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

randalolson.com

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

#41

Post by FireBeyond »

bonsai_spool wrote: post #32
colonCapitalDee wrote: post #26

Earlier quoted context omitted.

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…

> Doctors are incentivized to prescribe treatments, because that's how they make money for themselves and their practice. This is literally illegal! Physicians cannot refer patients to entities they own or have an interest in. What is perverse is that, while we have the Stark Law to constrain physician behavior, we've decided that it's okay if a diffuse group like a non-physician-owned hospital chain enforces rules t…

Diagnostic imaging companies - each of the big ones (Siemens, GE, Philips) all offer in-house financing on very favorable terms for MRI, CT, etc., that they specifically advertise to physicians. They also all offer specialist consulting help to facilitate you getting a CoN (Certificate of Need) for your facility. Hell, they also will help you find other physicians in your area who'd like to go in with you on setting up a DI facility, and they will assist with spinning up the practice.

We then find that physicians who own a DI practice (or a share in one) refer their patients to diagnostic imaging at rates several standard deviations above other physicians and at rates that are "statistically improbable" when correlated to underlying ICD-10 diagnostic codes.

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

#42

Post by BrenBarn »

tbrownaw wrote: post #22
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.

That is still the insurer saying they know more about the medical situation than the doctor. The doctor is the one who is equipped to decide what is necessary.

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

#43

Post by Georgelemental »

BrenBarn wrote: post #42
tbrownaw wrote: post #22

Earlier quoted context omitted.

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

That is still the insurer saying they know more about the medical situation than the doctor. The doctor is the one who is equipped to decide what is necessary.

The doctor is not infallible. He or she is likely extremely busy, and under many pressures, e.g.:

- patients who adamantly insist on X treatment, make a fit and threaten a bad review, even though they don't need it

- fear of malpractice suits (e.g. 99.9% chance treatment is unnecessary and a waste of money, but in the 0.1% case I might get sued to oblivion if I didn't prescribe it)

- intense lobbying from pharma companies who spend boatloads of money trying to convince them to prescribe their products

In general, they don't directly pay the costs of using limited healthcare resources, but they can pay serious costs for failing to use them, so their incentives are skewed.

Our current system is far from ideal. But a system where a single person gets to make all the decisions, while foisting all the financial burden on someone else, would collapse within a week. Someone has to be the bad guy to sometimes say "we can't afford this, sorry".

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

#45

Post by naturalmovement »

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…

You may have had 10 minutes face-time with your doctor, but he spent time before your exam reviewing your case, and time afterwards dictating the notes. So likely 30-40 minutes was spent on you and this does not include the nurses and front desk support staff, the janitor cleaning the toilets, all who need a living wage, rent and/or property tax for the facility, facilities maintenance and upkeep.

Not to mention the $$$ paid to greedy software engineers for all the mandatory e-health software systems which are all recurring-payment SaaS now raking in crazy amounts of cash.

Do you think your doctor is pocketing all that money? The average do-nothing schlub working in tech is making more than his doctor.

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

#46

Post by DougN7 »

I was on one of the insurers that denied the fewest claims. However, they also had the fewest doctors. I live in a good sized metro area, but the only podiatrist was 50 miles away in a tiny town. I imagine that had the same ultimate result of denying claims.

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

#47

Post by mullingitover »

dghlsakjg wrote: post #30
IncreasePosts wrote: post #6

Earlier quoted context omitted.

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.

> Specifically, if you want to blame someone, it was Joe Lieberman who would have been the deciding vote, and he killed it.

I too believed that Joe Lieberman sucked, and sure, he did. However: there's a pattern of parties creating convenient designated villains within the party (usually someone not up for re-election) who can take the blame for doing the thing the party insiders planned to do all along. It's been especially noticeable in the current Congress.

When the designated villain sticks it to us next time, notice how there are zero consequences for them.

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

#48

Post by FireBeyond »

strictnein wrote: post #20
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

People like to complain about things and have very unrealistic perceptions of what other systems are like. It's also really unpopular online to say good things about the US healthcare system. It definitely has some issues, but it also does some things really, really well. These are, of course, anecdotes, but here some things from my life: - Next day MRI for my wife after she injured her back at the gym. Had it been m…

> - Next day MRI for my wife after she injured her back at the gym. Had it been more serious she would have been seen the same day.

I had same-day CT for suspected diverticulitis/kidney stones. I had same day x-ray, ultrasound for hyperextension of my wrist (steering wheel airbag going off pushed my hand backwards towards my elbow)... all good. I was told to start PT immediately...

... "we can see you in 8-10 weeks." "We're not accepting new patients". "In 3 months, does that work?"

I've also worked for 14 years as a paramedic and EMT, and seen first hand the sheer number of simple things that become acute care issues requiring the ER that could have been prevented by simple access to a primary care provider.

> Nice pharmacies all over the place, which also provide things like vaccinations. Lots of our medications are now just shipped to our house directly

My insurer will only authorize 90 day prescriptions if you use their wholly owned pharmaceutical subsidiary. Otherwise they will deny anything longer than 30 days for no medical reason. They still charge precisely 3x30 days, but they just want exclusivity with their own vertical integration (which, conveniently, is exempt from laws on insurer profit margins - the only way for an insurer to make more money per capita is if healthcare, including pharma, costs go up).

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

#49

Post by FireBeyond »

eightysixfour wrote: post #36
claw-el wrote: post #34

Earlier quoted context omitted.

I would watch out for insurance as an industry having to increase rates because successful claims rate are increasing much faster than the industry can handle. Not supporting nor opposing the insurance industry, just something I think the public should watch out for and understand.

Again, this is already happening. Hospital side care providers use systems which optimize for expected payout value. That increases payout totals and insurance costs for everyone. The ACA tried to make health outcomes a part of the calculation for everyone involved but it is hard to compete with the all mighty dollar.

"Repricers" work on both sides of the equation - providers and provider networks use them to maximize the procedure codes around an ICD-10 diagnosis code.

And insurers use them to minimize the list of procedures they'll accept and pay for around a given ICD-10 code.

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

#50

Post by bonsai_spool »

lostlogin wrote: post #38
bonsai_spool wrote: post #32

Earlier quoted context omitted.

> Doctors are incentivized to prescribe treatments, because that's how they make money for themselves and their practice. This is literally illegal! Physicians cannot refer patients to entities they own or have an interest in. What is perverse is that, while we have the Stark Law to constrain physician behavior, we've decided that it's okay if a diffuse group like a non-physician-owned hospital chain enforces rules t…

> This is literally illegal! Physicians cannot refer patients to entities they own or have an interest in. There has to be a done of exceptions to this. You see a cardiologist and they recommend a stent. They aren’t going to recommend a different cardiologist does it. You see a doctor, and they refer you for a test. They have a share portfolio that contains shares in the facility they referred to. Medicine is riddled…

> You see a cardiologist and they recommend a stent. They aren’t going to recommend a different cardiologist does it.

Things must be different in NZ.

First, it's true that you're going to want to go to who your doctor knows/recommends. The law in the US is just that they can't refer you to a group they own/their spouse owns, or for which they get a financial benefit.

Next, you're speaking about the doctor doing a consult visit before doing a procedure. That is not the same thing as ordering a treatment for you to go get the treatment elsewhere—which describes what happens you go to the pharmacist to get drugs.

Finally, the cardiologist you see in the office is almost certainly not doing stents for you as those are very distinct skillsets (in the US).

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