How medical insurance works
How medical insurance works
156 comments
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i have a friend who's a transplant patient and has been taking the same meds for over 10 years post transplant-- every year it's a furious battle with insurance who, every year, decides the meds are no longer "medically necessary" and drops coverage for it. fucking helloooo these are anti-rejection pills, the textbook definition of "medically necessary."
it's not that insurance companies are stupid, it's that they're saving money on people dying when those people don't get what they needed to live.
insurance is the biggest fucking scam of all time
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The insurance system does not work in the medical field, it would never work because insurance is for managing risks that are unknown, like a house flooding or your car getting hit in an intersection.
In medical "insurance" it is often dealing with known issues, and the insurance system is just not set up to deal with preventative care, annual check ups, mammograms, blood tests, or pre-existing conditions. It would be like trying to use car insurance to pay for an oil change, which is just as ridiculous as it sounds in your head.
That's exactly why the term "insurance" should be used when discussing a single payer system, it's not really insurance, it should be a collective action group that works together with the medical community to find a middle ground where hospitals can still exist and pay wages to their staff, the people can get the medical care they need without getting thrown into poverty for daring to get sick, and the government benefits from having a healthier population as a whole.
Too bad theres way too much money in the short term in keeping this all private, and having a sicker population, so we have decades of insurance company propaganda to work against, and a huge population of people that don't understand that by doing single payer health care your taxes would go up, but you also wouldn't be paying out the nose for medical insurance & medical care (because they don't cover anything). Also think of a world where your health care isn't beholden to your employment, all the different choices you'd make in your life.
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I have a chronic condition that requires expensive medication. Every. Single. Year. I have to fight insurance to renew the prescription. I went without for months the first time and ended up needing a far more expensive surgery to fix the damage it caused. I was already pretty left-leaning before my diagnosis, but now I don’t believe there is any justification for private anything in healthcare. It’s a completely morally bankrupt business to be making money off of people’s unavoidable suffering.
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But insurance companies said that if everyone paid for insurance, especially the people who don't need it, that costs would go down
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I don't get it why americans still put up with this if I suffered from that in France I would just leave my country.
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Frank didn't even look at it. He just fed your claim into their computer and it spat out a rejection.
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Bold to assume he bothered to feed it to a computer when you can just reject without having to do that. Feeding something to a computer takes time, and time is money y'know.
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If check: accept
Else: reject
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I work for a neurologist practice, and the amount I have to argue with insurance (and inevitably have to get the neurologist on the phone to directly request something for many) is insane. A good chunk of my job isn't providing care, but arguing with insurance that the care is necessary. These companies are actively delaying patient care, and try to blame the physician whenever possible.
Wildly infuriating, especially when the denials are worded along the lines of "we reviewed this, and don't consider it medically necessary". Motherfucker, a doctor said it was necessary and listed the clinical reasons why this test or procedure would be beneficial. Nothing has radicalized me for universal healthcare more than working in healthcare.
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How is that even legal? How is someone who hasn’t examined the patient and isn’t their physician allowed to make treatment decisions? If they even have the necessary qualifications.
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Because of money!
Every time you see something that feels illegal but isn't, or that makes no sense in general, look for the money trail. There's always one, and it always leads to the explanation.
In this case, insurance companies have made such an absolute ass ton of money by killing off their customers that they have become a political entity. They now use their deep pockets to lobby politicians to keep their scam legal.
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They're technically not making treatment decisions, they're making payment decisions about treatment decisions. Effectively it's a distinction without a difference though. And it's usually a "doctor" working for the healthcare company rubber stamping the denials. It's a thoroughly shitty system.
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People love to shit on the VA, because they're the largest American healthcare provider in the country so there's a lot of bad stories
But my last MRI went like this:
Doctor: you need an MRI, let me check if it's open. (Less than a minute on laptop). Ok, go down to room ____ and they can get you in now.
There's a huge up front cost for that machine, so for profit hospitals went everyone to use it to make the money back, and insurance wants no one to use it so they don't have to pay.
Take insurance out of the picture, take the hospital trying to make money out of the picture. And it's really that easy. No one pushes for unnecessary tests, no one tries to prevent necessary tests. And there's a huge push towards preventive medicine, because it's cheaper to catch shit early.
We already pay more than what it would cost, it's just the healthcare industry donates to both parties, so as long as both standards are "at least they're not the other team" shits never going to get fixed.
If we hold higher standards than that, it won't take many election cycles to get change to actually happen
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It's cheaper to catch shit early.
This is a huge takeaway. Insurance doesn't care about your longevity, health, quality of life or even long term costs.
People hop insurance providers all the time so the companies are literally focused on profits quarter by quarter.
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On the flip side, I can't imagine being the person arguing for the insurance companies makes them a better or happy person in the long term. Being a devil's henchman, over time it must destroy important parts of them like empathy, trust in people, and their basic human decency. Virtues that are needed now more than ever in society.
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Well yeah that's why they keep doing it
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I expect it’s like any call center - the computer spits out a result and they have a script to follow, and are not allowed to stray from the script
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This part isnt brought up enough. You can take more severe examples, folks working in slaughter houses, military translators marking targets based on vague phrasing, and they have well documented negative effects on people who work those jobs in general.
Theres no reason to think someone working an insurance claims job might not develop the same type of problems if they feel they are helping cause harm, even if to a lesser degree.
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And some doctors themselves will be hesitant to give care that might not be provably required beyond all doubt but is objectively prudent.
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Hospitals should unionize and sue the the ever-loving shit out of insurance companies for lost time. Not like our neoliberal politicians are going to do anything about it.
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I feel like we're getting to the point that this needs to be an election deciding issue. It won't be this upcoming election, but probably the one after where the presidency isn't on the line. We need to ignore republican/democrat talking points and elect based on a will to completely revamp the system. Obama tried but it didn't go far enough. Once its bad enough that people are willing to cross party lines to fix it, then you'll see change, and I (probably too optimistically) think we're almost there.
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Had my buddy over who brought over his incredibly questionable 30yo brother who shared some real incel levels of talk. He used my bathroom and asked if I wore tampons since a pack was visible. Like bro, I have a wife and a daughter.
Anyways, that guy works in health insurance!
I don't know how much decisions he can actually make. But that dude has a middle-school level education about sex ed and struggled to explain what a period is. And he is one of the barriers to approving/rejecting your health care.
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“You want me to whip out my dick and slap you with it since that was the stupidest question I’ve heard?”
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You should see what @pancakes@sh.itjust.works wrote in this very thread. You basically just answered their question about what this industry must do to a person's ability to empathize and be a decent person to others. Or in this case, maybe lack thereof is a job requirement?
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So here is a question:
A medical professional examined the person IN PERSON and has a requirement.
In comes the insurance to tell you your doctor is wrong and that you're perfectly fine, your doctor is basically lying to you.
Question: how the fuck did any of this ever become legal?
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Question: how the fuck did any of this ever become legal?
I would guess lobbying.
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Politics are dumb but very important.
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You do need some checks and balances because what's to stop a hospital from profiting off the insurance companies by asking for a CT scan/whatever of every single patient just because they can.
I suppose we could have the government run the hospitals too. But noooooo, that's never going to work out because communism or something.
Maybe we should try effective altruism and accelerationism instead? Let's just hand over all our money to a few tech bros and then we can go beg them to pay for the scans. And if they don't pay for it, surely someone will come up with a cheaper technology to do the same. Yes, that'll definitely work.
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You could just get rid of the for-profit medical industry entirely and then there would be no incentive to over treat patients.
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Yes, it's clear why it's legal and necessary to some extent. In a for-profit system, a doctor's office or hospital, every procedure or test the doctor can order (and have the patient pay for) will generate profit. Doctors have an incentive to order as many tests as possible. I assume that most doctors are somewhat honorable and won't abuse this too much, but they'll probably still err on the side of ordering as many tests as possible not necessarily because of profits, but because more tests gives them more information.
Meanwhile, in a for-profit system, an insurance company will generate the most profit by agreeing to as few tests and procedures as possible. So, they will have an adversarial relationship with doctors and will try to arrange as few tests and procedures as possible. My guess is that the average insurance company is less ethical than the average doctor, so they're probably more likely to refuse to allow tests that are actually medically necessary.
In a sane system, there would be a neutral referee, the government, who would resolve disputes and severely punish any actor in the system that was behaving badly. But, AFAIK that only rarely happens in the US, where the idea is that the "invisible hand of the free market" will magically make it all work.
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If a hospital is found to push doctors to prescribe unneeded medicine or tests, the entire top staff should be questioned and jailed for fraud where applicable.
If an individual doctor does this, same treatment
We're not just talking money here were talking human lives. If you risk health for money, off yo jail you go
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what's to stop a hospital from profiting off the insurance companies by asking for a CT scan/whatever of every single patient just because they can
The patient saying no. Also a system where the patient isn’t forced to use insurance.
We could have markets run the hospitals but heaven forbid people would consent to their economic interactions.
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It became legal when we decided medicine was too important to be handled by a free market, and we created a labyrinth of laws governing how medicine must be administered.
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Medicine in the US is the closest we have to a free market. (Newly developed pharmaceuticals being a bit of exception due to the nature of our patent system) In a free market you work on principles of supply and demand. An important concept here is that of inelastic demand. For certain goods, up to a certain point demand will remain constant regardless of price as they are essential to life or addictive. Think gasoline, water, cigarettes, etc...
With medicine people will generally spend whatever it takes often even going into debt if necessary because they value continuing to live very highly. As a result, hospitals are able to charge as much as they think people are willing to pay before they decide that dying is a better financial decision.
You could argue that in a free market, hospitals which charge less will see more business pushing costs down. For certain areas like elective plastic surgery the whole free market model actually works out fairly well since people have the option to shop around. However, let's say you get in a life threatening car crash. In that moment you don't have the time to shop around for the cheapest ambulance provider and run a cost benefit analysis on which one has the closest ambulance. After that you can't shop around local hospitals to see which can offer the cheapest solution for your procedure because first off you don't know exactly what's wrong until you get to the hospital. Second, you're currently suffering from serious injuries and need to get to the closest hospital. This is why just about the entire developed world apart from the US has nationalised healthcare. Is it completely free of issues? No. Are there some markets where private healthcare can offer better service? Yes. However, you don't have people going into financial ruin because they needed emergency medical care.
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You literally take the wrong takeaway from all this.
A free market for healthcare is a disaster. A few big companies will form that will squeeze every last cent out of dying people, you get the US system. US healthcare and it's free market literally is the worst. Be healthy and bankrupt or die
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Sometimes the Frank is an AI that is wrong 90% of the time. That's fine, because reasons.
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I fucking wish. At least then I wouldn't have to be put on hold for 30 min just to have to eventually explain to a person who was hired 3 weeks ago how to do their job.
Private insurance always has you speak to an actual adjuster for authorization, mainly because they know any sort of automated system would be more accurate and faster than having you talk to their undertrained and understaffed employees.
Private insurance's goal is to erect as many barriers between the provider and the patients as possible, and then blame the provider for all the barriers. It works every time.
"I have the best insurance, they told me it would be covered". Nope, Medicare is the best insurance and you traded that away for a privatized Medicare supplemental that lies to you about your coverage.
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Sometimes the Frank is an AI that is wrong 90% of the time. That's fine, because
reasons$$$.
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Also, there's this common "feature":
Dr: "You need this procedure."
Me: "How much will it cost me?"
Office Manager: "I won't know until I bill your insurance and find out if it is covered."
Me: "What is the cash price I would pay you if it isn't covered by insurance."
Office Manager: "I have no idea."
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Actually, since January 2022, you have the right to request a good faith estimate for services from healthcare providers if you're not billing insurance.
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I'd like to see a law that says you get a complete and correct bill in 3 months or less as well. I avoid getting healthcare because even though I have insurance, every single time I've gone, the billing gets fucked up and I don't find out about it until 6 months, or even up to 2 years later, and I'm on the hook for that. It ought to be law, that if your office is so fucked up that you can't produce a correct bill for services in 3 months and deliver it to your customer, then you should have to nullify it.
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This is great information, thanks! In several cases it wouldn't have helped us because of the 3 day advance request requirement, but at least its an improvement. Still not as good as what auto mechanics are required to provide, but its a step in the right direction.
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I’m actually ok with this system, but only because I throw the bills away after
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Prior authorization should 100% be outlawed. It's either insurance adjusters practicing medicine without a license, or insurance doctors making diagnoses without examining a patient, both of which are unethical or illegal.
Though I think the real solution is a system where every time a prior authorization denial is overruled by the DOO or a court, the insurance company has to pay punitive damages of at least $200,000 to the patient.
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Last time my doctor had to bill my insurance he said he would just run it immediately, because apparently "routine denial" is a thing where they just automatically deny it because if you really need it the doctor will then have his office try again with more justifications. He hated this a lot, because it basically meant he had to just assume first denial for no real reason and then his staff had to take the time to almost always go back and resubmit. He said sometimes he would submit it with the info, it would be denied, and then he would resubmit it two more times and suddenly it would be approved.
Like seriously, what the fuck. But only does that hold up necessary care, it also makes doctors do more bureaucratic work and hire more staff, which, of course, makes medicine more expensive. Brilliant.
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Shared risk pools are a good idea. Making them for profit is not.
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The cruelty of the US American for-profit health system is what should be uniting all US Americans in protest, riot, and violent overthrow of the current system.
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The sad thing is they do hire some licensed healthcare professionals to fall back on when appealed. They just look for the least compassionate MDs to rubber stamp denials.
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Eh, generally a peer to peer won't get denied but requiring a peer to peer is a good way to waste the doctors time in the hopes they'll give up on the request. The instance company isn't paying the doctor extra time to perform the peer to peer after all. Now if that time was billable, you'd see it go away real fast.
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While I think the job selects for doctors with less compassion, but I believe some of them are there for genuine harm reduction
The system they're installed in is just insidious. They are given extremely short amounts of time each request, they face basically no consequences for a bad rejection, but they do face them for a bad acceptance. Their main metrics boil down to "rejections per hour"
A "bad acceptance" often means "improper paperwork". If the doc fills in a form wrong, you send it back. If the doctor files in a way that doesn't link relevant history correctly in their system, send it back. If the doctor fails to state a required prerequisite for the procedure, send it back (even if it was previously stated, or stated differently)
It's a pure lawful evil system, it's designed to slow things down and delay, hoping the problem will go away. It requires doctors to navigate a complex hostile bureaucracy perfectly, and often blindly. We're at a point where each patient is seen for an average 15 minutes before 45 minutes of paperwork to get insurance to pay for it
Then the requests are read feverishly to meet metrics. They can't think they're doing good, but I buy that some of them are doing their best to reduce harm in a broken system
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The private for profit health insurance industry - because what could make number go up better than a (LEGALLY MANDATED) do nothing middle man who's only purpose is to take your money and ensure as little as possible is spent on healthcare sitting between you and not dying?
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American health insurance in a nutshell: https://youtu.be/llx-SaGq4Fs?si=eDIny0fqcGYFkB2a
And before non-Americans ask, yes, that's actually how it is. The humor in this video isn't from exaggeration, the comedy derives from the unexpectedly clear way the absurdity of the system is explained.
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it seriously blows my mind that the overwhelming majority of my fellow americans tolerate this system, that is if they don't downright approve of it. The issues mentioned in that video are not isolated incidents. They are common, everyday, business-as-usual practices that almost all of us deal with.
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Yep! The last bit is more of a joke, but the rest is pretty spot on with how the stupid system works. Here's another example of a video explaining US Healthcare.
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The episode of South park where they walk into this 22nd century insurance building and ask to make a claim. They get sent to the "claims office" and it's like they went back in time to the 1980s with dot matrix printers, rotary dial phones, and fax machines.
Here is the link if anyone is interested: https://www.youtube.com/watch?v=VAfy26xs6e0
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I love BDG, everything he makes is fantastic
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And when the patient turned out to be fine after the scan, the insurance company will try to blame that the doctors are lying so that the insurance company has to pay the hospital more It's like they thought that the doctors must be able to see through the patients' body as if they forgot that the reason for these equipments to exist in the first place is that because the doctors can't really be 100% sure about what's actual situation inside human body
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There's two sides to this coin. On the one end, you have insurance companies refusing to pay for anything because the modern industry is just six scams in a trench coat.
But on the other, you have doctor's offices where the physician literally leases an MRI machine to the tune of several million dollars and then has to run a certain number of patients through the scanner every year or lose money. That's because the MRI patent is held by GE and they can charge 10-100x markups on hardware that is fundamental to modern medicine.
Its the same with diabetes treatments. Insurance companies will try and refuse service or kick people off their policies if they are at risk. But then pharmacy companies will sell $3 of insulin for $75, then kickback a chunk of the balance to judicial/congressional bribes in order to guarantee the cash flow.
At some level, the only insurance companies that can survive in such a market are the ones that say "No!" to everything. The even-remotely-ethical firms just get fleeced by the for-profit industry until they get bought out or go bankrupt. That, or you're Medicare/Medicaid and you have an infinite wallet backstopped by the US Treasury. You don't care if you're paying multiples of whatever any other clinic anywhere else in the world would charge on an enormous population of poor and elderly patients, because you have an unlimited money cannon to mow it all down with.
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Very uninformed take, its almost laughable.
GE isn't the only one who makes MRIs. The other big players are Siemens, Philips, United, and to some extent Canon, Fujifoto, and Hitachi.
No, that's really how much it costs. The margin on MRI machines is terrible. I'd like to see you do it cheaper... "Just" build then supercool magnet for superconduction for 3T of homogenius magnetic field, build coils that handle KW of RF/gradients that can fit a human comfortably without artifacts, build the high power and precision circuitry to transmit and receive said RF, then control that equipment accurately and safely.
Super easy, off-the-shelf stuff.
Oh, and you can't use any ferrous parts, nor can your power supplies generate any noise.
That's like, senior design level stuff amirite
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Six scams in a trench coat
Fucking poetry lol. I'm gonna use this.
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cough single payer fixes all this cough
Sorry, cough has been acting up. I should go see a doctor with a MRI about that...
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Shouldn’t that patent have expired by now?
This kind of thing is why it bothers me when people complain about “free market medicine”.
A market where only one entity is allowed to build MRI machines, or license the tech to others to build, is not a free market. That’s a government-enforced monopoly.
Even the fact that a patient can’t just go get their own MRI at Scans-R-Us, but needs to get a doctor’s referral first, is a huge departure from what an actually free market for medicine would look like.
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IThey can't even be sure after the MRI. Which again, proves your point. It took one MRI battery and one alert and skilled MRI tech to catch my brain cyst, THEN another whole set, I straight up spend a whole 8hr shift in an MRI machine, Then a TEAM of neurologists studied my custom hand made brain for MONTHS. THEN they had a really good set of educated guesses. Then they did the surgery, and only after they opened up my brain case did the actually see what in the hell was going on. Even after all that, my neurologists was like ''This is what we think is happening'', I asked what it would take to really know factually, he said an autopsy. He didn't recommend it. The point is, Doctors save lives with these scans, and nothing is certain. That's not a barrier to treatment, but no scans Is a barrier to treatment.
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This is why we need transporter tech from star trek.
Beam yourself into the copy buffer, kill the copy, and do an autopsy.
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They hire doctors who can't handle being practicing doctors to prop up their delusions. I've only had one on the line in a dispute and he acted quite offended when I asked for his license to prove he was a real doctor. Turns out he was barely a doctor at all. He decided instead of practicing medicine and killing people he would work for a insurance company and kill them that way.
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I had a friend who needed a CT head, chest and abdomen. The insurance company decided she could have the head and abdomen, but not the chest, and couldn't really explain why when asked. American health care is a joke.
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I recently went in because I had a thunderclap headache, thought it was about to die from a brain aneurysm. No insurance. They did 1 CT scan and billed me for a Head CT, Neck CT and a Cervical Spine CT, each costing over $3K. After months of calling their billing department I ended up having to setup a payment plan before they sent it to collections. Not a single person in the billing department, up to and including the head of billing, could tell me the difference between a neck CT and a cervical spine CT. Still on the hook for over $11K. Probably going to have to file for bankruptcy soon. My life is effectively over.
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Your life isn't over. Discharge the debt through bankruptcy and move on. I honestly mean no offense, but if you were already uninsured and an 11K debt would effectively end your life, you're not going to be much further back than where you were before bankruptcy. Maybe even a little ahead.
Bankruptcy isn't just for rich people and corporations, although it sure is treated that way sometimes. Do it now, don't keep letting debt holders guilt you into "bootstrapping" it. They're just squeezing as much money out of you as possible while they can.
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There's no difference. Holy fuck I'm sorry.
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"Because I said so."
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My insurance that I pay a ridiculous sum of money for has started doing this neat new thing. When the doctor orders imaging, they mark it as “requested more information but never received any”, and reject the claim. They don’t actually request any additional information, and they ignore me when I contest their decision. So glad that I pay like $400 per month for this coverage.
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Yes, I think that's exactly what my doctor was trying to describe. He said if they're at that point, they basically have to guess what information they're looking for other than "I'm a qualified physician that has run diagnostic tests and determined this is the best course of treatment. Here are those tests and why it indicates X and therefore requires Y."
I've had to do unnecessary labs to prove an ailment wasn't something else that some person hundreds or thousands of miles away thought it might be.
If you think you hate insurance companies, find an honest doctor and ask them what they think of the US Healthcare system and health insurance. I've never seen a doctor so worked up and angry than when discussing the current medical system.
Edit: this guy is fun to watch on this topic: https://youtu.be/s33AVskz3T8?si=Qqx2nAJjguMOxnNL
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It's like calling your ISP and you can see the fucking wire dangling down from the pole but they won't continue unless you turn the modem off and on first.
I worked in Pharmacy claims remediation for a while. Fun times. Never again. Why the fuck is my barely-above-minimum-wage-ass the one that has to tell medicaid that little Timmy is gonna die if he doesn't get his chemo?
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I file a complaint with the department of insurance instantly when they deny anything. I don't negotiate with them for 3 months first, I jump straight to sicking the Feds on them and my doctors have always provided me every bit of data I need and cheered me on.
And I've won every time. It annoys me that I have to do it, but I enjoy that it costs the insurance extra every time.
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I didn’t even know that was an option. Thank you! I will do that from now on.
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Maybe if you can't afford to pay premiums that allow you to have an IRM, just
don't indulge in expensive illnessesdie already. -
This shit really needs to end.
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tl;dr: It doesn't.
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Yes I would like to change this, too. Who do I vote for to make this happen? Just kidding I don't have access to $10B of "free speech."
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My $7000/mo medication has a bunch of "cost relief" programs so they can pretend that they give a shit about affordability, then when you actually try to use them they make you do like 20 phone calls over the span of several months until they finally let you enroll and when you do it only lasts for a short amount of time before they kick you off and you have to start the process all over again. I've had to miss multiple doses of the medication which is dangerous for my physical health because I don't have the money to pay for it and this process takes so fucking long.
Recently, they signed me up for some super shady thing where I pay for the medication upfront and then they pay me back after showing me the receipt. What they didn't tell me is that it has a limit for how much it will pay for, so I pay for the medication, and what a surprise, they rejected my claim and now I lost $5000 to the medication, which could have paid for a car or a semester of community college. Our healthcare system does a great job at making dying sound like a decent alternative to healthcare.
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Had surgery to correct an underbite a few years ago after prepping for it with braces for years. For context, I was still young enough to be on my parents' insurance. The surgery involved moving my upper jaw forward and my lower jaw back because the underbite was so severe. The insurance denied the claim. My parents (I love them so much for this) decided beforehand that, if the claim and the appeal were denied, they would instead "gift" me the money out of their own retirement savings and have me pay for it. The procedure alone cost, I believe, $16k out of pocket. (I don't remember the specific reason why they gifted me the money instead of paying for it outright.)
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Fuckingcapitalists
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Capitalism is based on free markets.
Deviations from free market status in this scenario include:
- The MRI machine is extremely expensive because it’s from a government-enforced patent monopoly
- The insurance is expensive because it’s mandated by government
- The MRI requires a doctor’s prescription because that’s the law
If we had capitalism in medicine, OP would be paying $150 out of pocket to buy an MRI scan from a private company, and that would be that.
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Where did you pull $150 from?
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Sure we could save lives by listening to doctors! But who will save our dollars, huh? The REAL value!
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America is one of the richest countries, but life expectancy is so low because of all these inequalities and shootings.
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Everyone should also remember that it's going to get worse. People, especially nurses, are leaving the medical field. GPs are becoming scarce, and boomers are taking more and more of the medical resources available as they age. It's going to get harder and harder to get timely medical care at all, let alone getting it without bankruptcy.
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No way ? insurances have a say against the word of doctors ? I must be hallucinating, I thought I knew all about it
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Well. No. They have a say about whether they'll pay for what the doctor has decided is best for the patient.
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I really believe a lot of this comes down to poorly automated systems and people not allowed to go off script … and insurers have no reason to change this.
When there’s a claim it gets entered into the insurer system by procedure code. It’s only decided based on what procedure code is recognized by the system. The peon deciding to reject it likely has no power to say otherwise nor incentive to. Even when they do ask for a doctors opinion, do you really think he reads all the case notes, or even has access to them, or has time to read them, or incentive? Nope, just whatever codes were entered into the system. You read a lot about issues where procedures have to be recoded for insurance, but I’ll bet many more of the rejects are as simple as the code not supporting the treatment and no one at the insurer looking farther. This is more a form of institutional incompetence but insurers have a profit motive in maintaining this incompetence
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I did pharmacy billing for a while and this is a kind of innocent take that people are just being lazy. The training was terrible (I was taught the basics of the software and then given a photocopy of various employees hand written notes for common rejection solutions over the years ....most of which didn't still apply and those employees had long left; when I left in sure my notes were copied to the pile). There were metrics that kept being increased meaning spending more than 30 seconds on a claim was going to put you behind (I did night shift and my boss was talked to about me once or twice because I sometimes had an hour or two where I'd cleared everything I could and had nothing to do because the rest of the world was asleep). And, finally:
The software was designed to actively fight us. My most common reject was insurance won't pay for anything $X or more with X being stupidly low. For many insurances you could not put in a recurring override for monthly maintenance meds. Your options were either give the patient a 2/3/whatever day supply to get the cost down and they'd just have to visit the pharmacy for pickup so much they might as well work there. Or do a one time special override every. Single. Time. Which involved me doing a special code on my end (which wasn't the same for every insurer and sometimes they'd just randomly change it for shits and giggles with no communication, I had a list of codes that were often used I'd try guessing with). Calling their help desk whose employee retention and training were also in the toilet. If the insurance end person knew the process for a one time special override, great. If not I started specifically keeping notes by insurer to teach new people because otherwise I'd be subjected to an hour of phone hockey while they tried to find someone who both knew how to do it and could cram my call into their metrics. Then we'd have to go through generating specific rejects just because we needed it in our logs we tried shit we knew wasn't going to work. Doctor note saying md knows med is expensive and that pt needs it to live regardless attached? Okay run it through as cost doctor approved to get the "fuck the doctor we don't want to pay" reject. Insurance doctor/nurse team reviewed that yes the doctor is correct the patient needs this med to live code put in? Okay run it again to get the fuck our own doctors we still won't pay reject. Now insurance help desk has to message their next level support to get authorization for a one time override for medical necessity. Okay now it'll go through on the insurer end (as long as they didn't fatfinger anything because the override only works for one single attempt). Great, we did it one try team! Now my turn to do it on my end which involves me removing all my codes because the software no longer recognizes the reject so will reject me for needless codes which will make us have to get the One Single Try Authorization again......
You don't have to die to visit hell just work in medical billing.
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What a graphic presentation of life in hell
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Think we could make Lemmy a household name by having the C suite of companies that do this SWATed? The government doesn't work so we're going to have to do this ourselves.
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Can someone explain how universal healthcare would solve this issue? It seems like an additional problem beyond the fact that prices are gouged based on insurance that not everyone has. On top of that bullshit, insurance does this stuff. What about universal health care, if implemented tomorrow in the US, would make it different?
(Side note: I love how I get all these downvotes for trying to learn more! What a fucking asshole, right? Yall are too used to trolls, grow up and humble yourselves. Learn to distinguish asking about how barriers work from advocating for those barriers to stay. Jesus fucking christ some of you are so much dumber than you realize you are.)
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There wouldn't be an insurance company to tell you no in a single payer system
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Damn. That's gonna be really hard to get to in the US. Several steps at least. I'm guessing the next step that we can work for is just guaranteeing universal coverage. But there's gonna be bloody battles over just removing an entire industry from the US market in our lifetime. So I guess this problem is here to stay, even if we're lucky enough to get guaranteed coverage regardless of employment.
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There wouldn't be a for-profit middleman taking billions out of the system for themselves yearly.
Critics point out that government-run healthcare would be less efficient and would also have to draw the line in approving/denying care somewhere too, but I can only imagine that it would pale in comparison to the insurance companies who have a profit-motive to screw you over.
Supporting this assumption is the fact that Americans already spend way more on healthcare than other countries, even those that already have universal:
So, basically we're all overspending solely to make insurance companies rich.
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Hey but we're 60th in life expectancy in the world! So... wait.
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How things work in BC:
When a practitioner changes for a service, they can't bill any more than what the Payment Schedule says that procedure costs. So if the Medical Services Plan isn't being billed (eg the doctor or patient opted out of MSP, the patient is a non-resident, the service is in the Payment Schedule but the Payment Schedule requirements consider it unnecessary) or MSP isn't covering the full cost (some stuff like a second or third biopsy will only be covered 50 %), then the doctor can't bill the patient any more than they would've billed MSP. This means practitioners have no incentive to not bill MSP.
The Payment Schedule (and thus allocation of the MSP budget) is set out by the Medical Services Commission which is composed of three representatives from the government, three from the Doctors of BC (the professional association which promotes the interests of member doctors) and three members of the public. So even if the government pushes for more stringent coverage requirements and budget surplus, the doctors are there to push for higher fees and less billing paperwork (besides exceptional circumstances like out-of-country care, patients can't submit claims directly; everything is on the practitioner's end), and the public is there to push for more coverage.
In practice this means that for the vast vast majority of services, the only justification that the practitioner needs to give MSP for coverage is the International Classification of Diseases diagnostic code for the condition being treated.
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Brit here. Not saying the NHS has no problems, long waiting lists being the most obvious, and on a practical/personal note shared wards, but at least in principle if the doc says you need X then you get X. There's no beancounter to persuade that you really need this thing who then says no anyway. There might be another step: GP -> specialist -> diagnosis -> solution but in principle it's pretty straightforward. It's funded by a 9% tax so you pay according to your ability, and it's free at the point of delivery to all British citizens.
If the solution is a pill or potion from the chemist then you get it free if you're on a low income, but at a capped price on prescription.
Because it's free to use, you (can) go to the doc as soon as you have a problem, unlike in the USA where you dread massive bills so you hope it goes away on its own, meanwhile it gets worse so you go when you have to and when the bills are at their highest. And because the NHS is tied into the government who regulate the pharmaceutical industry they (should but don't always) get best prices on everything, along with bulk discounts because it's just one buyer for the whole country.
I'm probably oversimplifying a lot here; I don't work in the NHS so this is just my view as an outsider. I think there are some regional variations; every so often "NHS postcode lottery" comes up in the news, but I don't know how they work.
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The health insurance company has little motivation to care about your health, but doctors have little motivation to care about money and money is actually important too. Ultimately you end up paying for all that unnecessary testing and there has to be some mechanism for controlling cost.
With that said, one time I was appealing a rejection of home care for my grandfather and I mentioned that his condition had declined and he was currently in the hospital. The guy from the insurance company said that clearly someone in a hospital doesn't need home care and so my appeal should be rejected and I should file a new claim (which can take months) after my grandfather was home again. The arbitrator didn't agree with that (although she said that she could postpone the hearing until he was discharged if that was what the insurance company wanted) but I was still so angry.
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That study is idiotic. It's literally an embodiment of the joke: "You could have found it faster if you looked in the last place first".
Standardized triage testing has been shown over and over to save many more lives than doctor intuition alone. Just because a test rules out a diagnosis doesn't make it "unnecessary".
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I also didn’t see anything about costs of test - a cheap test that rules out even a small chance of something catastrophic can be a very good investment
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20 years of experience believes
What are 'experience believes'? Is this sentence missing some punctuation?
Edit: I get it : sub-clauses are hard. Remember they're delimited on both ends. This is grade-school stuff, kids.
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Oof man. Reread the entire sentence.
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There should be a comma after experience.
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No it's fine as is. That person just read it wrong, that's all.
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No, there shouldn't.
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I'm drunk in the back of the car and I'm crying like: a baby coming home from the bar.
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156 comments
Universal health care? I don't want government making my health care decisions! We have for-profit companies for that.
Death panels?
Believe it or not, that's also Frank.
Fun fact, he was named after the health insurance industry’s inspiration, 1789 France.
Frank is a busy man. Denying medical treatments, sitting on death panels. Is there nothing Frank can do?
Oh yeah, Frank can't approve medical treatment.
Don't be so sure it would be different. I collapsed, nearly drove off the road 3 times in one week and decided that it was enough and went to the doctor. He sent me home, wrote me in as extreme burnout (completely true, I had to sleep at work for every coffee break to make it through the day and 30 mins before driving home to actually make it). So I thought Great, I will rest for a few months and go back to work after that! Nope. The state heath insurance office said Our specialists decided, that you are perfectly fine. No sick pay. Get back to operating the industrial concrete blender. The health center doctors signed a letter, but no, I was fucked. So on top of this I got extreme financial stress. We got out of this crap by renting our cabin and starting going full into an outdoor adventure business. What a great time. Where was this? In Sweden in January 2019.
Sounds like a flaw in the system. I fail to see how health insurance should ever be involved between patient and doctor in a "universal" health care system. Sure doesn't happen where I live.
In theory a government is beholden to its constituents, a corporation is beholden to its shareholders. Governments aren't perfect, but there are at least avenues to effect positive change without financial incentives being a prerequisite.
Do people believe that there? I can assure you the government has no roll in our health care decisions, and what the doctor wants the patient can always get.
Oh yeah, it was a major propaganda position back in the 00s and it’s part of how obamacare got that way.
Far too many, yes.