A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims • Hacker News Board

Re: A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

#191

Post by sjg007 » Mon, Mar 26, 2018, 4:25 PM UTC

tptacek wrote: post #123

ethagknight wrote: post #117

Earlier quoted context omitted.

Health insurance for my healthy young family of 4 spiraled out of control WITH ACA, so much so that I didn’t purchase proper health insurance in 2017, while also underfunding my income tax in hopes that ACA cannot legally “send me a bill” for 2.5% of my household income. (I mean shit, in a red blooded patriotic American, but that penalty made me absolutely furious) All this while paying cash for prenatal visits for o…

You have a young family of four, and can barely afford insurance premiums. Basically, without insurance, every single year you're hitting on a blackjack 17 against bankruptcy. You see the ACA penalty, and you see the insurance premium cost, but you're not factoring in the 5-digit cost of virtually any significant medical expense. Rising insurance premiums aren't good for anyone. The ACA set out to fix the problem of…

"the idea that you can repeal the ACA, do nothing else, and get lower health insurance premiums for real coverage is sleight of hand." --> it's a lie actually.

Re: A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

#192

Post by sjg007 » Mon, Mar 26, 2018, 4:26 PM UTC

whatshisface wrote: post #128

tptacek wrote: post #123

Earlier quoted context omitted.

You have a young family of four, and can barely afford insurance premiums. Basically, without insurance, every single year you're hitting on a blackjack 17 against bankruptcy. You see the ACA penalty, and you see the insurance premium cost, but you're not factoring in the 5-digit cost of virtually any significant medical expense. Rising insurance premiums aren't good for anyone. The ACA set out to fix the problem of…

If enough people didn't have access to insurance, then there would be pressure on hospitals to find ways to reduce prices (so that their volume could go up). As it stands the medical industry is allowed to hold the poor for ransom ("accept our increased costs or they won't get treated") against the US's deep but finite pockets. Before, we had the (very poor) demand elasticity of people paying everything they had and…

Medicaid and medicare are what keep hospitals open. Most of the volume comes from those patient populations.

Re: A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

#193

Post by aaavl2821 » Mon, Mar 26, 2018, 4:36 PM UTC

lotsofpulp wrote: post #178

aaavl2821 wrote: post #132

Earlier quoted context omitted.

I agree. The current players in the healthcare system view people as numbers, and that is terrible. Doctors are the most natural patient advocates, but unfortunately physicians' ability to influence healthcare, on a system or patient level, has decreased significantly in recent years. I would love to see (and am hoping to build) solutions that give more power back to doctors and patients, and focus on patient experie…

Allocating healthcare resources is numbers, and there is nothing wrong with that. If you want to decrease costs, then increase the supply of healthcare. Healthcare = doctors + medicines + equipment, so all you need to do is increase that supply. However, you’ll find that the doctors don’t want to increase their supply and they’re very effective. Drug manufacturers also don’t want to increase supply, and they’re also…

I'm an Econ major so am totally on board with being analytical about allocating resources, but it's not quite as simple as just increasing supply

Healthcare services (doctor salaries + facility overhead) is 80%+ of US healthcare spend. At first glance increasing supply of doctors seems reasonable. But how do you do that? Number of doctors (esp primary care and mental health) has been declining because of decreasing reimbursement / payment and increasing burnout. Being a doctor requires a decade or more of making no money, working long and unpredictable hours, and tremendous stress -- literally making life and death decisions. Can't just spin up supply overnight. To really increase supply you'd need to increase doctor salaries or decrease the cost of becoming a doctor. The former would not reduce costs, and the latter also is not ideal

One perhaps better way to increase supply is by rolling back consolidation. So same # of docs, but more independent practices. Another way is letting nurses / others practice at the top of their licenses, although I'll grant your point that physician societies sometimes make this hard. Also, one could argue that having more work done by low cost providers would encourage more volume and potentially unnecessary care

The main overarching issue though, even if it was as simple as increasing supply, the healthcare system in the US is not designed to optimize cost efficient care. It is designed to maximize profit and regulations arent optimized around this. So when hospitals view patients as numbers, the implication is that they will milk every last dollar out of a patient (30% of healthcare spend is unnecessary care). Insurance companies are incentivized to deny as much care as possible. No organization with any power in the system is incentivized to view and manage healthcare costs in an optimally cost efficient way

Re: A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

#194

Post by sjg007 » Mon, Mar 26, 2018, 4:36 PM UTC

pasbesoin wrote: post #146

tptacek wrote: post #32

Earlier quoted context omitted.

The rate of increase for health insurance prices went down after the ACA was enacted. The motivation for enacting the ACA was, in large part, the untenable increase in insurance prices in the 10 years leading up to it. People have a bad habit of blaming the ACA for insurance prices. The ACA failed at its goal of making individual health insurance affordable, that is true. But it didn't cause that problem, and it did…

Businesses were screaming about double-digit percentage, year over year premium increases for their employees. As I see it, the ACA was a very middle-of-the-road policy initiative. Building upon a Republican governor's program, namely Romney's in Massachusetts. It was meant to appeal to and help business as much as uninsured individuals. It was conservative in that it didn't throw out the existing system of insurance…

And it worked for the Republicans, they used it as a wedge issue to regain control and ultimately the Presidency. That in turn allowed them to pick our pockets and hand out tax breaks to the wealthy. The media failed in its duty to protect the public by exposing these dirty tricks.

Re: A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

#195

Post by sjg007 » Mon, Mar 26, 2018, 4:39 PM UTC

theluketaylor wrote: post #186

tptacek wrote: post #14

If you're a tech entrepreneur, it's the first story in here that should alarm you the most. It's about denying coverage altogether, not about denying individual claims. Outside of the "guaranteed issue" ACA market, there is virtually no due process for coverage denial. You can be denied on a whim, with little recourse. The list of conditions for which insurance outside the ACA will be denied is long and opaque. The s…

As a Canadian observer I don't understand why Democrats don't go after the small business angle of single payer much, much harder. Don't get me wrong; the lack of health care for poor and at risk populations in the US is a complete disaster, but that argument hasn't swayed the debate for decades now, so it's time for a new approach. Health care being tied to employment is anti-startup and anti-small business, full st…

I dunno, the poor get medicaid which is great insurance. The real problem is that they are too poor to utilize it. The other issue is that medicaid has a state component so you see drastic differences in implementation even though there are Federal minimums.

Re: A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

#196

Post by bzbarsky » Mon, Mar 26, 2018, 4:59 PM UTC

b1daly wrote: post #174

curun1r wrote: post #115

Earlier quoted context omitted.

I'm sick of people making this comment because it's flat out wrong. Insurance is about lowering variance, not about subsidizing high risk. The ACA tries to make insurance affordable for everyone, and in the process, some people pay less than their actuarial cost and others pay more. That is not just insurance, it's forcing people with a lower actuarial risk to subsidize those with a higher risk. Insurance is about ta…

You seem to be making an argument based on “semantics” here? The idea of extending an insurance program into a mechanism for subsidizing those who can’t pay the premium does not mean it magically transforms the program into a totally different thing. In the limited definition, it is still the case that the healthy pay the cost of sick. The extension of the concept of insurance fits semantically, because it is based o…

> because it is based on the idea that there is an element of chance inherent in who gets sick

That statement is true, but health "insurance" covers lots of non-chance things, because it covers lots of things that are not a result of "getting sick". Some examples:

* Birth control.

* Basic childhood vaccination.

* Well-child checkups.

* Annual health checkups for adults.

* Basic screening tests for adults (mammograms, colon cancer screens, that sort of thing).

All these things should be provided, imo; insurance is the wrong vehicle for providing them. Politically, I _think_ (hope?) there would be a lot more support for "provide all children with basic health checkups" than there is for the ACA. Of course there would be less support for the "birth control" item, which is why people like to bundle these all together, and with things like emergency medicine and end-of-life medicine. Which are _also_ quite different in terms of their risk profiles, tradeoffs, and elements of chance.

It also covers some things that in an ideal world would not be chance but are in practie (e.g. routine births with no complications; they are more chance than they should be because as a society we suck at birth control, on both the organizational and personal level).

I really wish we separated our "health care" a bit more along some of these axes, because I suspect that the "right" answer is to have single-payer for some aspects of it, an insurance scheme (private or public or both) for other aspects, and "you're on your own" for still others, with expensive and invasive end-of-life interventions heading this last list.

Re: A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

#197

Post by dv_dt » Mon, Mar 26, 2018, 5:41 PM UTC

lotsofpulp wrote: post #183

kup0 wrote: post #182

Earlier quoted context omitted.

The ACA is bad for people that even do care and even initially supported the ACA, like myself. It has plenty of good parts, but I have to be honest, my choices of insurance options went to almost nothing, and the prices skyrocketed. Part of this may have to do with certain parties in Congress purposely underfunding the ACA to make it fail, so I don't know how much blame goes to the ACA and how much goes to those tryi…

ACA allowed more people to get access to healthcare. This means increased demand. ACA did not increase supply of healthcare. This means higher prices, implying higher premiums and deductibles. Your options are fewer now because you have to be bigger to able to absorb the costs of the extremely high cost individuals such as those with anemia and premature babies and cancer patients. Everything you’re experiencing is b…

Simplistic supply and demand analysis does not reflect the complexities of the US healthcare market. There are numerous public analysis of where the costs from our market come from - and they are strongly correlated with the fact that it's a "market" at all.

e.g. the US as more doctors per capita than the UK and Canada - both of which have much lower healthcare costs than the US.

Re: A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

#198

Post by pnutjam » Mon, Mar 26, 2018, 7:24 PM UTC

ModernMech wrote: post #23

tptacek wrote: post #14

If you're a tech entrepreneur, it's the first story in here that should alarm you the most. It's about denying coverage altogether, not about denying individual claims. Outside of the "guaranteed issue" ACA market, there is virtually no due process for coverage denial. You can be denied on a whim, with little recourse. The list of conditions for which insurance outside the ACA will be denied is long and opaque. The s…

My 5 day stint in the mental hospital was billed at $14,000. With my gold plated health insurance plan, it was still $3k.

Geez, that's enough to drive you crazy.

Re: A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

#199

Post by aaavl2821 » Mon, Mar 26, 2018, 7:31 PM UTC

Spooky23 wrote: post #49

aaavl2821 wrote: post #41

Earlier quoted context omitted.

a lot of hospitals do eat denied claims. look at this [0], the annual financial report for HCA, the biggest publicly traded hospital company. ctrl-f for "provision for doubtful accounts". this represents denied claims / treatments for uninsured patients. this is ~7-10% of revenue. now look at EBITDA, a common metric representing cash flow. look at EBITDA / revenue, ie cash profit margin. this is around 20%, which is…

Did you get any sense of how they ran their businesses? My doctor was part of a medium sized practice that was swallowed up by a big regional system. Since that acquisition, they make the .gov that I work for look efficient and streamlined. They literally added 5-6 non-billable staff to an office that was staffed by 2. Per my doctor, that’s typical in most offices!

Most of them focused on two metrics: 1) increasing inpatient admissions (ie volume) and 2) increasing surgical volumes (biggest profit driver in HC services). To increase inpatient volume and surgeries they often buy outpatient clinics so they can control that patient flow. So they often view primary care as a loss leader that is directing patients to the profit center of surgeries. If those nonbillable staff are optimizing billing, or generating / managing patient flow, they are accruing profits to the health system even if they are losing money for the individual clinic

Negotiating good rates with payers is a top priority and a lot of strategy derives from that (which is another reason why they bought your doc: if they control all patient flow in and out of hospital, they have more leverage with payers)

how does your doc like working for a big health system?

Re: A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

#200

Post by currymj » Mon, Mar 26, 2018, 8:42 PM UTC

theluketaylor wrote: post #186

tptacek wrote: post #14

If you're a tech entrepreneur, it's the first story in here that should alarm you the most. It's about denying coverage altogether, not about denying individual claims. Outside of the "guaranteed issue" ACA market, there is virtually no due process for coverage denial. You can be denied on a whim, with little recourse. The list of conditions for which insurance outside the ACA will be denied is long and opaque. The s…

As a Canadian observer I don't understand why Democrats don't go after the small business angle of single payer much, much harder. Don't get me wrong; the lack of health care for poor and at risk populations in the US is a complete disaster, but that argument hasn't swayed the debate for decades now, so it's time for a new approach. Health care being tied to employment is anti-startup and anti-small business, full st…

Democrats do not all want single payer healthcare. Only the left wing of the party really wants it, although this is slowly changing.

Center and center-right Democrats are pretty happy with the ACA as it was intended, although often not as it actually turns out in many states. Unsurprisingly, a lot of them take big contributions from insurers and pharmaceutical companies.

I think if single payer becomes widely accepted within the party, you probably will see the "helping entrepreneurs" angle as a big part of the messaging -- individual candidates do bring it up.