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Feds help health insurers hide their dirty secret: denials on the rise

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Re: Feds help health insurers hide their dirty secret: denials on the rise

#201

Post by ethbr1 »

fny wrote: post #195
dboreham wrote: post #94

Earlier quoted context omitted.

Otoh some medical providers like to over bill and over treat.

Yes, insurance companies deny claims, but this is mostly because they don't have the money to pay for things most of their money is spent on care in the first place: they're forced to optimize and people get hurt in the process. Providers do far more damage. UHCs profit margins are only 6%, their operating costs are extremely low[0], and if you look across G7 insurers in the US pay more than the government does in ev…

Underappreciated reality.

Because customer-insurer relationships are the only side of the healthcare system that most people see, they're oblivious to what are actually pass-through insurer-provider issues.

As you said, the reality is that insurers operate with pretty reasonable margins and incredibly meager per-claim overhead costs. They're stuck trying to make 2 + 1 = 2.

If the finger should be pointed at root causes in the US health system, it should be at:

   - Providers overbilling (particular in certain specialties)

   - Medical schools, for charging too much and under-expanding capacity

   - The federal government/Congress, for failing to expand residency funding to increase supply (especially in generalist provider categories)

Re: Feds help health insurers hide their dirty secret: denials on the rise

#202

Post by dheera »

foundart wrote: post #174
dheera wrote: post #60

Just leaving this here for reference: In 2022 I was denied full insurance payment of a routine, preventative echocardiogram at Stanford Healthcare to monitor my heart issues. I was balance billed $5000+. The insurance company was HealthNet. The policy clearly indicated full coverage of preventative procedures, without a deductible. They said they did not recognize the procedure as preventative. Fuck them, I know bett…

Thanks for the tips. I do have a question about one thing you said: > I know better about what's preventative and what's not than them. How is that? From your profile I don't see any medical training.

The insurance companies don't have medical training either. I know far, far more about my body's medical situation than them.

Doctors and medical research may supply me with additional medical knowledge, but the insurance company can go to hell. They don't know a damn thing about any of this.

Re: Feds help health insurers hide their dirty secret: denials on the rise

#203

Post by cjbenedikt »

jbb67 wrote: post #77
garciasn wrote: post #47

I was just denied a colonoscopy as not medically necessary by UHC, coincidentally three days before their CEO was killed, because they don't want me to have anesthesia to do it; they argue I should be awake. When I called to refute the denial, which was denied, I asked them to find the person, if it was a person, who denied it and shove a tube up their ass without anesthesia and then reassess whether it's medically n…

But it's not usual to have an anesthetic for a colonoscopy is it? I've had two without. I was offered a light sedation but then I couldn't have driven home afterwards. It wasn't particularly awful without. It's it usual to be asleep? I've not really heard of that. Is it a US thing?

Same here, just had one in the US and I refused to be sedated as I knew from previous one in EU that it is tolerable. You should have seen the song and dance of the provider trying to convince me to get sedated. In the end they accepted my decision. Afterwards about everybody in the clinic came to see me as if I was a hero of sorts. However,the whole episode gave me a good insight as to why US healthcare is so expensive.

Re: Feds help health insurers hide their dirty secret: denials on the rise

#204

Post by scarecrowbob »

timr wrote: post #115
garciasn wrote: post #47

I was just denied a colonoscopy as not medically necessary by UHC, coincidentally three days before their CEO was killed, because they don't want me to have anesthesia to do it; they argue I should be awake. When I called to refute the denial, which was denied, I asked them to find the person, if it was a person, who denied it and shove a tube up their ass without anesthesia and then reassess whether it's medically n…

> I was just denied a colonoscopy as not medically necessary by UHC, coincidentally three days before their CEO was killed, because they don't want me to have anesthesia to do it; they argue I should be awake. It sounds like something is getting lost in translation. Presence or absence of anesthesia does not change the medical necessity of the procedure. > I'm 45. Colonoscopies are a thing. I had a friend die at 52 t…

"Anyway, I absolutely don't want to reflexively defend the health insurance industry in the US, but ..."

I am glad you are able to recognize behaviors that you don't like doing, as that's the first step in not doing them.

Re: Feds help health insurers hide their dirty secret: denials on the rise

#205

Post by ethbr1 »

There's an easy solution to this that the Federal Employee Program (aka FEP) [0] uses -- regular, external accuracy audits.

The relevant metric to customers isn't "What percentage of claims are denied?" given the substantial amounts of medical claim fraud.

It's "What percentage of claims are denied... that should have been approved?"

So you regularly audit a random sampling of denials, publish the results of that audit transparently, and provide a financial incentive for insurers to keep their numbers below a certain threshold.

It's worked pretty well for FEP -- to the extent that FEP insurers typically have segregated operations from the rest of the company and do much better on denial accuracy and other metrics.

[0] https://en.m.wikipedia.org/wiki/Federal_Employees_Health_Ben...

Re: Feds help health insurers hide their dirty secret: denials on the rise

#206

Post by [deleted] »

timr wrote: post #184
seanmcdirmid wrote: post #146

Earlier quoted context omitted.

When my doctor recommended mine, she said that they could do screening but if they found anything, they would have to do a colonoscopy and then it wouldn’t just be covered as screening (since it was an incident rather than preventive at that point). She said it was better just to get the colonoscopy due to health insurer rules.

> It wouldn’t just be covered as screening (since it was an incident rather than preventive at that point). She said it was better just to get the colonoscopy due to health insurer rules. Well yeah...it isn't screening then. It's a treatment. So the question becomes whether or not the treatment is necessary. If the prior "screening" didn't show definitive evidence that the treatment is necessary, then...what are you…

[deleted]

Re: Feds help health insurers hide their dirty secret: denials on the rise

#208

Post by relaxing »

ethbr1 wrote: post #201
fny wrote: post #195

Earlier quoted context omitted.

Yes, insurance companies deny claims, but this is mostly because they don't have the money to pay for things most of their money is spent on care in the first place: they're forced to optimize and people get hurt in the process. Providers do far more damage. UHCs profit margins are only 6%, their operating costs are extremely low[0], and if you look across G7 insurers in the US pay more than the government does in ev…

Underappreciated reality. Because customer-insurer relationships are the only side of the healthcare system that most people see, they're oblivious to what are actually pass-through insurer-provider issues. As you said, the reality is that insurers operate with pretty reasonable margins and incredibly meager per-claim overhead costs. They're stuck trying to make 2 + 1 = 2. If the finger should be pointed at root caus…

What’s the source of limited supply of doctors meme? Is there a good rundown somewhere?

Because anecdotally, among my friends, I’ve never known someone to not make it through the system to practicing medicine who wanted to, but I do know several who persevered despite being real idiots. I don’t see how opening the pool wider would lead to better care.

Re: Feds help health insurers hide their dirty secret: denials on the rise

#209

Post by OutOfHere »

dheera wrote: post #147
AdmiralAsshat wrote: post #108

Earlier quoted context omitted.

That might have gotten them to stop bugging you, but I imagine your credit score still took a hit?

It didn't show up on my credit score at all. I also wasn't too concerned about that because (a) I believe medical debts don't affect credit scores for a long time. (b) I believe medical debts are required to have complete erasure from a credit report if cleared so if I actually needed my credit score to buy a house or whatever I could take the $5K hit to restore the credit score at that time. (c) I sent them a formal…

Fwiw, in New York state, medical debt is prohibited from being reported on the credit report or from affecting the credit score. California has also passed such a law that takes effect soon.

New York's law focuses on prohibiting healthcare providers and related entities from reporting medical debt, while California's law directly restricts credit reporting agencies from including medical debt in credit reports.

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