I’m claiming that insurers do not erroneously deny claims in the hopes that people give up. I don’t have data for it, but I’ve also never seen data that shows insurers deny coverage just to dissuade people (post ACA).
> experience the problem with our health care system is not just denial of claims, but about the cost of medical services and medicine.
Yes, I agree here about the cost of healthcare, but that is a separate issue from insurance companies erroneously denying coverage.
> how does that even make sense?
Prices for medications are extremely obfuscated, and you will never know the true price paid due to various rebates and fees on the backend between manufacturers, insurance companies, and retailers. There are various reimbursement rules from CMS (centers for Medicare and Medicare services), state Medicaid, various employers, and it’s a very, very inefficient method of price discrimination.
> Since they are by law limited to earn a capped percentage on premiums minus costs (at least in my state),
ACA caps health insurer profit margins federally, so it applies to all states. Assuming there are multiple competing health insurers, then unless they collided, they would not be able to arbitrarily raise prices to increase the absolute value of their profit margin.
The problem was the political compromise that had to be made in order to pass ACA, which is that it allowed employers to maintain their silo’d group of employees. So you have a whole bunch of healthy white collar lives taken out of the healthcare.gov market, which leaves it with all the sick and poorer lives, making it less viable for multiple health insurers to exist. If everyone had been forced onto healthcare.gov, then it’s feasible for multiple health insurance companies to exist and compete. Also, there should be no state boundaries, since some states’ populations are so small that they can’t afford to spread around the healthcare costs.
I’m claiming that insurers do not erroneously deny claims in the hopes that people give up.
You keep saying "erroneously" but I'm not sure what you mean by that.
My experience is that for any major change in medication (either dosage or brand, but for the same chronic condition) the insurance will initially deny the claim. This kicks off many hours of phone tag between my family, the insurance, and the doctor. Eventually the insurance company will pay up, but usually well after we've already paid out-of-pocket for the first month, which then requires another few hours on the phone to get reimbursed.
This isn't a single insurance provider. This has spanned decades, 4 employers, 5 insurance companies, and at least 3 medical providers.
>You keep saying "erroneously" but I'm not sure what you mean by that.
"Erroneously" as in denying coverage for something that should be covered (per the terms of the contracts).
It's unfortunate that you have to go through all of that when changing medications. I don't know the reason for it in your specific case, but I would hope it's not widespread fraud across all of those companies.
Sure, I won't go as far as calling it outright fraud. But, it certainly is part of the business. And as the consumer, at the time of service, I really don't care why it happens, only that it does and that it costs me time and money and delays treatment.
As far as I can tell, it's a byproduct of an adversarial relationship between the 3 parties (consumer, doctor, insurer). Insurance doesn't trust the MD to do his job, so hires their own MDs to second guess. And on anything that costs more than $100, that second guessing is the default action - the insurance company's own MDs are only there to provide legitimacy to the initial denial. I say this because in ALL cases, my medical needs have eventually been covered, but not before committing more time and energy than should be necessary.
At the end of the day, we pay more money (and time) for worse outcomes than most of Western Europe and the wealthier nations in Asia.
>the insurance company's own MDs are only there to provide legitimacy to the initial denial.
I have first hand knowledge that this is false. Especially if the insurer is just acting as an administrator for a state Medicaid or federal Medicare or other payer, since there are big penalties for denying coverage just to save money. The insurers even have MDs and PharmDs to audit their own MDs and PharmDs to see if they are appropriately approving or denying treatment.
A lot of the problem is probably coming from lack of proper EMR and supporting documentation justifying treatment, and subjectivity in justifying treatment because there are many gray areas.
This same approval denial situation happens under taxpayer funded healthcare also, since no one has unlimited resources. But yes, the US implementation of it with myriad payers and rules certainly makes for an unpleasant experience and results in subpar healthcare.
I guess, but if so, that's a massive amount of cost to the insurer (and eventually falls back on the consumer) around paperwork/review/approval for something they're going to approve eventually. I really don't understand it. Certainly in my experience, the insurer could get rid of their internal review process and people, just rubber-stamp whatever our MDs are prescribing, and save us all a lot of money and headache.
>the insurer could get rid of their internal review process and people, just rubber-stamp whatever our MDs are prescribing, and save us all a lot of money and headache.
If that was true, there would be an insurer doing that and offering lower premiums on healthcare.gov
But it's not true, and the review processes do control costs (even if wrongly at times). I think the government farms this task out to insurers specifically so the insurer can take the heat for the denials, when it's actually the government's rules and standards for the requested therapies that is resulting in denial of coverage.
I've personally seen this with Medicaid or CMS penalizing for erroneously approving payment for treatments and also erroneously denying payment for treatments. And it gets very fun when the rules are not clear and there is a lot of gray area.
If it is fraud, then it's not manifesting in outsize profits for insurance company. Almost all premiums go towards paying for benefits, and they are left with ~5% or less in profit. The executives are not earning outsized compensation compared to executives at other large companies, there is no army of people with FAANG salaries, so who is the fraud benefiting?
This is all public information per their SEC filings. You can drop the compensation for all the bosses down to zero and it wouldn't move the needle on how much more healthcare they could be providing the insureds.
I have some exposure to the claim adjudication space, and I can say that there are undeniably people who see it as a fiduciary duty to make people jump through hoops before paying out a claim. This is a large part of why so many prior authorization proccesses suck royally.
However, w.r.t. long term medications getting denied, keep in mind that every claim starts denied until a path through to an approval can be traversed. This is a fundamental starting pount for any insurance related system. It is fundamentally a filter.
You as the customer do not have readily available access to many of the clinical programs going on in the background. Opting in and out by a plan sponsor can substantially change the footprint or character of approvable claims. Especially if paired with formulary changes.
If you happen to be on any type of high cost or specialty treatment, you're on course to misery-town, because you just popped up on the radar for entire divisions worth of second guessing justified by fiduciary duty, but often implemented in ways that leaves the patient both helpless to know what is going on, and holding the bag.
I agree. I think if the US is going to stick with this insurance as an agent for the patient system, then the federal government should standardize the prior authorization process, as well as EMRs and do whatever it takes to make the communications quicker and easier for the patient. I would also recommend dropping the state boundaries when it comes to healthcare, it makes everything literally 50x more complicated for no reason.
There's no reason why all these billing codes and coverage conditions should be shrouded in mystery.
Regardless of any progress that has been made, I think anecdotal evidence is important here, and pretty much anybody who has actually used the system knows that it sucks. Nobody knows what to pay and what not to pay, for one thing. There isn't any trust - as many posters here describe, paying medical bills in the US is (feels like?) a constant struggle against being defrauded by both your insurance company and your doctor.
I always tell the same story in opposition to our current capitalist healthcare model:
1. When my oldest daughter was born 10 years ago with Spina Bifida we had private insurance through my employer. The premiums for this were something like $15,000/yr. At the time this was probably 1/3 of my total income.
2. Despite that, we continue to receive bills that we couldn't possibly pay for years after that.
3. Since my third child was born, the children have been covered by a state program (Georgia), and pretty much everything has been covered, no questions asked. As a consumer, this is pretty much all I care about.
I recognize that the current system is bad for the service providers as well, as evidenced by this article. The doctor in question gotten all he's gonna get from insurance companies. He has no hope of collecting this money, so he may as well turn it into good PR (cynical perspective, I guess, but that's me).
While the system may suck, it's leagues better than it was before ACA for most people. Even your example shows it, since before ACA, there was no out of pocket maximums, and hence you continued to receive bills. In fact, before ACA, there was a maximum benefit amount the insurers would pay up to, and then after that, the costs would fall on you.
And your GA state program is most certainly made possibly by the expanded Medicaid funding due to ACA.
>There isn't any trust - as many posters here describe, paying medical bills in the US is (feels like?) a constant struggle against being defrauded by both your insurance company and your doctor.
This is true, but it would help if healthcare providers would list the codes they will charge so that people can look up the cost with their insurer and aren't signing blank checks every time they enter a medical office.
I’m claiming that insurers do not erroneously deny claims in the hopes that people give up. I don’t have data for it, but I’ve also never seen data that shows insurers deny coverage just to dissuade people (post ACA).
> experience the problem with our health care system is not just denial of claims, but about the cost of medical services and medicine.
Yes, I agree here about the cost of healthcare, but that is a separate issue from insurance companies erroneously denying coverage.
> how does that even make sense?
Prices for medications are extremely obfuscated, and you will never know the true price paid due to various rebates and fees on the backend between manufacturers, insurance companies, and retailers. There are various reimbursement rules from CMS (centers for Medicare and Medicare services), state Medicaid, various employers, and it’s a very, very inefficient method of price discrimination.
> Since they are by law limited to earn a capped percentage on premiums minus costs (at least in my state),
ACA caps health insurer profit margins federally, so it applies to all states. Assuming there are multiple competing health insurers, then unless they collided, they would not be able to arbitrarily raise prices to increase the absolute value of their profit margin.
The problem was the political compromise that had to be made in order to pass ACA, which is that it allowed employers to maintain their silo’d group of employees. So you have a whole bunch of healthy white collar lives taken out of the healthcare.gov market, which leaves it with all the sick and poorer lives, making it less viable for multiple health insurers to exist. If everyone had been forced onto healthcare.gov, then it’s feasible for multiple health insurance companies to exist and compete. Also, there should be no state boundaries, since some states’ populations are so small that they can’t afford to spread around the healthcare costs.