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Health insurance claim denial rates range from 13% to 35% by insurer

randalolson.com

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Re: Health insurance claim denial rates range from 13% to 35% by insurer

#61

Post by naturalmovement »

beej71 wrote: post #56
naturalmovement wrote: post #45

Earlier quoted context omitted.

You may have had 10 minutes face-time with your doctor, but he spent time before your exam reviewing your case, and time afterwards dictating the notes. So likely 30-40 minutes was spent on you and this does not include the nurses and front desk support staff, the janitor cleaning the toilets, all who need a living wage, rent and/or property tax for the facility, facilities maintenance and upkeep. Not to mention the…

I didn't assert the doctor was pocketing it all out that there weren't other expenses. But if it costs $850, I'd like insurance to pay $850.

I don't think you understand how deductibles and coinsurance work.

If you want a near-zero plan, you will pay more per month in premiums.

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#62

Post by rainsford »

bonsai_spool wrote: post #19
lp4v4n wrote: post #16

>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 heal…

> 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…

But in a case where either treatment choice could be reasonable, doesn't it seem like a better answer for the insurance company to defer to your doctor rather than their own assessment? Whoever is making that determination at the insurance company doesn't know you, hasn't treated you, may or may not have more expertise on the specific illness than your doctor, and as you pointed out the insurance company doctor is ultimately motivated by keeping costs low more than they are motivated by keeping you healthy.

Obviously I can see why the insurance company would prefer to be making decisions about your treatment, but it's not obvious why any of the rest of us should view that as an optimal or even acceptable way of running healthcare. It's essentially the car insurance model but with vastly higher consequences, and it's not great even when it comes to car insurance.

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#63

Post by jemmyw »

s0ibeanz wrote: post #14

What 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 tha…

Basically 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.

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#64

Post by dogmatism »

bonsai_spool wrote: post #50
lostlogin wrote: post #38

Earlier quoted context omitted.

> This is literally illegal! Physicians cannot refer patients to entities they own or have an interest in. There has to be a done of exceptions to this. You see a cardiologist and they recommend a stent. They aren’t going to recommend a different cardiologist does it. You see a doctor, and they refer you for a test. They have a share portfolio that contains shares in the facility they referred to. Medicine is riddled…

> You see a cardiologist and they recommend a stent. They aren’t going to recommend a different cardiologist does it. Things must be different in NZ. First, it's true that you're going to want to go to who your doctor knows/recommends. The law in the US is just that they can't refer you to a group they own/their spouse owns, or for which they get a financial benefit. Next, you're speaking about the doctor doing a con…

>Finally, the cardiologist you see in the office is almost certainly not doing stents for you as those are very distinct skillsets (in the US).

Umm, what? No. It's exceedingly rare for an interventional cardiologist in the US not to do office work. The average number of PCI/yr is like 50 or something. Plus if one spent all one's time in the cath lab, they'd have a spinal fusion, knee replacement, thyroid cancer, and cataracts.

But what you are trying to get at is that there is law about self-referral ("Stark law") but in reality there are exceptions that render it fairly useless

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#65

Post by washadjeffmad »

beej71 wrote: post #57
EtienneDeLyon wrote: post #24

Earlier quoted context omitted.

Did you try looking for a less-expensive ENT?

I did not, but in my experience it's difficult to pry prices out of medical providers in advance.

As 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.

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#66

Post by beej71 »

naturalmovement wrote: post #61
beej71 wrote: post #56

Earlier quoted context omitted.

I didn't assert the doctor was pocketing it all out that there weren't other expenses. But if it costs $850, I'd like insurance to pay $850.

I don't think you understand how deductibles and coinsurance work. If you want a near-zero plan, you will pay more per month in premiums.

I do understand, and that's not what happened in this case. I have top of the line gold coverage.

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#67

Post by bonsai_spool »

dogmatism wrote: post #64
bonsai_spool wrote: post #50

Earlier quoted context omitted.

> You see a cardiologist and they recommend a stent. They aren’t going to recommend a different cardiologist does it. Things must be different in NZ. First, it's true that you're going to want to go to who your doctor knows/recommends. The law in the US is just that they can't refer you to a group they own/their spouse owns, or for which they get a financial benefit. Next, you're speaking about the doctor doing a con…

>Finally, the cardiologist you see in the office is almost certainly not doing stents for you as those are very distinct skillsets (in the US). Umm, what? No. It's exceedingly rare for an interventional cardiologist in the US not to do office work. The average number of PCI/yr is like 50 or something. Plus if one spent all one's time in the cath lab, they'd have a spinal fusion, knee replacement, thyroid cancer, and…

> But what you are trying to get at is that there is law about self-referral ("Stark law") but in reality there are exceptions that render it fairly useless

What are the exceptions that render it useless? I have never heard of them in my 10+ years of hearing about it.

I did not know that I-cards do office work, not my area of medicine.

IR is in the angio lab daily without cataracts, thyroid cancer, etc., so that part of your statement is clearly not true.

I also don't understand what you mean about knee replacements... humans are generally capable of standing without requiring surgical intervention.

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#68

Post by codeddesign »

umpalumpaaa wrote: post #29
lp4v4n wrote: post #16

>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 heal…

It should be noted that they use the term “medically necessary” which is a very low standard. There is also “medically reasonable”. For example getting your teeth cleaned professionally is not medically necessary. But it’s medically reasonable. I don’t want a health insurance that only does “Medically necessary” things.

Dental is completely different than medical in the U.S. and a different insurer/carrier. Sorry, but comparing apples to oranges here.

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#69

Post by lostlogin »

bonsai_spool wrote: post #67
dogmatism wrote: post #64

Earlier quoted context omitted.

>Finally, the cardiologist you see in the office is almost certainly not doing stents for you as those are very distinct skillsets (in the US). Umm, what? No. It's exceedingly rare for an interventional cardiologist in the US not to do office work. The average number of PCI/yr is like 50 or something. Plus if one spent all one's time in the cath lab, they'd have a spinal fusion, knee replacement, thyroid cancer, and…

> But what you are trying to get at is that there is law about self-referral ("Stark law") but in reality there are exceptions that render it fairly useless What are the exceptions that render it useless? I have never heard of them in my 10+ years of hearing about it. I did not know that I-cards do office work, not my area of medicine. IR is in the angio lab daily without cataracts, thyroid cancer, etc., so that part…

> What are the exceptions that render it useless? I have never heard of them in my 10+ years of hearing about it.

It sounds so unlikely that there is a blanket rule that you can’t refer to something you have a shareholding in. If you own a shareholding in a hospital you work at, you can’t refer internally for a test?

I just don’t believe that.

Edit: I did some hunting. ‘Per click’ payments or bonus payments based on volume are illegal. Rents must be fair market etc.

It looks like owning a chunk of the place you refer to is fine. https://www.healthcarecompliancepros.com/stark-law-explained...

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#70

Post by burnt-resistor »

URL now points to Teaching an AI Agent to Make Beautiful Charts

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.randa...

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