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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

#211

Post by ahepp »

JohnMakin wrote: post #201
ahepp wrote: post #194

Earlier quoted context omitted.

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.

Maybe I'm just not understanding what you're saying here, but it seems pretty straightforward that you can't run an insurance system without reviewing claims. That's true whether it's a for-profit, not-for-profit, or government run insurance provider.

There's broad consensus that there is a ton of unnecessary and unwarranted care being done in the US. Doctors are not all experts in population health. Even the most well-meaning doctors are still subject to incentives that can lead to excessive testing and expensive treatments that have a low likelihood of improving patient outcomes.

Obviously it is also true that having a profit motive to deny claims incentivizes improper denials. But to simply say "no claim should ever be subject to review or denial, and anyone working to make the system efficient is evil" is deeply ignorant and fundamentally incompatible with the concept of insurance.

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

#212

Post by LorenPechtel »

sethammons wrote: post #209
fiej wrote: 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?

No. Lots of problems with patients wanting things they've heard of. Think all that drug advertising is for nothing??

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

#213

Post by LorenPechtel »

ceejayoz wrote: post #199
tt24 wrote: post #198

Earlier quoted context omitted.

Feel free to cite something that proves that Australian diets are similar to American diets. I don’t believe claims made without evidence. Deaths are pretty much 1:1 with drug use. Us having more fentanyl deaths mean we have more fentanyl users. Feel free to cite something that proves that Australia has the same amount of drug users as the United States. It’s a contributing factor. Americans consume healthcare at muc…

> Feel free to cite something that proves that Australian diets are similar to American diets. I don’t believe claims made without evidence. https://www.abc.net.au/news/2010-04-14/australian-diet-worse... https://www.nationalhogfarmer.com/market-news/study-finds-am... https://www.youtube.com/watch?v=omT2ENVQziM https://www.theguardian.com/australia-news/2025/nov/19/austr... > I don’t believe claims made without evide…

Yes, but there is a major gotcha in fixing this.

It "costs" much less--because in reality we end up footing the R&D bill. The drug companies tolerate sales to the UHC countries so long as it's above their marginal cost. If US customers were also paying $31 for that Sofosbuvir there's no way the company would recoup costs and they would not develop it.

Fixing this will cause big shakeups in the universal coverage systems and thus big political shakeups. It should be done, but gradually.

I will also say the comparison is false--my wife is on Atorvastatin, it's even less than what you are quoting for Australia. You're comparing the brand name with the generic.

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

#214

Post by autoexec »

Henchman21 wrote: post #205
autoexec wrote: post #188

Earlier quoted context omitted.

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?

So far I only pay my insurance company to sit between me and my doctor and dictate what I need and I just do all the fighting with them myself instead of needing to pay someone else to do it on my behalf on top of what I pay the insurance company and the doctor.

I suppose that if I did pay someone else to more effectively fight the insurance company for me the insurance would have to pay for more of the medical care I need, and would invest in new and better ways to fight back, and my insurance costs would increase even faster. I'm happy that for now at least I don't have to finance both sides of an arms race in order to get the healthcare I've already been paying for.

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

#215

Post by JohnMakin »

ahepp wrote: post #211
JohnMakin wrote: post #201

Earlier quoted context omitted.

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

Maybe I'm just not understanding what you're saying here, but it seems pretty straightforward that you can't run an insurance system without reviewing claims. That's true whether it's a for-profit, not-for-profit, or government run insurance provider. There's broad consensus that there is a ton of unnecessary and unwarranted care being done in the US. Doctors are not all experts in population health. Even the most we…

> But to simply say "no claim should ever be subject to review or denial, and anyone working to make the system efficient is evil" is deeply ignorant and fundamentally incompatible with the concept of insurance.

I did not say this. but you do you.

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

#216

Post by ahepp »

JohnMakin wrote: post #215
ahepp wrote: post #211

Earlier quoted context omitted.

Maybe I'm just not understanding what you're saying here, but it seems pretty straightforward that you can't run an insurance system without reviewing claims. That's true whether it's a for-profit, not-for-profit, or government run insurance provider. There's broad consensus that there is a ton of unnecessary and unwarranted care being done in the US. Doctors are not all experts in population health. Even the most we…

> But to simply say "no claim should ever be subject to review or denial, and anyone working to make the system efficient is evil" is deeply ignorant and fundamentally incompatible with the concept of insurance. I did not say this. but you do you.

I'm not sure how you could deny it when you just wrote quite a bit of detail about how you think anyone doing that work is an evil sociopath.

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

#217

Post by fiej »

sethammons wrote: post #209
fiej wrote: 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?

Over utilization, especially after deductibles are met. Demanding tests and treatments that aren’t warranted, and physicians have huge pressure to comply because they’re very heavily goaled on patient happiness (rather than quality outcomes).

Patients have zero incentive to shop around on price, so if an academic research hospital MRI costs $6,000 and an independent lab has the same machine and charges $600, most patients don’t care or even know the price difference and let insurance foot the bill.

There’s also a small but expensive population of people who are uninsured and go to the ER very frequently and stay for a while (faking illness, requesting drugs, or simply a warm bed and meal). Clearly a societal problem, but hospitals foot the bill for those stays and raise prices for everyone.

A lot of the structure of insurance plans (deductibles, co-pays, co-insurance, HMO/PPO, enrollment periods) emerged to provide a counterbalance to patient behavior, characterized by adverse selection and moral hazard primarily

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

#218

Post by silexia »

The root problem is not health insurers, they are just a happy beating dummy. The root problem is the government restrictions on the numbers of new doctors that existing doctors have passed to restrict supply and keep their salaries astronomically high.

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

#219

Post by tt24 »

ceejayoz wrote: post #207
tt24 wrote: post #204

Earlier quoted context omitted.

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

How are those two things contradictory

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

#220

Post by Henchman21 »

autoexec wrote: post #214
Henchman21 wrote: post #205

Earlier quoted context omitted.

You’re describing the status quo?

So far I only pay my insurance company to sit between me and my doctor and dictate what I need and I just do all the fighting with them myself instead of needing to pay someone else to do it on my behalf on top of what I pay the insurance company and the doctor. I suppose that if I did pay someone else to more effectively fight the insurance company for me the insurance would have to pay for more of the medical care…

IMO you're looking at it from your perspective only. Services to negotiate medical debt by interacting with the insurance company to find errors and/or intention denial -- these exist today -- you're giving me the impression you're healthy enough or well off enough to not need them?

I suppose we're not yet at the point where this gates services for all -- but we're CERTAINLY at the point where hospitals refuse to help you if you can't show ability to pay up front.

Ugh, this is a total shitshow. None of this is what it should be. Profit motive has absolutely corrupted everything.

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