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How often do health insurers say no to patients? (2023)

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Re: How often do health insurers say no to patients? (2023)

#81

Post by mattnewton »

savanaly wrote: post #72
mattnewton wrote: post #27

Earlier quoted context omitted.

I just don't think #1 is possible, how can you have a functioning marketplace for a good when the demand is hard to forecast for an individual, almost completely inelastic and often extremely time sensitive. I'd say the US really tried and the incentives just aren't there for a stable system.

>demand is hard to forecast for an individual, almost completely inelastic and often extremely time sensitive These don't preclude a free market working well. For instance, they're all apt descriptors of me when I find myself needing an Uber home. I'm not completely inelastic, since I could take a series of long bus rides to get home, or walk, but accepting for the sake of argument those aren't life-threatening, the…

Taxi demand is actually usually quite easy to forecast for an individual, which makes planning alternative competition easier, although we often don’t try anymore because we’re used to good app competition. This is before even getting to how much lower the infrastructure and personnel barriers are to competing in the medical space versus the taxi space.

I know that most nights I am going to want to sleep in my own bed, this is somewhat inelastic sure, but not a surprise. The apps can’t raise prices too much however because they are in competition with us making plans to use the bus or call a friend. There is not a good equivalent in the medical world, it’s webmd and herbal compresses versus licensed doctors and prescription only drugs, with your life on the line.

Re: How often do health insurers say no to patients? (2023)

#82

Post by tim333 »

firesteelrain wrote: post #41
kstrauser wrote: post #37

Earlier quoted context omitted.

Elected representatives answerable to their constituents would be a vast improvement in health outcomes.

How would it all be paid for if not by increasing premiums (like what happened with ACA)?

The US could copy virtually any other health system in the world and get lower costs.

Re: How often do health insurers say no to patients? (2023)

#83

Post by Guvante »

ceejayoz wrote: post #12
Guvante wrote: post #7

Earlier quoted context omitted.

You are on a high deductible plan. With those plans you pay the first $X and after that a percentage of costs (coinsurance) up to $Y. Sometimes certain things are covered before you hit your deductible other times not.

Yes, but you'll often find that in a high-deductible plan the insurance company gets a "discount" of your $1k med down to $200, which they brag about in your EOB… but the medication's cash price for uninsured people would be $20. You're out of pocket $180 more than you should be, and paying the $20 cash price out of pocket means your deductible doesn't budge.

Unless you are comparing a generic to a name brand in a situation where the insurance company forces the name brand that shouldn't be the case.

For better or worse in your hypothetical the uninsured price legally has to be $1,000 for medicine. They can write off part of that but no one would write off 99.8% as the insurance company would sue their pants off.

Re: How often do health insurers say no to patients? (2023)

#84

Post by Guvante »

mindslight wrote: post #64
ceejayoz wrote: post #12

Earlier quoted context omitted.

Yes, but you'll often find that in a high-deductible plan the insurance company gets a "discount" of your $1k med down to $200, which they brag about in your EOB… but the medication's cash price for uninsured people would be $20. You're out of pocket $180 more than you should be, and paying the $20 cash price out of pocket means your deductible doesn't budge.

It's straightforward fraud. Both the providers and insurers goal is to mislead people into thinking the "adjustment" represents a payment from the insurance company. The pattern is even more flagrant when done with post-facto billed services, since the price hasn't even been assented to. The whole medical industry has essentially normalized many different types of fraud against patients, and yet the industry is so en…

As long as it is a legitimate discount (which it legally always is) they aren't lying perse.

After all the discount getting inflated by charging non-insured people ludicrous prices is the real issue but not one you can meaningfully complain about as an insured.

And unfortunately if you ask for pricing they will give you the inflated pricing meaning it isn't necessarily deceptive there.

Re: How often do health insurers say no to patients? (2023)

#85

Post by wtbdbrrr »

braabe wrote: post #19
wtbdbrrr wrote: post #3

All the time is not a number but in Germany it's common that your legitimate insurance claim gets rejected at first and then you appeal once or twice and do the paperwork and document the proof again, citing all terms & conditions that apply and you get what you are owed or you get a lawyer to do the whole thing again and get what you are owed then. "Arbeitsbeschaffungsmassnahmen" ( German for "employment creation sc…

I have had this experience, but not with healthcare insurers (in Germany). I cannot remember the last time I had to contact them - the last two times they contacted me, was to explain to me, that they have expanded their preventive care offerings and they recommend I go and get them. Blanket rejections are an extremly efficient measure from the perspective of an entity when the consumer has nowhere else to go and you…

> is that it often turns into a class indicator

Oh, man. One could rant for hours about this. You are absolutely right. But in the end it's not really a class indicator because info about this particular and similar schemes could theoretically be packed into a weekend long workshop. In any small company or big factory, and definitely in schools as early as grade 10.

But it's a matter of character and you have to be damn lucky if you get a teacher who cares that much. Even neighbors will more often than not, NOT enlighten "the less fortunate" about stuff like this. It's pathetic.

But that's why this cascade works so well to keep almost all of the "more fortunate" under perfect societal control by which I don't mean some mythological conspiracy but "Steuerungsmechanismen" (some dude who got out of some cult beautifully explained this but I forgot both his name and the title of the book), keeping almost all of them in line, mostly silent, and alienated from the inter-generational usefulness of critical thinking.

And there is no irony in all this. Too many peoples mindsets never left the modern dark ages. One can only raise a brow and chuckle at all this.

It's a class indicator for sure, but, in my opinion, not class in the sense of hierarchies but of intellectual style, niveau. These tactics are low, like punching drugs.

Re: How often do health insurers say no to patients? (2023)

#86

Post by pdonis »

mattnewton wrote: post #27
arwhatever wrote: post #22

Earlier quoted context omitted.

1. A properly competitive marketplace 2. Socialized medicine 3. What we have now I would like to see #1 tried but at this point I’ll gladly accept #2

I just don't think #1 is possible, how can you have a functioning marketplace for a good when the demand is hard to forecast for an individual, almost completely inelastic and often extremely time sensitive. I'd say the US really tried and the incentives just aren't there for a stable system.

> how can you have a functioning marketplace for a good when the demand is hard to forecast for an individual, almost completely inelastic and often extremely time sensitive.

Most health care is not like this. Most health care is fairly routine: periodic physical exams and checkups, or getting evaluated when you have cold or flu symptoms. These sorts of things are much better provided for in a free market.

It's true that, if you have an emergency, it's probably not something that could have been forecast, and you don't have much of a choice about what care you need. That is indeed the sort of situation that insurance is intended for. But what we call "health insurance" isn't limited to those things. It also covers everything else--all the stuff above that isn't unpredictable or time sensitive. The result is a mess.

Re: How often do health insurers say no to patients? (2023)

#87

Post by pdonis »

mattnewton wrote: post #52
arwhatever wrote: post #36

Earlier quoted context omitted.

When did the U.S. really try?

Isn’t this just a no true Scotsman? The US claims at least to have built a free market solution, and if nobody else has been able to make it work at scale, why isn’t that enough.

> The US claims at least to have built a free market solution

I don't know that "the US" has actually claimed this, but in any case any such claim is false. There are lots of reasons for that, but the key one is simple: the people getting care, patients, don't know how much it costs. You can't have a free market if the person receiving a good or service doesn't know the cost of what they're getting, and so can't judge whether what they're getting is worth what it costs.

Re: How often do health insurers say no to patients? (2023)

#88

Post by dragonwriter »

Eddy_Viscosity2 wrote: post #44
firesteelrain wrote: post #41

Earlier quoted context omitted.

How would it all be paid for if not by increasing premiums (like what happened with ACA)?

Health insurance companies do not provide any medical services. They are the middle man between patients and the places/people that actual do provide medical services. So when they deny coverage, they just keep all the premiums paid by the patient. That money is sucked up by the middle man. So you don't need to raise premiums, you need to lower profits at health insurance companies. Every billion they make in profit…

> Health insurance companies do not provide any medical services.

This is substantively not true (though literally true at the level of a company, due to separate companies within the Kaier consortium) of the nation’s largest managed core organization, the Kaiser consortium consisting of the Kaiser Foundation health plans and the Kaiser Permanente Medical Groups.

> No when they deny coverage, they just keep all the premiums paid by the patient. That money is sucked up by the middle man. So you don't need to raise premiums, you need to lower profits at health insurance companies.

Something like limiting retained profits at the plan level to a fixed fraction of costs covered, and requiring refund of excess premiums to members?

Re: How often do health insurers say no to patients? (2023)

#89

Post by mindslight »

Guvante wrote: post #84
mindslight wrote: post #64

Earlier quoted context omitted.

It's straightforward fraud. Both the providers and insurers goal is to mislead people into thinking the "adjustment" represents a payment from the insurance company. The pattern is even more flagrant when done with post-facto billed services, since the price hasn't even been assented to. The whole medical industry has essentially normalized many different types of fraud against patients, and yet the industry is so en…

As long as it is a legitimate discount (which it legally always is) they aren't lying perse. After all the discount getting inflated by charging non-insured people ludicrous prices is the real issue but not one you can meaningfully complain about as an insured. And unfortunately if you ask for pricing they will give you the inflated pricing meaning it isn't necessarily deceptive there.

The problem is that it's framed as a payment from the insurance company, so people think the insurance is helping with the bill. What has actually happened is the insurer and pharmacy are cooperating to create sham prices/paperwork and confuse the market.

It's even more glaring for post-facto bills from providers, because those prices are being presented on a cost-reimbursement basis (not contractual). The provider is essentially saying "You owe us $500 because that is what it cost to provide your care". But it obviously could not have cost $500 to provide the service, because they're happy to accept $150 in total.

Re: How often do health insurers say no to patients? (2023)

#90

Post by dragonwriter »

refurb wrote: post #67
kstrauser wrote: post #37

Earlier quoted context omitted.

Elected representatives answerable to their constituents would be a vast improvement in health outcomes.

Elected representatives should determine what healthcare I get? Really?

Irrespective of how healthcare is financed, they are going to do that (well, the government is, it is possible that the government may not be comprised of elected representatives), the question isn’t whether they should, but how many other actors that are neither you nor your doctor should.
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