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Feds help health insurers hide their dirty secret: denials on the rise

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Re: Feds help health insurers hide their dirty secret: denials on the rise

#251

Post by seanmcdirmid »

stvltvs wrote: post #188
seanmcdirmid wrote: post #146

Earlier quoted context omitted.

When my doctor recommended mine, she said that they could do screening but if they found anything, they would have to do a colonoscopy and then it wouldn’t just be covered as screening (since it was an incident rather than preventive at that point). She said it was better just to get the colonoscopy due to health insurer rules.

If they find something suspicious during the colonoscopy, they won't bill it as a free screening anymore and you'll be on the hook for it. Ask me how I know. No regrets about getting screened though. It saved my life.

Sorry, I meant: if you do a non-colonscopy screening first and they find something, the follow up colonscopy isn't covered as preventive. And the non-colonscopy screenings have a higher false positive rate than a colonscopy screening.

Re: Feds help health insurers hide their dirty secret: denials on the rise

#252

Post by joquarky »

antisthenes wrote: post #223
harimau777 wrote: post #161

Earlier quoted context omitted.

It seems to me that should then be handled by the legal system or perhaps the licensing boards. That is to say, the insurance companies should be forbidden from denying coverage and if they believe that something is going on then they can alert the police or take the doctor to court.

Will never happen. Doctors have strong lobbying of their own and they really like their second vacation homes and Porsches.

So are we to just do nothing and die in the crossfire between these two entities?

Re: Feds help health insurers hide their dirty secret: denials on the rise

#253

Post by nradov »

harimau777 wrote: post #161
dboreham wrote: post #94

Earlier quoted context omitted.

Otoh some medical providers like to over bill and over treat.

It seems to me that should then be handled by the legal system or perhaps the licensing boards. That is to say, the insurance companies should be forbidden from denying coverage and if they believe that something is going on then they can alert the police or take the doctor to court.

That's simply unrealistic. Medicine is more of an art than a science and most treatment plans fall into gray areas. While insurers do file formal complaints with authorities when there is clear evidence of fraud (like a single provider billing for more than 24 hours of patient encounters in a single day), there is an enormous amount of waste and abuse by providers which can't be proven in court as fraud. The fee-for-service financial model incentivizes over treatment.

https://www.npr.org/sections/health-shots/2019/10/22/7673763...

The fundamental problem here is that demand for healthcare is virtually infinite while supply is limited. Healthcare already consumes about 20% of the US economy and there is no excess capacity to expand it further without dragging everything else down. We can make some things more efficient and reduce administrative burdens but ultimately we have to draw the line somewhere and ration care. That's going to be true regardless of whether we have commercial insurers or socialized healthcare.

Re: Feds help health insurers hide their dirty secret: denials on the rise

#254

Post by nradov »

dheera wrote: post #60

Just leaving this here for reference: In 2022 I was denied full insurance payment of a routine, preventative echocardiogram at Stanford Healthcare to monitor my heart issues. I was balance billed $5000+. The insurance company was HealthNet. The policy clearly indicated full coverage of preventative procedures, without a deductible. They said they did not recognize the procedure as preventative. Fuck them, I know bett…

Under the Affordable Care Act (Obamacare), there is a very limited and specific definition of preventive care services which health plans are required to cover. An echocardiogram is not on the list.

https://www.healthcare.gov/coverage/preventive-care-benefits...

In your particular case it might have been medically necessary, but not legally classified as preventive. This is a huge hassle for patients because the nuances aren't obvious or clearly documented. It's likely that Stanford Healthcare erred by failing to obtain the necessary prior authorization from HealthNet before performing the procedure.

Since 2022 there are some legal protections against balance billing. Although those might not have helped in your case.

https://www.cms.gov/newsroom/fact-sheets/no-surprises-unders...

Re: Feds help health insurers hide their dirty secret: denials on the rise

#256

Post by tboyd47 »

dgfitz wrote: post #249
tboyd47 wrote: post #194

Earlier quoted context omitted.

> Our healthcare system might be worse than some but that does not imply it's bad for you. Well, if you have that mindset, then you'll never achieve anything better, will you? It's not necessarily bad for us, so we'll just keep doing it. It's like the people who vote for the same set of loser politicians every 4 years and then complain that nothing ever changes.

You're making a very good non-coherent argument, and I'd claim you're moving the goalposts, but you don't even have goalposts.

Nice one. You made me stop and think.

I was thinking about condensing my thoughts into a post, but I'll make one point on the issue of premiums. In the article, it says the cost of insuring a family of four is $25,000 a year. That sounds accurate to me.

I know from experience (being self-employed for a period of time and having to figure this all out myself) that if your family is healthy, you can replace all 4 full-term plans with 4 short-term plans and pay about $4,000 a year for the same coverage. The only difference, really, is that your insurance coverage ends after one year and you have to apply for it again. This used to be seen as risky, but with the ACA, someone will always be forced to insure you. So, it's not the same anymore.

That's not even all we could collectively do to solve this problem. Just imagine if all the healthy people in America just did that. I know, there aren't many healthy Americans left. And a lot of people have health insurance as part of their benefits package.

But many of those people are paying their dependents' insurance out of pocket. So, someone on a full-term plan could switch all his dependents to short-term and save about $5k per year per person. And it doesn't cause any noticeable difference to someone's coverage.

Imagine if only 1 million healthy Americans went from full-term to short-term. The health insurance industry would lose 5 billion dollars of income a year. That's not huge for a $500B industry, but it's not nothing. Corporate America sits up and starts paying attention to what's going on at ANY loss of revenue.

This is not insurance advice, but just thinking out loud. Verify everything yourself, but my point is that there's a lot everyday Americans could do to hurt these companies in their wallets. We just need to come together, share ideas, and trust ourselves and each other more than nameless, faceless companies.

Here's a goalpost for you: a healthy person should not spend more than $2,000 a year, total, on any health care related expenses. Even that number is ridiculous. But it's probably about half of what people are paying. If we all focused on that, and helped each other achieve that totally achievable goal, we'd change a lot about this rotten system.

Re: Feds help health insurers hide their dirty secret: denials on the rise

#257

Post by lapcat »

tristor wrote: post #250
lapcat wrote: post #175

Earlier quoted context omitted.

The Affordable Care Act received precisely zero Republican votes in Congress. It was entirely a Democratic product.

John McCain, a Republican, famously voted to save the ACA during a time when the Republicans had a Congressional majority, even though his health was failing. He died shortly after the vote.

I was talking about the 2010 passage of the ACA, not the 2017 repeal attempt. The 2010 legislation was written by Democrats. Moreover, since as you mention, the Republican repeal attempt failed, it can't truly be said that Republicans have "gutted" the ACA. It is true that for some (dumb) reason the ACA gave significant power to the states, which has been abused by Republican governors and legislatures, but that was entirely the choice of the Democrats who wrote the ACA.

Re: Feds help health insurers hide their dirty secret: denials on the rise

#258

Post by skeaker »

nradov wrote: post #247
DennisP wrote: post #109

Earlier quoted context omitted.

Agreed. France, Germany, and Japan have health systems similar to the ACA, with the following differences: insurance is nonprofit with an effective mandate, there's a national price list for medical services, and claim denials are prohibited for anything on the list. Germany has an especially effective digital system that guarantees payment within a week. All three systems get better health results than the US, by me…

The other side of that is that some expensive services and drugs are simply unavailable in other countries, or are very tightly rationed. The USA has higher 5-year survival rates for most types of cancer than France, Germany, and Japan. I'm not saying that the US system is better overall, but it does do some things extremely well. We should make sure that any reforms don't sacrifice our unique advantages. https://doi…

This obviously goes without saying. In fact, I'm not sure how implementing a system like Germany or Japan has would impact this at all.

Re: Feds help health insurers hide their dirty secret: denials on the rise

#259

Post by ethbr1 »

rawgabbit wrote: post #230
axus wrote: post #219

Earlier quoted context omitted.

Why are the providers behaving differently and in different circumstances in US vs. Japan/Germany/France?

It is for the same reason why “Medicare Advantage” plans exist. These plans are operated by private companies using tactics to deny health coverage. https://www.newsweek.com/how-medicare-advantage-scams-senior...

Expanding, essentially the US has the worst of all possible worlds.

Most provider costs are obscured / complicated by insurers sitting in the middle of transactions.

If they weren't, providers wouldn't do some of the all-but fraudulent coding shenanigans that have become normalized. But overbilling a faceless insurer is fine.

And likewise, patients would have an incentive to shop around for the most cost effective services, instead of no one in the system being able to proactively say how much something would cost until the insurance claim is submitted and processed.

Re: Feds help health insurers hide their dirty secret: denials on the rise

#260

Post by EasyMark »

One thing that will help greatly is to regulate hospitals into having an umbrella of "services" that allows "private" operators BUT those operators have to be covered by any insurance that wants to work with the hospital rather than these 3 nurses in one pay center, this surgeon in another, assistant surgeons in a third, and the anesthesiologist so far out of network he laughs and isn't part of any HMO, PPO or anything else.
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