Hacker News Board Hacker News, browsed like a classic message board
Live data from Hacker News

"Not Medically Necessary": Helping America's Health Insurers Deny Coverage

propublica.org

Post reply on HN
Print view View original

91–100 of 224 posts

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#91

Post by Sohcahtoa82 »

jmspamerton wrote: post #21
ervine wrote: post #11

Earlier quoted context omitted.

What's a libertarians take on how health care should work? Completely privatized, completely socialized, somewhere in between?

The fact that the hospital doesn't know what a procedure costs (they make it up based on deals with medicare, medicaid, and individual insurance companies) should give you a hint. Yes, the patient needs skin in the game. People need to take care of their own health. Most procedures are given to grossly unhealthy people. Yes, completely privatize it. Make people pay for their care so their daily decisions are weighed…

So what if someone gets cancer or some other potentially fatal disease despite eating healthy, exercising, not smoking, etc, and they can't afford to pay for treatment?

They just get to die, or what?

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#92

Post by cj »

wingspar wrote: post #71
vanc_cefepime wrote: post #3

“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 defens…

I’ve saved a message that was reposted by Bill Ackman on dealing with denials. Thankfully, never had occasion to use it yet: >> So, your doctor ordered a test or treatment and your insurance company denied it. That is a typical cost saving method. OK, here is what you do: 1. Call the insurance company and tell them you want to speak with the "HIPAA Compliance/Privacy Officer" (By federal law, they have to have one) 2…

Anyone looking for a startup idea? Here you go.

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#93

Post by nick__m »

ben-johnson wrote: post #82
nick__m wrote: post #76

Earlier quoted context omitted.

I live in Québec, Canada and the longest I had to wait was 3 months for a gallbladder ablation. And my wife, who is on her fourtht year of ribociclib to prevent her spinal metastasis (breast cancer) from coming back, have timely periodical CT-PET and IRM scans. MAID is popular not because of lack of care but because Québécois values their autonomy and quality of life above being simply alive for the longest time poss…

In the US nobody waits three months for a simple gall bladder ablation. What's crazy is you think that's normal. She has 'timely' scans because they are made months in advance.

But it was truly not urgent, I would have been ok with waiting 6 months!

And the scans are not scheduled months in advance. We complained that we were only informed of the date and time of the next scan a few days before it... The explanation was that they have a must not be done before and a must be done after dates but the actual scheduling is done just in time so urgent case are prioritized before routine care.

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#94

Post by AlotOfReading »

jmspamerton wrote: post #13
vanc_cefepime wrote: post #3

“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 defens…

Physician and Hospital resources is a real zero sum game, how do you fairly regulate the medical landscape so those who's lives will benefit most from a procedure will receive the procedure? Who decides this? You? Should we allow everyone in the world who needs a procedure to receive one free and get ahead in line for Americans who need the same procedure? That's what the current climate looks like with unbridaled im…

I guarantee you that the insurance company has zero clue or consideration for any physician and hospital resource constraints.

Gating access to medical care is the job of the patient's PCP and or other doctor. If the care is truly, meaningfully rationed (like transplant organs and blood banks), there are triaged priority lists managed by medical organizations.

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#95

Post by d_burfoot »

f33d5173 wrote: post #10
d_burfoot wrote: post #6

America 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…

I 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…

I'll accept your first sentence for the sake of argument. You are still better off with a localist / federalist approach, because state governments are much less vulnerable to corruption and bribery. It is far more economically efficient for the bad guys (whoever they are in your view) to bribe a few DC legislators than dozens of state politicians in places like Montpelier and Hartford. Centralized, unaccountable power in DC means that when big rich corrupt companies bribe the right people, they can force the entire country to followed their preferred policies. A good example is how Purdue Pharma bribed the head of the FDA to approve OxyContin, leading directly to the opioid crisis.

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#96

Post by BeetleB »

ben-johnson wrote: post #84
throwway120385 wrote: post #65

Earlier quoted context omitted.

> In Canada, the wait is so long for free specialized procedures that many patients choose euthanasia instead. This claim is so outlandish that I'd like to see some sources for it.

[flagged]

Where in the link does it say they're opting for euthanasia due to long wait times?

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#97

Post by ceejayoz »

tptacek wrote: post #75
psadauskas wrote: post #74

Earlier quoted context omitted.

... nor the providers.

In fact it's overwhelmingly going to the providers. https://nationalhealthspending.org/

https://sph.brown.edu/news/2025-11-10/unitedhealthcare-optum...

> Today, many of those practices have been bought up by large corporations, including hospitals, private-equity firms and even health-insurance companies. It’s a shift that not only has changed how money moves through the health care system, but may also be helping some insurers boost their profits, according to new research published in Health Affairs.

> A study from researchers at Brown University’s Center for Advancing Health Policy through Research and the University of California Berkeley found that UnitedHealthcare, the nation’s largest health insurer, pays doctors who work for its own physician network, Optum, more than it pays independent practices for the same care.

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#98

Post by tptacek »

ceejayoz wrote: post #97
tptacek wrote: post #75

Earlier quoted context omitted.

In fact it's overwhelmingly going to the providers. https://nationalhealthspending.org/

https://sph.brown.edu/news/2025-11-10/unitedhealthcare-optum... > Today, many of those practices have been bought up by large corporations, including hospitals, private-equity firms and even health-insurance companies. It’s a shift that not only has changed how money moves through the health care system, but may also be helping some insurers boost their profits, according to new research published in Health Affairs.…

This isn't a response to anything I just said. I really don't understand why people collapse into all this handwaving when people point out the obvious: the money in our system is going to providers, and, in particular, it's going to practitioners.

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#99

Post by BeetleB »

Animats wrote: post #37
CalChris wrote: post #26

Medicare 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. W…

Yes. "Medicare Advantage" = HMO. All the usual HMO problems. The best Medigap plan is Plan F, which is no longer available to new subscribers. "Discontinuation of Medicare Plan F was a strategic decision aimed at promoting responsible healthcare spending and ensuring the financial sustainability of the Medicare program." It covers just about everything Medicare doesn't pay, including the various deductibles Medicare…

> "Medicare Advantage" = HMO. All the usual HMO problems.

Not on Medicare, but I switched to an HMO over 10 years ago at work, and have never been happier.

There are fantastic and crappy PPOs, and fantastic and crappy HMOs.

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#100

Post by ceejayoz »

d_burfoot wrote: post #95
f33d5173 wrote: post #10

Earlier quoted context omitted.

I 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…

I'll accept your first sentence for the sake of argument. You are still better off with a localist / federalist approach, because state governments are much less vulnerable to corruption and bribery. It is far more economically efficient for the bad guys (whoever they are in your view) to bribe a few DC legislators than dozens of state politicians in places like Montpelier and Hartford. Centralized, unaccountable pow…

> It is far more economically efficient for the bad guys (whoever they are in your view) to bribe a few DC legislators than dozens of state politicians in places like Montpelier and Hartford.

State politicians are much cheaper, and no one from the New York Times pokes around when you buy off the state representative of East Bumfuck, Montana.

Post reply on HN