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

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

#131

Post by righthand »

My 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.

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

#132

Post by IX-103 »

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/

It's going to the administration overhead. If you have to document everything and argue for every medical procedure and deal with 20+ different processes for filing claims then it takes time. And, as a provider, you have to pay someone to spend that time if you want to get paid.

It doesn't help that our healthcare billing systems are so outdated and broken. I once had a doctor visit denied with the reason code that it should charge the other insurance (for people on multiple plans). I was only on one plan, but my wife was on two. The doctor and I went through all the paperwork - my name was right, my birthday was right, my policy number was right and when I got notice of the rejection it had my name on it. Eventually we traced it to an error - not in my insurance company, not in the company that handles claims in this areas for my insurance, but instead in some middle-man company that was responsible for transferring claims between the two. Nevermind that all three companies claimed to be BlueCross BlueShield. This took over a year to resolve.

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

#133

Post by ceejayoz »

tptacek wrote: post #130
ceejayoz wrote: post #123

Earlier quoted context omitted.

> It literally breaks practice and net cost of insurance out! But it's not a "Cost of Health Insurance" item. It's an expense at the practicioner level! They have to factor that non-billable time into what they charge for the procedure! Read their definitions: https://www.cms.gov/files/document/quick-definitions-nationa... "Administration" is the insurer's side of it.

This is special pleading.

Oh, now who's dodging?

If an insurer manages to double a doctor's administrative costs for billing/appeals/etc., where does it show up in your tables, per your link's PDF of definitions?

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

#134

Post by ordersofmag »

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.

In the US around 26 million people have no form of health insurance. These same people are unlikely to be able to afford a 'simple' gall bladder ablation out of pocket. Which implies an effectively infinite wait time. What's crazy is that some people think this is normal.

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

#135

Post by toast0 »

lewdev wrote: post #61

If insurance companies are for profit then they are incentivized to deny coverage. This fucking sucks.

Not 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.

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

#136

Post by tt24 »

ceejayoz wrote: post #129
tt24 wrote: post #124

Earlier quoted context omitted.

Yeah they are. Americans engage in more unhealthy eating, crime, and drug use than Australians. It’s very easy for me to believe that they’re 3 times as sick.

Australia is very close behind the US in obesity and illicit drug use. Side note: I'm an Australian citizen, living in the States. An Australian hospital doesn't need a billing/collections department and the docs don't sit on appeals calls with insurance; when my wife broke her foot visiting, they basically didn't know how to bill her (for surgery and three days in a ward!). My son needed a badly ingrown toenail trea…

I didn’t say obesity, I said unhealthy eating. Those aren’t the same thing.

I straight up don’t believe the drug use one, we have way more fentalyl deaths than you and it’s not even close.

You didn’t address crime. We have much more of it. More gun ownership and gun usage as well.

I’m not quite sure what this anecdote has to do with my comment.

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

#137

Post by randycupertino »

ChrisMarshallNY wrote: post #51

I 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.

There'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/

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....

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

#138

Post by ceejayoz »

tt24 wrote: post #136
ceejayoz wrote: post #129

Earlier quoted context omitted.

Australia is very close behind the US in obesity and illicit drug use. Side note: I'm an Australian citizen, living in the States. An Australian hospital doesn't need a billing/collections department and the docs don't sit on appeals calls with insurance; when my wife broke her foot visiting, they basically didn't know how to bill her (for surgery and three days in a ward!). My son needed a badly ingrown toenail trea…

I didn’t say obesity, I said unhealthy eating. Those aren’t the same thing. I straight up don’t believe the drug use one, we have way more fentalyl deaths than you and it’s not even close. You didn’t address crime. We have much more of it. More gun ownership and gun usage as well. I’m not quite sure what this anecdote has to do with my comment.

> I didn’t say obesity, I said unhealthy eating. Those aren’t the same thing.

Australians eat a substantially similar diet to Americans, and have similar health issues (obesity, heart disease, etc.) as a result. They are deeply related things.

> I straight up don’t believe the drug use one, we have way more fentalyl deaths than you and it’s not even close.

Gee, I wonder if not having healthcare (including access to things like therapy and rehab) might drive up drug death rates.

> You didn’t address crime.

Sure; you didn't address how it's responsible for 3x the healthcare costs.

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

#139

Post by tptacek »

ceejayoz wrote: post #133
tptacek wrote: post #130

Earlier quoted context omitted.

This is special pleading.

Oh, now who's dodging? If an insurer manages to double a doctor's administrative costs for billing/appeals/etc., where does it show up in your tables, per your link's PDF of definitions?

You have no evidence for this argument. It's just vibes. The numbers here are stark. It's not like it's close, between providers and insurers. Insurers are almost literally a rounding error.

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

#140

Post by tptacek »

IX-103 wrote: post #132
tptacek wrote: post #75

Earlier quoted context omitted.

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

It's going to the administration overhead. If you have to document everything and argue for every medical procedure and deal with 20+ different processes for filing claims then it takes time. And, as a provider, you have to pay someone to spend that time if you want to get paid. It doesn't help that our healthcare billing systems are so outdated and broken. I once had a doctor visit denied with the reason code that i…

No it's not. There is absolutely no way to get from $360B of insurer admin and net cost of insurance to $2.5T --- two point five trillion --- in practitioner costs on paperwork overhead. That is not a plausible argument.

The numbers here are not close. They're stark.

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