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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

#181

Post by tt24 »

ceejayoz wrote: post #138
tt24 wrote: post #136

Earlier quoted context omitted.

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 t…

> Australians eat a substantially similar diet to Americans

Sorry I don't believe this

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

Lol, yeah that's why we have so many fentanyl addicts, the lack of therapy, I'm sure that's it

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

Gunshot wounds obviously, we have way more guns and gun crime than Australia

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

#182

Post by fiej »

I worked at one of the companies mentioned in this article for a brief period of time as a junior employee.

The entire framing on the inside is about helping the industry adhere to evidence-based medicine and reign in the skyrocketing costs of healthcare.

The analysts would periodically share results of their anomaly detection, finding physicians who order MRIs at rates multiple standard deviations above the average physician, and further find that these physicians own their machines.

There are a lot of examples of this kind of fraud. There’s also bloat and over prescription as doctors are terrified of malpractice and have patients demanding tests or procedures they read about online.

When I was working in the company, I really felt like I was helping reign in unnecessary costs. We had many people reading medical literature, consulting with other physicians, scientists and others to create guidelines that form the basis of the pre-approval decisions. It felt like we were centralizing all of that knowledge and “providing it” as a service to society.

One day, a brave junior employee asked the company CFO at a lunch and learn, “If we’re doing such a great service for patients, why is it the insurance companies paying us, instead of patients?” The CFO gave one of those replies that is only memorable because of how fumbled it sounded.

I realized quickly after that what purpose the company really served and how the incentives created a serious conflict of interest. But my time at the company has convinced me to this day that there are no “innocent” parties in the payer-provider-patient triangle. Every party involved has their own set adverse incentives against each other and the balance of power swings like a pendulum with every merger, acquisition, or regulation passed.

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

#183

Post by array_key_first »

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/

The reason it's going to providers is because US healthcare is extraordinarily inefficient. Providers spend too much time doing, well, everything. From admin, to medical records, to documentation. Very little of their time goes to actual, direct care and decisions around care. You can talk to a doctor about this if you want, they'll all tell you the same thing.

Even surgeons. Ask a surgeon how much time they spend in the OR. It's less than you think.

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

#184

Post by array_key_first »

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…

Ah yes, more fragmentation. Surely that will lower the complexity and administrative burden, thereby leading to reduced costs!

The reason healthcare in the US is expensive is very simple: too many cooks in the kitchen. Private insurance simply should not exist. The undeniable reality is that the only way to achieve maximum efficiency is top-down administration.

I understand that that makes libertarians uncomfortable. But what we all have to acknowledge is what we have is not working. Other countries have worked it out. There's no reason to reinvent the wheel here.

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

#185

Post by logankeenan »

Patrick Rucker, one of the authors, spent time at our company, Claimable, last fall so he could investigate this issue further. Claimable is a startup where we leverage AI to help people appeal their health insurance denials. Ask me anything, I work in this space every day.

https://www.getclaimable.com/

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

#186

Post by nradov »

missedthecue wrote: post #146
wrs wrote: post #33

Earlier quoted context omitted.

The theory behind Medicare Advantage is that it would cost the government less than traditional Medicare because the private insurer would be more efficient. Guess what happened.

Well the only ways to make any sort of insurance pool (whether it's run by the government or a private organization, for or non profit) more efficient is to deny more payouts or aggressively select for a less risky risk-pool. Medicare insures everyone over age 65, so the second option doesn't work. You can't just leave half the elderly uninsured because they're fat and likely to run up $100,000 in knee replacements.…

It's not that simple. Something like a quarter of all healthcare procedures aren't justified on an evidence-based medicine basis and do nothing to improve patient outcomes. Higher quality care actually costs less. But there's a huge amount of waste and mismanagement at all levels of the system.

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

#187

Post by nradov »

anarticle wrote: post #145

I think in the case of Optum + UnitedHealthCare being the Scylla and Charybdis of a healthcare situation, we should break up this style of business. Owning both sides of the equation means there is no competition if you are unlucky enough to find this combination. Feels like two wolves negotiating on how much of the sheep (the sheep is you) they get to eat. Dare I ask, who is for the "consumer"? If we should even use…

That same basic "payvider" business model has been around since Kaiser Permanente pioneered it in the 1940s. The problem isn't with the business model per se, but with consolidation that has effectively eliminated competition in some regions.

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

#188

Post by autoexec »

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.

It'd be pretty dystopian if in order to get medical care Americans had to pay some middle man app/service so that it can fight with the middle man the private insurance company they were paying had already inserted between them and their doctor. All if it just raises the total cost of care for the American and absolutely none of it is necessary. The actual fix is to just get rid of the private insurance company and cover everyone's medical needs under a single payer plan.

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

#189

Post by freeone3000 »

tt24 wrote: post #110
freeone3000 wrote: post #103

Earlier quoted context omitted.

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

Why isn’t it “any procedure performed by a doctor all the time with no limits”? Do you think there’s a cabal of doctors doing medical procedures for funsies? And that if such a thing did exist, it would be a bigger problem than some company who has never seen you, never examined you, and you’ve already paid money to, denying the claim because they judge it “unnecessary” when the doctor who did see you claims it is?

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

#190

Post by rsynnott »

wrs wrote: post #33
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…

The theory behind Medicare Advantage is that it would cost the government less than traditional Medicare because the private insurer would be more efficient. Guess what happened.

Ah, yes, nothing cuts costs like, er, inserting a middleman?

I've no idea how anyone ever thought this could work.

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