21–30 of 31 posts
Earlier quoted context omitted.
Do you have an example provider/plan?
I don't know the specific plan since it's through $employer but it's through Aflac. I actually hope my insurance denies me now because it's better, they pay in full and I don't have to be in-network.
A few years ago, as my rebellion ramped up, I enrolled in a Christian Health Sharing Ministry. They published extensive disclaimers, telling members, "THIS IS NOT INSURANCE. DO NOT TREAT IT LIKE INSURANCE. WE RECOMMEND THAT YOU CARRY REAL INSURANCE." Of course, I couldn't afford both the Health Share and real insurance, so I took the risk. But it soon became apparent that I was in over my head. I barely understood th…
I’m sorry you’re having so many troubles with your insurance. I hope it gets resolved.
It is never based on quality care, but on increasing friction and pain in the system in order to minimize payments out of money already collected from patients. It is a criminal racket and nothing makes me angrier in my entire practice.
It's as if you need insurance for the insurance. Does anyone know if this service exists? E.g. if they deny, you don't even talk to them, you forward it straight to your insurance insurance and their lawyer instantly threatens to sue them?
Some employers will have healthcare concierges that help with resolving such issues. An example is HealthAdvocate[1] (no relation). I believe some of these services will take a cut (e.g. 25%) of the money they save for you. I cannot speak to how effective these services are. My general experience with "proxy" services have not been great, due to inadequate care or training. [1] https://www.healthadvocate.com/site/pro…
It's the societal version of Kurt Vonnegut Jr's "dynamic tension." Just muscles pulling against muscles for their own sake, with no actual work getting done. Surely this is a recipe for downfall.
Second, and as a commentor here reminds, patients are often on the line for money (accountability) when the axis of control (the other side of same coin) is between the hospital and insurer.
Every time accountability is separated from control you've get big problems, and incentives to do the wrong thing.
Variations include providers over billing, billing wrong procedure etc. or denying claims on the other side.
All that stuff is done electronically between the provider and insurer (an axis of control) without the insured ever even knowing. Thus bad providers see the patient's policy like a wallet found on the ground.
Contrast with most commercial transactions: the service provider has no/none/zero access to any customer money directly or indirectly. All the provider can do is bill the customer (with an itemized bill). This way the customer decides if they part with money instead of the provider helping themselves to money.
I could add my own horror stories .. but will not waste your time.
I would love to see in the next 20 years,
- accurate itemized bills from hospitals/providers
- bills submitted to patients and only patients. Provider access to patient's insurance cutoff.
- patients if they agree electronically submit to their insurance giving them incentive to not commit fraud and use their benefits smartly
- providers and insurers who mostly work between each other put the insured in the center of the picture
- which requires providers and insurers to simplify and bring their business practice more in line with everybody else.
Yes, health care billing is more complicated than buying a car or upgrading your bathroom, but I harbor the suspicion that patients can do a lot more and insurance people act like it's impenetrable through self inflicted and self injected complexity.
Earlier quoted context omitted.
It's not even just insurance companies. My wife and I had a child earlier this year, uncomplicated natural birth, fully covered under insurance. However the hospital initially filed the claim incorrectly, causing the claim to be denied and us to receive a bill in the thousands well in excess of our deductible/coinsurance. Hours of phone calls to insurance and hospital later, we think we have it resolved but are infor…
> There should really be a law that makes institutions liable for such errors. Does there need to be an explicit law? Could one sue in small-claims court for the time and expense damages?
It's basically insane that we require individuals to sign a blanket billing authorization prior to receiving care. Perhaps the hospital should have to provide a maximum amount that is at risk (hopefully creating pressure to operate in a sensible way).
Here and in taxes complexity is a problem. Any chem Eng or Drucker/Ishikawa/Deming person will want to simplify. Second, and as a commentor here reminds, patients are often on the line for money (accountability) when the axis of control (the other side of same coin) is between the hospital and insurer. Every time accountability is separated from control you've get big problems, and incentives to do the wrong thing. V…
So if they are making medical decisions, why aren’t they liable for the consequences? Sometimes the “peer” denying care doesn’t even have a medical license!
Earlier quoted context omitted.
> There should really be a law that makes institutions liable for such errors. Does there need to be an explicit law? Could one sue in small-claims court for the time and expense damages?
Why is small claims court better than a law flipping the default liability? It's basically insane that we require individuals to sign a blanket billing authorization prior to receiving care. Perhaps the hospital should have to provide a maximum amount that is at risk (hopefully creating pressure to operate in a sensible way).
Some very clever people have architectected an effective scam to prevent the democratic system from solving this. And I'm not referring to a republicans vs democrats debate about free socialized care vs hands off privatization. I'm talking about little steps that chip away at the problem like the one you described. Or forcing them to pay first, and only later have a debate about it. Or holding insurance liable for injury resulting from denying coverage. There is plenty of room for improvement and yet the representatives manage to accomplish nothing along these lines.
Evicore is a highly suspicious company, and the story of the patient who passed away in this article is sad. But I have noticed insurers do this (false claim denials) all on their own too. I and many friends have experienced Aetna routinely denying things that are explicitly covered by their plans and mentioned in the plan documents. They force you into an exhaustive cat and mouse game of chasing their team to reproc…
My dad passed away from cancer over 20 years ago, and this was Aetna's plan even then. Each claim followed the exact same process of deny, approve but pay only pay a fraction, and then finally pay the correct amount. Literally every single claim. My mom built an automation in Excel to track the calls for each claim and to prompt her at the various time intervals required to follow up at each phase.
Personally, I experienced this went I went to the ER with acute abdominal pain and ended up having emergency surgery within a few hours. Naturally, Aetna tried to deny that my ER visit was an actual emergency. On the phone with the rep, I asked them if they new of any non-emergency situations where someone was able to have a surgery scheduled only 4 hours in advance. They agreed that it was an emergency and promptly paid $8k of the $16k bill. After another call several months later, they paid all but $800.
Here and in taxes complexity is a problem. Any chem Eng or Drucker/Ishikawa/Deming person will want to simplify. Second, and as a commentor here reminds, patients are often on the line for money (accountability) when the axis of control (the other side of same coin) is between the hospital and insurer. Every time accountability is separated from control you've get big problems, and incentives to do the wrong thing. V…
The angle I would love to hear is that these people denying medical care are not culpable for the consequences. If I don’t order a test/surgery/whatever and the patient is harmed, I may face civil or criminal liability. But if the insurer refuses to authorize care (which, in practice, means the care doesn’t happen) and the patient suffers harm they have no recourse. The argument is that the insurance company isn’t ma…