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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

#101

Post by ceejayoz »

tptacek wrote: post #98
ceejayoz wrote: post #97

Earlier quoted context omitted.

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 .

The insurers are buying the practices so they can eat at both sides of the trough.

(And the independent practicioners are having to use a significant portion of the money they take in to… fight the insurers!)

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

#102

Post by jghn »

ben-johnson wrote: post #64
hdgvhicv wrote: post #56

Earlier quoted context omitted.

Every other country seems to solve it

[flagged]

I'm in the US. I have 4 different appointments that are in 2027 because the relevant specialists book that far out.

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

#103

Post by freeone3000 »

ben-johnson wrote: post #66
throwway120385 wrote: post #63

Earlier quoted context omitted.

Why not pay for these things out of taxes? I don't think you'll be so quick to defend the system if you ever find yourself needing care beyond a checkup once a year. It's designed to make the insurance carrier money by constantly having little costs slip through the cracks that should be covered. Get a dental checkup? Sorry one of your X-Rays wasn't covered but the other ones were. Now you get to spend hours fighting…

Because there are a finite number of doctors and hospital beds and you can't create either by throwing more money at the problem. You didn't actually read the content did you

The doctor has already managed to find time for the service - she’s seen you. Potentially even done the procedure. The hospital has made room for you. The resource is already consumed by you, like a restaurant meal. The question is who is picking up the check, when you already have a subscription service paid for.

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

#104

Post by tptacek »

ceejayoz wrote: post #101
tptacek wrote: post #98

Earlier quoted context omitted.

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 .

The insurers are buying the practices so they can eat at both sides of the trough. (And the independent practicioners are having to use a significant portion of the money they take in to… fight the insurers!)

What difference is that supposed to make? The money is still going into the pockets of practitioners. And: no, the claim you're making here about practitioners fighting insurers: closer to the opposite thing is true.

The idea that the problem with our system is health insurers is just slopulism. We have grave problems with our system! But they start with the providers, where the majority of all the funding in our system goes, not to the scapegoats they've stoop up in our insurers. The distinction is vitally important, because the most popular answer to this problem is to extend Medicare to everybody, and Medicare is just as victimized by this as everything else is!

We pay doctors too much, and we artificially restrict the supply of practitioners. Those doctors routinely overprescribe. Every other problem in the system is marginal.

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

#105

Post by ceejayoz »

tptacek wrote: post #104
ceejayoz wrote: post #101

Earlier quoted context omitted.

The insurers are buying the practices so they can eat at both sides of the trough. (And the independent practicioners are having to use a significant portion of the money they take in to… fight the insurers!)

What difference is that supposed to make? The money is still going into the pockets of practitioners. And: no, the claim you're making here about practitioners fighting insurers: closer to the opposite thing is true . The idea that the problem with our system is health insurers is just slopulism. We have grave problems with our system! But they start with the providers, where the majority of all the funding in our sy…

"The money is still going into the pockets of practitioners."

And by inflating that amount...

> Using newly available federal price transparency data, the researchers found that UnitedHealthcare pays Optum physician practices about 17% more than non-Optum practices in the same region. In markets where UnitedHealthcare holds a large share of the insurance business, that difference was even larger, up to 61%.

their capped-by-law 20% cut of premiums goes up, too. "Oh, those mean old providers we own charge so much! We have to raise premiums again!"

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

#106

Post by tptacek »

ceejayoz wrote: post #105
tptacek wrote: post #104

Earlier quoted context omitted.

What difference is that supposed to make? The money is still going into the pockets of practitioners. And: no, the claim you're making here about practitioners fighting insurers: closer to the opposite thing is true . The idea that the problem with our system is health insurers is just slopulism. We have grave problems with our system! But they start with the providers, where the majority of all the funding in our sy…

"The money is still going into the pockets of practitioners." And by inflating that amount... > Using newly available federal price transparency data, the researchers found that UnitedHealthcare pays Optum physician practices about 17% more than non-Optum practices in the same region. In markets where UnitedHealthcare holds a large share of the insurance business, that difference was even larger, up to 61%. their cap…

Show me the more recent NHE table where this effect shows up and I'll be ready to have the conversation, but right now this seems like a dodge. Whatever effect you're describing, if it's material, has to have started after the NHE data I just posted, from 2023. I don't remember thinking that the health system in 2022 was good.

Fun thing about the NHE: you can project it as far back as you want. The data is there.

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

#107

Post by AIorNot »

cj wrote: post #92
wingspar wrote: post #71

Earlier quoted context omitted.

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.

Interesting

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

#108

Post by ceejayoz »

tptacek wrote: post #106
ceejayoz wrote: post #105

Earlier quoted context omitted.

"The money is still going into the pockets of practitioners." And by inflating that amount... > Using newly available federal price transparency data, the researchers found that UnitedHealthcare pays Optum physician practices about 17% more than non-Optum practices in the same region. In markets where UnitedHealthcare holds a large share of the insurance business, that difference was even larger, up to 61%. their cap…

Show me the more recent NHE table where this effect shows up and I'll be ready to have the conversation, but right now this seems like a dodge. Whatever effect you're describing, if it's material, has to have started after the NHE data I just posted, from 2023. I don't remember thinking that the health system in 2022 was good. Fun thing about the NHE: you can project it as far back as you want. The data is there.

> Whatever effect you're describing, if it's material, has to have started after the NHE data I just posted, from 2023.

What? Insurers have been playing this game far further back than 2023.

If an insurer doubles the time a doc has to fight over denials and has to hire extra billing staff to assist, where do you imagine that cost shows up?

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

#109

Post by enaaem »

cj wrote: post #92
wingspar wrote: post #71

Earlier quoted context omitted.

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.

Imagine this: patients buy an AI service to get approval. Insures build an AI to deny claims. 21st century AI wars..

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

#110

Post by tt24 »

freeone3000 wrote: post #103
ben-johnson wrote: post #66

Earlier quoted context omitted.

Because there are a finite number of doctors and hospital beds and you can't create either by throwing more money at the problem. You didn't actually read the content did you

The doctor has already managed to find time for the service - she’s seen you. Potentially even done the procedure. The hospital has made room for you. The resource is already consumed by you, like a restaurant meal. The question is who is picking up the check, when you already have a subscription service paid for.

The service is not “free healthcare for any procedure ordered by a doctor all the time without limits”, they have the right to refuse something they feel is unnecessary
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