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

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201–210 of 224 posts

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

#201
post #194

I am perplexed by the type of people that are able to stomach working in these kind of positions - how do they rationalize it? Do they really just not care? Like, in some industries that are not doing great things, or bordering on evil things, I can see sometimes how one could convince themselves they were actually doing good. But this denial stuff is nearly like, "press this button to make money, knowing you may be…

What are you saying here? Do you just think it's unnecessary to audit the way 18% of US GDP is being spent? You think there is no waste, or it's so small to be negligible? Despite the fact that it's well established the US spends more and gets less benefit?

This isn't an audit, and drives up prices. But I guess this response kind of answers my question.

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

#202
post #113

Earlier quoted context omitted.

Worse, we spend more in tax dollars on it than any other country total , and then add on the private spending on top. We do the worst of both worlds. https://commons.wikimedia.org/wiki/File:OECD_health_expendit... (And we’re middling in outcomes!)

Yeah because we consume way more than other countries

sources please

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

#203
post #92

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.

lmao someone in the comments works at such a company using ai to do this

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

#205
post #92

Earlier quoted context omitted.

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 c…

You’re describing the status quo?

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

#206

“The algorithm cannot say no, however. If it finds problems, it sends the request for review to a team of in-house nurses and doctors who consult company medical guidelines. Only doctors can issue a final denial.” As a physician, I’ve had to speak to these so called “peers” in a peer to peer denials with both my clinic and hospital setting. They are usually people who aren’t physicians as a first line of their defens…

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…

Seems useful, but bureaucracies don't refuse, they delay and obfuscate. So before trying this I would probably seek info on how to deal with bureaucratic realities.

Example: I had an inpatient hospital stay where the payment assistant person was never available, never returned calls. Not while I was in the hospital for days, nor in the weeks afterwards.

Technically, I "left against medical advice", though the last doctor I spoke to agreed with what I was doing.

Over two days of trying to manage costs, then 36 hours of planning and asking to leave all basically got me nowhere and I had to kind of force walk out.

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

#207
post #204
post #202

Earlier quoted context omitted.

sources please

Don’t have any. Not concerned with whether you believe me or not

Two hours ago you posted "I don’t believe claims made without evidence", lol.

https://news.ycombinator.com/item?id=48135626

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

#208

“The algorithm cannot say no, however. If it finds problems, it sends the request for review to a team of in-house nurses and doctors who consult company medical guidelines. Only doctors can issue a final denial.” As a physician, I’ve had to speak to these so called “peers” in a peer to peer denials with both my clinic and hospital setting. They are usually people who aren’t physicians as a first line of their defens…

As someone who needs expensive medication, thank you. I appreciate it. 2 questions: * This time, is it paid? Is it billable? Is it part of the visit I pay for? * What can I - as a patient - do to make this process easier?

1. It’s unpaid, short answer. Not part of your visit, usually a visit code is just one time based code for everything you provided and maybe a procedure if you did something like ear flushes, wart burning, quick wound fixes, etc. Long answer below.

If there’s a billing code for it, I’m not aware of it and frankly I shouldn’t have to use it. For providers, it’s part of their “administrative time” which used to be a full day of catching up. In most hospital or insurance-owned clinics, that admin day is gone. You now do this during your lunch break and anytime you can squeeze a phone call. Fun fact, in the hospital, these peer to peers are at the mercy of the insurance company and only give you 24-48hrs to do it, so the hell to the overworked provider and their schedule, again this is exactly what they want. A overworked provider who doesn’t have the energy to fight. Providers are so overworked, they no longer can you catch up on charts and hence why the patient-provider relationship has eroded and become so cold when you see your provider just typing away instead of focusing on you.

2. Fight. Appeal your denial. Make sure your provider does the same. Follow this: https://news.ycombinator.com/item?id=48126000#48128288 Can’t speak to all providers, but most of us are good people trying to do their best to help people. Few bad actors out there give us a bad name, but every field has good vs bad. It’s not right to make hasty decisions based on legitimately a few bad providers out there because of their greed, corruption, fraud, etc and lump everyone to prove they’re not fraudsters. Your basic primary care physician/NP/PA or surgeon isn’t the problem. It’s the conflict of interests of the health care industry, private equity groups, etc who create these issues, exploit the system and make it a breeding-ground for fraud/etc then complain that it needs to be fixed with more middle men.

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

#209
post #182

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…

> are no “innocent” parties in the payer-provider-patient triangle

not the patient?

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

#210

I am perplexed by the type of people that are able to stomach working in these kind of positions - how do they rationalize it? Do they really just not care? Like, in some industries that are not doing great things, or bordering on evil things, I can see sometimes how one could convince themselves they were actually doing good. But this denial stuff is nearly like, "press this button to make money, knowing you may be…

By this logic how could you ever work in Healthcare? If you're a Doctor why are you taking a day off to - of all things - go to the beach? Do you really just not care? Take this day off, knowing you may be denying someone critical care that could kill them or cause them harm? And you're comfortable doing that? Do you love the beach that much?
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