Health insurance claim denial rates range from 13% to 35% by insurer • Hacker News Board

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#21

Post by airstrike » Sun, Jun 21, 2026, 6:14 PM UTC

xnx wrote: post #15

bluefirebrand wrote: post #11

Earlier quoted context omitted.

> I like the US healthcare system as much as anyone I can't tell if you're being serious. I'm not American but all of my American friends tell me the US healthcare system is an absolute nightmare

That phrasing may not translate well. "as much as anyone" means "Most people don't like it, and I don't like it either.". My criticism of the analysis is not a defense of US healthcare.

s/like/dislike would have made it easier to understand at the expense of missing out on the (possibly accidental) sarcasm which makes the comment more rewarding to those who did understand it

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#22

Post by tbrownaw » Sun, Jun 21, 2026, 6:15 PM UTC

lp4v4n wrote: post #16

>The popular image of a denial is an insurer overruling a doctor on whether a treatment is needed. That is the exception. Only about 5% of denied in-network claims were turned down because the care was deemed not medically necessary. The rest were administrative, for an excluded service, for a missing referral or prior authorization, or for a reason the insurer never specified. When an insurance company denies a heal…

4. It's something that might help a bit, but the patient would still be fine without. Ie, a disagreement over what "necessary" means.

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#23

Post by claw-el » Sun, Jun 21, 2026, 6:18 PM UTC

If patients and doctors start using LLMs to strategize how to maximize claim approval rate, I wonder how would the insurance companies react to it. Would it start getting more strict and start requesting for more evidence?

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#24

Post by EtienneDeLyon » Sun, Jun 21, 2026, 6:19 PM UTC

beej71 wrote: post #17

When I went to an in-network ENT (that I found on my insurer's website) they were billed $850 for my 10-minute exam. The insurance said they'd pay $550. So I got to pay the rest. And this is gold coverage with an already-met deductible. You just never know what the roulette wheel is going to hand out. Makes me think of that study a few years ago that found most Americans couldn't afford an unexpected $400 medical bil…

Did you try looking for a less-expensive ENT?

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#25

Post by fny » Sun, Jun 21, 2026, 6:21 PM UTC

Before everyone wants to throw a rock at another CEO...

> Only about 5% of denied in-network claims were turned down because the care was deemed not medically necessary. The rest were administrative, for an excluded service, for a missing referral or prior authorization, or for a reason the insurer never specified.

I worked in health tech for a while, and I can tell you the muck around a lot with ICD/CPT codes to maximize billing along with other shenanigans. There was actually a project at an innovation center at a well-known medical center which leveraged ML to maximize the amount of codes they could bill for without being rejected. The same kind of thing is often done by physicians who want to juice insurance.

Be mad--very mad--at hospitals and drug cos. As providers, they present themselves as patient advocates, but they're responsible for the outrageous healthcare costs. The dollar amount paid out by US insurance companies is maybe 2x that of other OECD countries, but the healthcare we get back from providers is trash (and extortive) by comparison.

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#26

Post by colonCapitalDee » Sun, Jun 21, 2026, 6:23 PM UTC

lp4v4n wrote: post #16

>The popular image of a denial is an insurer overruling a doctor on whether a treatment is needed. That is the exception. Only about 5% of denied in-network claims were turned down because the care was deemed not medically necessary. The rest were administrative, for an excluded service, for a missing referral or prior authorization, or for a reason the insurer never specified. When an insurance company denies a heal…

There is absolutely a middle ground? The healthcare system, like any system, has an incentive structure. Doctors are incentivized to prescribe treatments, because that's how they make money for themselves and their practice. Doctors are not angels sent from heaven, they're people like you and me, and they respond to incentives like you and me. It's also well known that people strongly prefer receiving treatment over not receiving treatment, even when the cost to their health of receiving that treatment outweighs the expected benefit! Given that people push their doctors into prescribing treatments, and doctors are incentivized to go along with it... you would obviously expect some proportion of prescribed treatments to not be medically necessary. 5% sounds about right. And the kicker is that denying these treatments improves health outcomes for the general population, because those medical resources can get routed to the people who actually need them. Every successful public health system has an opposing force built in to it to limit the spurious consumption of scare medical resources, because without such a force costs balloon and the system becomes unsustainable. Not to defend the US healthcare system of course, our cost problem is worse than anywhere else...

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#27

Post by eightysixfour » Sun, Jun 21, 2026, 6:27 PM UTC

claw-el wrote: post #23

If patients and doctors start using LLMs to strategize how to maximize claim approval rate, I wonder how would the insurance companies react to it. Would it start getting more strict and start requesting for more evidence?

Hospitals and some doctors already do - it isn’t a one-sided problem with insurance as the only group optimizing for their desired outcome.

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#28

Post by cucumber3732842 » Sun, Jun 21, 2026, 6:29 PM UTC

lp4v4n wrote: post #16

>The popular image of a denial is an insurer overruling a doctor on whether a treatment is needed. That is the exception. Only about 5% of denied in-network claims were turned down because the care was deemed not medically necessary. The rest were administrative, for an excluded service, for a missing referral or prior authorization, or for a reason the insurer never specified. When an insurance company denies a heal…

You ever been to an obstinate DMV? Dealt with an obstinate permitting office? They all act like this. They unilaterally concoct rules that make it hard for honest people doing honest things to get the outcomes they ought to.

Healthcare ain't no different. Bureaucracy gonna bureaucracy.

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#29

Post by umpalumpaaa » Sun, Jun 21, 2026, 6:30 PM UTC

lp4v4n wrote: post #16

>The popular image of a denial is an insurer overruling a doctor on whether a treatment is needed. That is the exception. Only about 5% of denied in-network claims were turned down because the care was deemed not medically necessary. The rest were administrative, for an excluded service, for a missing referral or prior authorization, or for a reason the insurer never specified. When an insurance company denies a heal…

It should be noted that they use the term “medically necessary” which is a very low standard.

There is also “medically reasonable”.

For example getting your teeth cleaned professionally is not medically necessary. But it’s medically reasonable.

I don’t want a health insurance that only does “Medically necessary” things.

Re: Health insurance claim denial rates range from 13% to 35% by insurer

#30

Post by dghlsakjg » Sun, Jun 21, 2026, 6:36 PM UTC

IncreasePosts wrote: post #6

vkou wrote: post #2

Good thing the moral hazard of getting unnecessary healthcare that your doctor ordered for you is controlled for. Perhaps someone should also control the moral hazard of the people owning and running this racket getting unnecessary amounts of money, or an unnecessary seat at the table.

Everyone is in on the grift in the industry. Obama wanted to go single payer but realized 10% of america would be out of a job if we streamlined the bureaucracy

Obama proposed and pushed for single payer and it was voted down in the senate. Specifically, if you want to blame someone, it was Joe Lieberman who would have been the deciding vote, and he killed it.

Joe Lieberman realized that he was from a state with massive moneymaking insurance operations. Had nothing to do with Obama streamlining bureaucracy.