatments. Health insurers aren't saints — but the core problem is structural. When you remove risk pricing while mandating coverage, adverse selection and cost shifting are inevitable. The ACA patched one serious issue (pre-existing conditions) by breaking the fundamental mechanism that makes insurance sustainable. We need to be honest about the tradeoffs instead of pretending this is still "insurance."
- amanaplanacanal 4mo agoIt makes sense. People don't want insurance, they want health care.
- jemmyw 4mo agoBasically you have a tax by another name. That's not necessarily a problem in and of itself, there's plenty of areas in life where we have essentially a tax by another name or system. The problem I see, looking from the outside from a country with a "universal" health system, is that the American way of doing it is extremely complex, which pushes up the price of everything. It's not that there are profits involved, it's that there are so many incentives, and then patches to prevent them, generating more in other places.
- lp4v4n 4mo ago>The popular image of a denial is an insurer overruling a doctor on whether a treatment is needed. That is the exception. Only about 5% of denied in-network claims were turned down because the care was deemed not medically necessary. The rest were administrative, for an excluded service, for a missing referral or prior authorization, or for a reason the insurer never specified. When an insurance company denies a health claim overruling a doctor, it can be necessarily concluded that either: 1. somehow the company knows more about the patient's condition and the doctor is wrong 2. the doctor is defrauding the system and the insurance company caught the doctor cheating 3. the company is defrauding its clients. There is no middle ground honestly, and yet "5% of denied in-network claims were turned down because the care was deemed not medically necessary". This is absolutely crazy and evil. I would expect a few thousand cases annually and probably for million of cases you get denied what you pay for because "we detected your doctor is wrong and we're not paying". >In fact the single largest category, 36% of denials, was an unexplained "other." A system that rejects tens of millions of claims a year and files more than 1/3 of those rejections under no stated reason is hard for an outsider, or a member, to audit. I can't even imagine getting lifesaving care denied because of "other". I didn't know things were so grim in the USA and honestly now I'm kinda surprised that more people are not getting "Luigi'd".
- bonsai_spool 4mo ago> 5% of denied in-network claims were turned down because the care was deemed not medically necessary". I think the truth is murkier than what you're providing. With the caveat that I am presenting a strong case here that likely isn't what occurs most of the time, consider this: A person may require long-term therapy after an illness. There are data suggesting that beginning this therapy works better once you attain a certain level of clinical recovery in the hospital. There are also data suggesting that it's better to begin the long-term therapy as early as possible. Both sets of data are, on their face, credible. There is no obvious reason to always believe one set of data over another. Reasonable people can make reasonable arguments to reasonable listeners for either case. Note that this does not mean that there is not a 'correct' interpretation for any given person's clinical situation! So what does your insurance company favor? Obviously it will always favor the less expensive option, and there will be no way for them to be convinced otherwise because the underlying question is just not well-determined.
- beej71 4mo agoWhen I went to an in-network ENT (that I found on my insurer's website) they were billed $850 for my 10-minute exam. The insurance said they'd pay $550. So I got to pay the rest. And this is gold coverage with an already-met deductible. You just never know what the roulette wheel is going to hand out. Makes me think of that study a few years ago that found most Americans couldn't afford an unexpected $400 medical bill.
- EtienneDeLyon 4mo agoDid you try looking for a less-expensive ENT?
- beej71 4mo agoI did not, but in my experience it's difficult to pry prices out of medical providers in advance.
- washadjeffmad 4mo agoAs an example, when my ex was trying to price ultrasounds on a breast lump as self pay before choosing where to go, the billing departments refused to quote her without the billing codes for the procedure, which require a treatment plan, which requires an appointment with a doctor at that office or hospital. It took a month of calling around before a nurse who worked between departments took pity and leaked her the common billing codes. Once she got a quote, the estimates dropped from thousands out of pocket on her insurance to a few hundred, to an office comping the procedure. She works in healthcare. I wouldn't have even known where to begin after being told no.
- memcg 4mo agoWhat insurance company do you use? I thought that in-network means the provider has agreed to accept the insurers usual and customary rate and that you are not liable for the difference.
- beej71 4mo ago
- claw-el 4mo agoIf patients and doctors start using LLMs to strategize how to maximize claim approval rate, I wonder how would the insurance companies react to it. Would it start getting more strict and start requesting for more evidence?
- eightysixfour 4mo agoHospitals and some doctors already do - it isn’t a one-sided problem with insurance as the only group optimizing for their desired outcome.
- claw-el 4mo agoI would watch out for insurance as an industry having to increase rates because successful claims rate are increasing much faster than the industry can handle. Not supporting nor opposing the insurance industry, just something I think the public should watch out for and understand.
- eightysixfour 4mo agoAgain, this is already happening. Hospital side care providers use systems which optimize for expected payout value. That increases payout totals and insurance costs for everyone. The ACA tried to make health outcomes a part of the calculation for everyone involved but it is hard to compete with the all mighty dollar.
- FireBeyond 4mo ago"Repricers" work on both sides of the equation - providers and provider networks use them to maximize the procedure codes around an ICD-10 diagnosis code. And insurers use them to minimize the list of procedures they'll accept and pay for around a given ICD-10 code.
- claw-el 4mo agoHonestly, if this means a more certain payment confirmation up front and not a surprise bill, I see this as a good thing for patients.
- fny 4mo agoBefore everyone wants to throw a rock at another CEO... > Only about 5% of denied in-network claims were turned down because the care was deemed not medically necessary. The rest were administrative, for an excluded service, for a missing referral or prior authorization, or for a reason the insurer never specified. I worked in health tech for a while, and I can tell you the muck around a lot with ICD/CPT codes to maximize billing along with other shenanigans. There was actually a project at an innovation center at a well-known medical center which leveraged ML to maximize the amount of codes they could bill for without being rejected. The same kind of thing is often done by physicians who want to juice insurance. Be mad--very mad--at hospitals and drug cos. As providers, they present themselves as patient advocates, but they're responsible for the outrageous healthcare costs. The dollar amount paid out by US insurance companies is maybe 2x that of other OECD countries, but the healthcare we get back from providers is trash (and extortive) by comparison.
- bonsai_spool 4mo ago> There was actually a project at an innovation center at a well-known medical center which leveraged ML to maximize the amount of codes they could bill for without being rejected. T I think this perspective makes sense from someone who works on the insurance side of things. On the other side, there is no way for the insurance company to acknowledge the clinical severity of a patient except via abstruse ICD code choices that only billing clerks know. So this is a perfect case for an LLM - map normal human words onto ICD claim codes to accurately convey patient severity.
- DougN7 4mo agoI was on one of the insurers that denied the fewest claims. However, they also had the fewest doctors. I live in a good sized metro area, but the only podiatrist was 50 miles away in a tiny town. I imagine that had the same ultimate result of denying claims.
- recursivecaveat 4mo agoIt seems kind of silly to tout the 5% "not medically necessary" line when 7 times as many were denied for "a reason the insurer never specified". I wouldn't really describe claim denials for reasons like administrative or missing referrals as value neutral either. These are roadblocks controlled by insurers that waste patient and provider time, and reduce access to care.
- burnt-resistor 4mo agoURL now points to Teaching an AI Agent to Make Beautiful Charts https://www.randalolson.com/beautiful-charts-with-ai/ https://www.randalolson.com/beautiful-charts-with-ai/ I'm guessing one of the referenced insurance companies threatened to sue. Archive link: https://web.archive.org/web/20260621173215/https://www.randalolson.com/2026/06/16/aca-insurer-claim-denial-rates/ https://web.archive.org/web/20260621173215/https://www.randa...