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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

#231

Post by mancerayder »

dboreham wrote: post #94
Miner49er wrote: post #72

It shouldn't even be legal for health insurance providers to deny claims. It's essentially them practicing medicine without a license, because they're making calls about what healthcare a person needs or doesn't need, only a person's doctor(s) should be able to make those decisions.

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

Yes, but in my opinion it falls to the patient to figure out the details and absorb the risk. That's the messed up part. That insurance providers and medical services might disagree on pricing or whatnot is an inevitability. What's not fair is throwing ordinary people under the bus to deal with it, which for many reasons is risky and can ruin lives.

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

#233

Post by maxerickson »

kstrauser wrote: post #228
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…

Please allow me to counter, from the perspective of someone who owned a medical practice for much of my adult life: - The ACA limits the amount of money, as a percent of revenue, that insurance companies collect as profit. If they wish to increase profit, their primary option is to collect higher premiums and pay more benefits. - (No experience with keeping someone alive overnight. I'm sure it's happened and couldn't…

- I'm not willing to lower the quality of physicians. Other studies have shown that the lack of upcoming doctors is due to fewer people willing to put up with the insane stress levels for mediocre pay. The stereotype of a doctor heading out at noon for an afternoon of golf are largely over for nearly all specialties. Frankly, there are many jobs that pay better with less stress and less personal responsibility.

This assumes that the things being done now are meaningfully contributing to the quality of physicians vs various proposals.

It's also probably a mistake to measure the quality of the doctor vs the quality of the care that is delivered. More doctors that are less stressed and can spend more time on each patient could easily outperform a smaller group of "better" doctors.

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

#234

Post by ASalazarMX »

Miner49er wrote: post #72

It shouldn't even be legal for health insurance providers to deny claims. It's essentially them practicing medicine without a license, because they're making calls about what healthcare a person needs or doesn't need, only a person's doctor(s) should be able to make those decisions.

I'm glad to see this phrased this way, because that was something I felt but hadn't articulated consciously. It's literally private accountants making healthcare decisions.

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

#235

Post by [deleted] »

DennisP wrote: post #109
Miner49er wrote: post #72

It shouldn't even be legal for health insurance providers to deny claims. It's essentially them practicing medicine without a license, because they're making calls about what healthcare a person needs or doesn't need, only a person's doctor(s) should be able to make those decisions.

Agreed. France, Germany, and Japan have health systems similar to the ACA, with the following differences: insurance is nonprofit with an effective mandate, there's a national price list for medical services, and claim denials are prohibited for anything on the list. Germany has an especially effective digital system that guarantees payment within a week. All three systems get better health results than the US, by me…

[deleted]

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

#236

Post by techdmn »

amarcheschi wrote: post #166

I don't know what happened but this super duper upvoted post disappeared from the home of hn. perhaps moderators temporarily shadow content that is upvoted too much? Or else?

Also curious about this. Several other posts of similar age and with fewer points are in top spots on the front page. This post is still gathering comments, but seems to be hidden.

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

#237

Post by __m »

codegeek wrote: post #82

My solution to this mess: - Health "Insurance" middleman mafia should not be the default b/w me and my doctor - Health Insurance should only exisit for Catastrophic events (big surgery, cancer etc) - Get rid of the regular Premiums, CoPays, Deductible, CoInsurnace, In network/Out network Bullshit. - For catastrophic events, we pay a premium (much smaller than now) - All hospitals and Doctors must offer an advertised/…

People will probably avoid going to the doctor if they have to pay cash, missing the opportunity to detect the big things early.

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

#238

Post by caeril »

Denial policy should be very very simple:

If you're seeking coverage for lung cancer, but you chose to smoke, denied.

If you're seeking coverage for type II diabetes, but you weigh 400lbs, denied.

If you're seeking coverage for cancer because you got unlucky with a cosmic ray incident on your DNA, approved.

If you're seeking coverage for a liver transplant because you refused to put down the bottle, denied.

If you're seeking coverage for injuries from an auto accident that was not your fault, approved.

I will NEVER understand why this type of blanket policy is so controversial. Cover bad luck, do NOT cover personal choices. It will fix not only costs, but the moral hazard endemic to the current system.

Or, AT THE VERY LEAST, allow prejudicial adjustments to premiums for fatties, smokers, and alcoholics.

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

#239

Post by adleyjulian »

ethbr1 wrote: post #205

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 au…

It's a question of what we want to measure. There's a metric that represents how much a claimant sees in unexpected costs due to denied claims vs impact on care from the insurer.

A denied prior auth results in no unexpected costs but perhaps a change or delay in care.

A denied claim to an in network hospital may result in the provider losing revenue but nothing for the claimant.

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

#240

Post by leereeves »

foundart wrote: post #191

This is an opinion piece. Its main claim is that the ACA requires denial rates to be available to consumers but they aren't. Additionally, it reports that denial rates have increased 10x in 10 years, based on the following chain: - "UnitedHealthcare nixed 1.1%, Humana 1.9%, Aetna 1.5% in 2013, per the American Medical Association." - "By 2022, major insurers were refusing to pay, on average, 15% of claims, according…

Excellent summary. I'd like to address the denials in particular.

As the article says: "No industry malfeasance could ever excuse murder."

With that in mind, we should remember that every death that happens because a valid lifesaving claim was denied is a kind of murder, and no amount of fraud could ever excuse denying valid lifesaving claims.

The stakes are too high: all claims should be approved, then adjudicated later. Fraud should of course be punished severely (with prison, not merely returning the money), but no one should die to protect insurance companies from fraud.

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