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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

#161

Post by tptacek »

ceejayoz wrote: post #159
tptacek wrote: post #158

Earlier quoted context omitted.

Yes, as I said, if we accept your claim at face value, that every dollar of American practitioner-side insurance overhead --- not the delta from Canada, but every single dollar of it --- is mis-spent, you managed to identify 3.6% of the waste in the system. Congratulations. I said earlier we'd gone round-and-round on this topic before, and I was a little burned out on it, but I didn't expect you to refute your own ar…

Insurance has more than one way to run the costs up; this is but one of them. Weird rebate deals with drug manufacturers. Vertical integration. Buying practices and paying them higher rates. > I was a little burned out on it I just did my taxes and am a little burned out by the $49k in healthcare expenses I got to deduct on them.

[flagged]

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

#162

Post by wingspar »

tiahura wrote: post #149
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…

https://www.snopes.com/fact-check/hipaa-medical-hack-insuran...

Well that’s disappointing…

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

#163

Post by tptacek »

ceejayoz wrote: post #144
tptacek wrote: post #143

Earlier quoted context omitted.

$360B in admin/net cost of insurance. $2.5T in practitioner costs.

> $2.5T in practitioner costs. Some of which is those practicioners' admin cost from dealing with the insurers . (And, you know, doing the actual work.) Denials are nice and cheap. Fighting them is not.

You stated this claim upthread, for the record, and tracked down an actual Canada vs. US statistic on this, which turned out to account for roughly 3.6% of total provider inpatient/outpatient expense.

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

#164

Post by ceejayoz »

tptacek wrote: post #163
ceejayoz wrote: post #144

Earlier quoted context omitted.

> $2.5T in practitioner costs. Some of which is those practicioners' admin cost from dealing with the insurers . (And, you know, doing the actual work.) Denials are nice and cheap. Fighting them is not.

You stated this claim upthread, for the record, and tracked down an actual Canada vs. US statistic on this, which turned out to account for roughly 3.6% of total provider inpatient/outpatient expense.

In 2011, when my premiums were $1600 a month. I dropped my plan when it hit $4900/month to go on my employer’s crappier plan.

And as noted in that other conversation, this is one aspect of many. UHC isn’t pursuing vertical integration for funsies.

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

#165

Post by ceejayoz »

tptacek wrote: post #161
ceejayoz wrote: post #159

Earlier quoted context omitted.

Insurance has more than one way to run the costs up; this is but one of them. Weird rebate deals with drug manufacturers. Vertical integration. Buying practices and paying them higher rates. > I was a little burned out on it I just did my taxes and am a little burned out by the $49k in healthcare expenses I got to deduct on them.

[flagged]

> Fun fact: given your background and field, you probably come out significantly ahead of where you'd be in countries with single-payer health care.

Oh, absolutely not. I’ve done the math on that, for sure. Unfortunately, one family member has a condition that makes emigration infeasible.

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

#166

Post by tptacek »

ceejayoz wrote: post #164
tptacek wrote: post #163

Earlier quoted context omitted.

You stated this claim upthread, for the record, and tracked down an actual Canada vs. US statistic on this, which turned out to account for roughly 3.6% of total provider inpatient/outpatient expense.

In 2011, when my premiums were $1600 a month. I dropped my plan when it hit $4900/month to go on my employer’s crappier plan. And as noted in that other conversation, this is one aspect of many. UHC isn’t pursuing vertical integration for funsies.

That's not an argument; it's just vibes. Whenever we get actual numbers to look at, your arguments fall apart.

Again, I want to be clear: I'm not here to defend the American health system. It's a disaster. It's just clear to me you don't have a bead on why that is. (The answer is artificial scarcity of practitioners, overprescription, and lack of price transparency).

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

#167

Post by nradov »

mindslight wrote: post #156
nradov wrote: post #141

Earlier quoted context omitted.

Your guess would be wrong. At least at the federal level there is no such law. (It's possible that some states might have more stringent laws.) https://healthlaw.org/wp-content/uploads/2025/11/Vanneman_Pr...

This seems like a straightforward argument based on existing practice of medicine laws rather than anything specific. Your arrangement with the health "insurance" company is that they will cover treatments that are objectively medically necessary. In our society, such judgements are made by licensed domain experts with a duty of care (whether a doctor, attorney, professional engineer, etc). Someone without that licen…

It might seem that way to you but that legal theory hasn't succeeded in court. Feel free to try again, though. I'm not claiming that the current legal situation is a good one but any significant change will require an Act of Congress.

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

#168

Post by ceejayoz »

tptacek wrote: post #166
ceejayoz wrote: post #164

Earlier quoted context omitted.

In 2011, when my premiums were $1600 a month. I dropped my plan when it hit $4900/month to go on my employer’s crappier plan. And as noted in that other conversation, this is one aspect of many. UHC isn’t pursuing vertical integration for funsies.

That's not an argument; it's just vibes. Whenever we get actual numbers to look at, your arguments fall apart. Again, I want to be clear: I'm not here to defend the American health system. It's a disaster. It's just clear to me you don't have a bead on why that is. (The answer is artificial scarcity of practitioners, overprescription, and lack of price transparency).

> That's not an argument; it's just vibes.

So is “insurance doesn’t have any externalities that might hide in my very broadly categorized numbers”.

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

#169

Post by nradov »

irishcoffee wrote: post #153
toast0 wrote: post #125

Earlier quoted context omitted.

> The requesting provider can do it for free, or the patient can pay cash. That might not be actually an option. Well the provider can do it for free, probably; but they may not be able to accept money for care that was denied coverage. A Medicare provider can charge patients for things outside the scope of Medicare, but generally can't charge for things in scope but deemed not medically necessary: ex if Medicare say…

I had to take my kid to an express care doctor in the US. My wife had the insurance cards and was on travel. I said I would just pay cash. They said because I had insurance I was not legally allowed to pay cash.

There is no such law. But many employees in healthcare provider organizations are ignorant about the law and just repeat what someone told them.

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

#170

Post by tptacek »

ceejayoz wrote: post #168
tptacek wrote: post #166

Earlier quoted context omitted.

That's not an argument; it's just vibes. Whenever we get actual numbers to look at, your arguments fall apart. Again, I want to be clear: I'm not here to defend the American health system. It's a disaster. It's just clear to me you don't have a bead on why that is. (The answer is artificial scarcity of practitioners, overprescription, and lack of price transparency).

> That's not an argument; it's just vibes. So is “insurance doesn’t have any externalities that might hide in my very broadly categorized numbers”.

Non-falsifiable argument is non-falsifiable. I could literally present you evidence that 2.2T of our medical expenditure is due to a price-fixing ring in syringes, and you'd still be able to use the same argument.
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