Seeing my health insurance deny hospital claims that were pre-authorized has been insane. The hospital checked in advance with my insurance that several operations would be covered and the insurance approved. Now that the bill comes, the insurance company has repeatedly denied and denied their claims. Health insurance companies are horrible and parasitic to everyone involved.
I've had BCBS reject prescriptions they've already pre-approved multiple times. First time, they denied all knowledge of the REQUEST (when my doctor has their APPROVAL fax in hand). Second time they acknowledged they had approved it but had to contact their pharmacy group to put in an "override".
I've submitted a complaint with the state insurance regulator though I doubt it goes anywhere.
Anyone for a class action lawsuit on the grounds of bad faith breach of contract and medical malpractice for obstructing access to care they already admit is medically necessary (by denying something already pre-approved)? I don't even want money. I want a Consent Decree enforced by the court that strikes fear across their whole industry.
Audio record every interaction you have with insurance and tell 'em you're on a recorded line.
> medical malpractice for obstructing access to care they already admit is medically necessary
This has been tried before and failed. The insurers argument is that they are not denying care, they are just not willing to pay for it, which isn’t practicing medicine.
The big problem with health insurance is that it accounts for 17% of the US GDP, so although it's parasitic for everyone involved, it's basically indispensable to the economy. That's a big reason why the Affordable Care Act panned out the way it did, as a partnership with the insurance companies.
That's not how the economy works though — the GDP is correlated, not causated, with economic strength. What drives the economy in the end is positive-sum value creation, not trade in itself (although without any market failures, trade tends to create value). The only reason we use GDP as a measure is because actual subjective value created is very hard to measure.
If I start an extortion business, and make you pay me money in order for me to not kidnap your family, this will increase the GDP but not economic strength. This is particularly obvious during wartime, when GDP is artificially inflated, but the actual economy tends to be doing very badly regardless.
In other words, a trade that harms one party more than it helps the other makes the economy worse — regardless of how it affects GDP.
>it accounts for 17% of the US GDP, so although it's parasitic for everyone involved, it's basically indispensable to the economy
if people weren't forced to spend it on healthcare, they would spend it elsewhere. if healthcare was free tomorrow, the GDP would be fine, just redistributed.
>The big problem with health insurance is that it accounts for 17% of the US GDP
Healthcare overall, not insurance. Insurance is just how most of it gets paid. Conflating the two is like saying credit card companies account for 50% (or whatever) of the US GDP because that's how most people pay for their stuff.
If for-profit health insurance is really almost 1/5th of US GDP, something is entirely wrong.
Then again, maybe it makes sense the country that perpetuates suffering all over the globe through being global police and lately just fucking up any sense of stability is the same one where almost 1/5th of our "output" is built on top of making money off of prolonging our own peoples pain and suffering.
There was a way to solve it in a much more economically effective fashion with the Dr. Ben Carson plan. It was (and still is) the only feasible way to fix things long term.
This happened in our family a few years ago. It was a penny dropping moment when the hospital revealed to me thar they routinely record all calls with insurance companies. So they had a recording of the insurer approving the procedure. They still refused to pay nevertheless.
Obviously frustrating and shouldn’t be happening. If it was pre-authed, is it possibly a billing code mismatch? That may be correctable if you book an in-person appointment with the hospital’s financial office.
Private insurance in the US needs to be completely dismantled, and we need to go to a single payer system. Not a panacea, of course, but what we have is so broken and irredeemable, it's the worst of all worlds. The US has best-in-class (if crazy expensive) health care despite our insurance system, not because of it.
I will never forgive Lieberman for killing the public option, which would at least have force private health insurance to compedte with the government.
I'm of the opinion that either a real free market or single payer would be better than what we currently have.
The main thing everyone should agree on is that the employer healthcare mandate that ties health access to W-2 employment is responsible for this situation and should be revoked.
What comes next matters less; every system has its drawbacks but ours is the worst. It has all the drawbacks and none of the benefits of everyone else's systems
I'd like their to be a single payer for my healthcare but I'd like that single payer to be me and not the government and not an insurance company. Just like I am the single payer for all my food and my housing why can't we have a world where I pay for my healthcare too?
This would work very well for medicine/procedures which are known to work very well, to both doctors and consumers. This includes medicine which is already OTC (pain relievers), but also probably anything they can do at an urgent care: x-rays for broken bones or sprains, throat cultures, antibiotics (drug resistance is complex for this but people generally know they work).
Where costs will inevitably get complicated are:
1. emergency medicine, where the purchaser is in severe pain or possibly unconscious.
2. conditions without cures, or possibly even well-established treatments, and there is thus active experimentation and disagreement
Both of these are unpredictably expensive to an extraordinary degree, and the second category is sometimes rare enough that economies of scale don’t come into play for individual conditions.
I think government coverage of emergency medicine, aka ERs for severe injuries, is relatively uncontroversial due to its nature of treating unconscious patients.
However, that other category is very large in modern medicine. It includes all chronic conditions without cures, for which many options are available and improved techniques are constantly sought - and it includes complicated conditions where treatment has risks involved, which is basically a huge range of surgeries.
The problem in these areas is that the consumer does not have adequate understanding of the efficacy of what they’re buying, yet they’re driven to buy it strongly by pain and suffering. They are likely to want to do whatever a doctor or hospital tells them to do.
What is needed here is a consumer advocate with medical knowledge to keep prices consistent. In the US, this is provided by a mixture of regulation, medical malpractice lawsuits, and insurance companies.
Insurance companies are now failing in that role, but removing them entirely without any sort of replacement is going to leave the courts as the major vehicle to manage the costs - that isn’t a system renowned for efficiency.
Because unlike food and housing health is something that can hit people very unevenly. Imagine walking down the road with a copy of yourself, everything in your life is equal, you earn the same, eat the same, same genetics, etc. All of a sudden a car hits your copy and leaves him with a broken leg. The car sped off and the driver is never caught. Now through no fault of his own your copy has potentially huge medical bills whilst you do not. The concept of insurance and government paid healthcare is simply to distribute these costs. Everyone pays a little, but when you need healthcare you get it. Of course the current US system is quite broken so you end up paying a lot and still not getting healthcare when you need it. The government has a lot more tools to regulate prices of healthcare and no runaway capitalist drive to make money which makes them far more apt at providing such basic services as healthcare.
We shouldn’t even have to pay for essential services like healthcare. If it’s a matter of life or death, the state should be taking care of its citizens.
Because there is a non-zero chance that at some point you'll need a medical procedure that is, even at non-inflated cost price, more expensive than your net worth in order to survive; and society considers it unethical to let you die in that case. With the same reasoning you're not actually the single payer for your food, and food stamps exist.
Just like you're single-payer for your emergency fire services, your police services, your road maintenance, your food supply health inspection service, OH WAIT. =)
Health care is yet another of those services where society as a whole does better if everyone's needs as a whole are considered and taken care of together. It is definitely frustrating for those who have more and wish to pay more to get better care, but heck, it's still a better deal in that case. There are all kinds of diseases that have been eradicated (or are on the way out) due to a broad social program to first discover and then distribute the cure. Paying for the very best leprosy care yourself pales in comparison to never catching it.
I haven’t seen any measure where the US is the best concerning healthcare. I usually see it in the teens for outcomes and generally other measures are worse. It’s just bad.
However we basically have 1 solution, and its not legal. And naturally, its the solution in this article.
To be completely fair, just from the people who I know who have terminal uncovered diseases, I'm surprised more "direct action" hasn't been done. Desperate people with no good options can and do take the terrible options.
The by far best system I've witnessed was the Swiss healthcare system, which is NOT a single-payer system.
Some features: (1) health insurance is obligatory for all residents (2) must be private, cannot be purchased/sponsored by company (3) minimum coverage is specified by law (4) health insurers are private companies, often (mostly? always?) non-profit (5) they cannot reject applicants, and can only discriminate (by price) on: (a) age, (b) residence (i.e. more expensive city/area => more expensive health insurance) (6) all procedures are paid - 10% copay is mandatory (up to a certain yearly amount) (7) health insurers make extra money on better health insurance ("private coverage") offering better service, more experienced doctors, private hospital rooms, extra coverage (e.g. for mental health, abroad etc.) etc. - those can discriminate on much more features, including existing health conditions sex (e.g. for young women it's more expensive, because of pregnancy)
In 2016, Switzerland’s healthcare expenditure, as a percentage of GDP, was the highest in Europe. The country spent 12.3% of its GDP on healthcare.
Swiss hospitals also accumulated losses amounting to CHF1 billion ($1.13 billion) in 2023. Most hospital costs are covered by the gov't though whereas in the US hospitals are private corporations.
A single payer system is politically impossible :/. But there are ways to get the system without overturning it completely. But they all come down to cutting or eliminating insurance profits in some way, I think.
For example, prohibjt insurances from making profits at all - earnings must go into savings, future rates need to go down when savings are getting built up beyond a safety buffer.
Another idea: a government mandated catalog of services that have to be covered, including fixed costs (maybe plus a small effort scaling factor based on provable additional needs for a patient). If a doctor claims medical necessity, the insurance is automatically required to pay that fixed amount - no rejection possible. If the claim is fraudulent, they can sue the doctor later.
Why? US healthcare costs have nearly nothing to do with insurance and everything with doctor and hospital payments.
I think the best way to improve US healthcare is to off all the righteous idiots. Just kidding!
The 2nd best way is outlaw health insurance of any kind except maybe genuinely catastrophic, like lump sum cancer insurance or emergency room coveragr. Don't provide any public option. Once everything is out of pocket the outrageous provider prices will be forced to come down either economically or politically (my preferred option is easy immigration and the recognition of medical degrees from OECD countries)
The costs just get worse as our understanding of disease prevention and chronic illness grows. The costs of neglecting early intervention are ultimately borne by society through programs like Medicare, as individuals age with significantly poorer health than they would have if they had received earlier treatment.
It's much cheaper to repair a roof that has a small leak than it is to clean out and rebuild a house rotted with mold.
I had to look up what “single player payer system” means since I thought it meant something like “each individual pays for themselves”, the opposite of a social safety net.
I was completely wrong. Single payer means there is a single (gov) entity paying health care for everyone. 1000% this is what we need.
Everyone needs to care about their health. When we need healthcare it’s so often for things out of our control, like cancer. Putting the burden on the individual is cruel.
Capitalism as applied to human health is fundamentally inhumane (literally, profit valued over human life). I’d be interested to heard arguments otherwise.
Of course, a universal healthcare system should take notes from capitalist markets to be efficient, but have the primary goal of maximizing human well-being
Caner isn't out of your control, it's usually caused by being fat and eating bad food. It's sometimes caused by genetics but that's a minority of cancers.
What class is US healthcare best in? It’s probably among the best in quality you can get as a rich individual, but as a system it’s deeply flawed in many factors. US doesn’t even make it into the list of best 50 countries by life expectancy or maternal mortality ratio. Which is batshit crazy for such a rich country.
What is the life expectancy and maternal mortality ratio for lean white people in New York and Massachusetts? I'll bet that it's better than most European countries.
In Netherlands we have a free market for health insurance, however there are regulations and pretty much all essential care is included. Also the insurance company is not allowed to reject any person. Furthermore, every person is required to get health insurance. So healthy people pay for the old.
"Single payer" really just means "no choice, and no competition". I wouldn't really expect things to get better under such a system, and worse it would put a much larger percentage of our freedom on the chopping block.
Just look at the all the stuff they pulled over COVID. It would usher in a terrible era where everything you do is free for someone else to say no to, because "we all pay for that".
I give it 10 years under such a system until we have a similar supreme Court ruling to the one we got for interstate trade. Except this time blowing out their scope of power to anything and everything, with no more limits
Medicare has been providing single payer healthcare to Americans 65 and older for nearly 60 years without running into the pitfalls you are worried about. Why do you think a single payer system for younger people would not be able to also avoid those issues?
Our "insurance" sucks because of all the government involvement. Putting government completely in control would solve some problems, but I personally would like to see how things go if we do the opposite and take government out of it completely.
One of the most interesting things about this whole situation is that nobody is trying to even pretend that the current system is fair or effective. The tone in media and from corporate PR, business leaders, and politicians is either silence or some version of "hey stop talking about that / well it's not MY fault." Everyone knows the system is unfair, parasitic, and literally murderous, but no one in power is willing to take responsibility of any kind or show real leadership in bringing change.
Nah nobody knows that, it is a lie. The reason healthcare in the US is expensive is primarily providers. As reported by e.g. Vox.
In fact us out of pocket spending is low compared to OECD, and overhead while relatively high is not huge. It's that the doctors and hospitals in the US are paid much more.
It's not just denials. This is anecdotal but my company moved from Aetna to UHC starting in January, and there are already dozens of threads in our internal slack about drug co-pays jumping 10-100x, despite the UHC rep's assurances that the plans were equivalent with what we had before.
Suing (or threatening to sue) everyone and anything that speaks poorly about the company is an interesting PR response, isn't it? I'm used to companies just ignoring the issue and hoping it goes away.
It's an extremely common response. I think you're used to remembering stories as "companies just ignore the issue and hope it goes away", summarizing away all the day-by-day coverage of letters they sent telling people to stop being mean, and that's probably how most people will remember this story in a few years too.
I had a baby. Months later, UH retroactively denied all birth and baby care claims. They claimed I had other insurance, which I don’t. Now I get to prove a negative. So fun.
Maybe there should be a government mediated system for "DMCA", denied medical claim arguements, where anyone could send in a DMCA against a health insurance company and automatically involve the formal legal court system at no cost to themselves. Normally I would not want to involve government but in situations relating to life and death I think it is justified (like other things govs regulate involving life/death).
Yeah, you’ve come to mostly the same conclusion as Mark Cuban(whole thread [0]). He agrees that you need some sort of watchdog to prevent fraud/waste/mistake but that insurance companies don’t work because their for-profit nature perverts their incentives. I don’t know if a government-based watchdog is the solution but I think you’re on the right track.
Readit News
Anyone for a class action lawsuit on the grounds of bad faith breach of contract and medical malpractice for obstructing access to care they already admit is medically necessary (by denying something already pre-approved)? I don't even want money. I want a Consent Decree enforced by the court that strikes fear across their whole industry.
Audio record every interaction you have with insurance and tell 'em you're on a recorded line.
This has been tried before and failed. The insurers argument is that they are not denying care, they are just not willing to pay for it, which isn’t practicing medicine.
I’ve tried this. They just hang up. So I record and then have a transcript generated, and I save my call logs.
If I start an extortion business, and make you pay me money in order for me to not kidnap your family, this will increase the GDP but not economic strength. This is particularly obvious during wartime, when GDP is artificially inflated, but the actual economy tends to be doing very badly regardless.
In other words, a trade that harms one party more than it helps the other makes the economy worse — regardless of how it affects GDP.
if people weren't forced to spend it on healthcare, they would spend it elsewhere. if healthcare was free tomorrow, the GDP would be fine, just redistributed.
Healthcare overall, not insurance. Insurance is just how most of it gets paid. Conflating the two is like saying credit card companies account for 50% (or whatever) of the US GDP because that's how most people pay for their stuff.
Then again, maybe it makes sense the country that perpetuates suffering all over the globe through being global police and lately just fucking up any sense of stability is the same one where almost 1/5th of our "output" is built on top of making money off of prolonging our own peoples pain and suffering.
That same economic activity could still occur with that money, it would just be in other sectors, and ideally ones that produce real economic value.
Sounds great to me!
The main thing everyone should agree on is that the employer healthcare mandate that ties health access to W-2 employment is responsible for this situation and should be revoked.
What comes next matters less; every system has its drawbacks but ours is the worst. It has all the drawbacks and none of the benefits of everyone else's systems
Where costs will inevitably get complicated are:
1. emergency medicine, where the purchaser is in severe pain or possibly unconscious.
2. conditions without cures, or possibly even well-established treatments, and there is thus active experimentation and disagreement
Both of these are unpredictably expensive to an extraordinary degree, and the second category is sometimes rare enough that economies of scale don’t come into play for individual conditions.
I think government coverage of emergency medicine, aka ERs for severe injuries, is relatively uncontroversial due to its nature of treating unconscious patients.
However, that other category is very large in modern medicine. It includes all chronic conditions without cures, for which many options are available and improved techniques are constantly sought - and it includes complicated conditions where treatment has risks involved, which is basically a huge range of surgeries.
The problem in these areas is that the consumer does not have adequate understanding of the efficacy of what they’re buying, yet they’re driven to buy it strongly by pain and suffering. They are likely to want to do whatever a doctor or hospital tells them to do.
What is needed here is a consumer advocate with medical knowledge to keep prices consistent. In the US, this is provided by a mixture of regulation, medical malpractice lawsuits, and insurance companies.
Insurance companies are now failing in that role, but removing them entirely without any sort of replacement is going to leave the courts as the major vehicle to manage the costs - that isn’t a system renowned for efficiency.
It's a bad idea because of the state of the rest of healthcare _due to the state of health insurance_, but nothing prevents you from self-insuring.
Deleted Comment
Health care is yet another of those services where society as a whole does better if everyone's needs as a whole are considered and taken care of together. It is definitely frustrating for those who have more and wish to pay more to get better care, but heck, it's still a better deal in that case. There are all kinds of diseases that have been eradicated (or are on the way out) due to a broad social program to first discover and then distribute the cure. Paying for the very best leprosy care yourself pales in comparison to never catching it.
However we basically have 1 solution, and its not legal. And naturally, its the solution in this article.
To be completely fair, just from the people who I know who have terminal uncovered diseases, I'm surprised more "direct action" hasn't been done. Desperate people with no good options can and do take the terrible options.
The by far best system I've witnessed was the Swiss healthcare system, which is NOT a single-payer system.
Some features: (1) health insurance is obligatory for all residents (2) must be private, cannot be purchased/sponsored by company (3) minimum coverage is specified by law (4) health insurers are private companies, often (mostly? always?) non-profit (5) they cannot reject applicants, and can only discriminate (by price) on: (a) age, (b) residence (i.e. more expensive city/area => more expensive health insurance) (6) all procedures are paid - 10% copay is mandatory (up to a certain yearly amount) (7) health insurers make extra money on better health insurance ("private coverage") offering better service, more experienced doctors, private hospital rooms, extra coverage (e.g. for mental health, abroad etc.) etc. - those can discriminate on much more features, including existing health conditions sex (e.g. for young women it's more expensive, because of pregnancy)
Swiss hospitals also accumulated losses amounting to CHF1 billion ($1.13 billion) in 2023. Most hospital costs are covered by the gov't though whereas in the US hospitals are private corporations.
For example, prohibjt insurances from making profits at all - earnings must go into savings, future rates need to go down when savings are getting built up beyond a safety buffer.
Another idea: a government mandated catalog of services that have to be covered, including fixed costs (maybe plus a small effort scaling factor based on provable additional needs for a patient). If a doctor claims medical necessity, the insurance is automatically required to pay that fixed amount - no rejection possible. If the claim is fraudulent, they can sue the doctor later.
I think the best way to improve US healthcare is to off all the righteous idiots. Just kidding!
The 2nd best way is outlaw health insurance of any kind except maybe genuinely catastrophic, like lump sum cancer insurance or emergency room coveragr. Don't provide any public option. Once everything is out of pocket the outrageous provider prices will be forced to come down either economically or politically (my preferred option is easy immigration and the recognition of medical degrees from OECD countries)
It's much cheaper to repair a roof that has a small leak than it is to clean out and rebuild a house rotted with mold.
I was completely wrong. Single payer means there is a single (gov) entity paying health care for everyone. 1000% this is what we need.
Everyone needs to care about their health. When we need healthcare it’s so often for things out of our control, like cancer. Putting the burden on the individual is cruel.
Capitalism as applied to human health is fundamentally inhumane (literally, profit valued over human life). I’d be interested to heard arguments otherwise.
Of course, a universal healthcare system should take notes from capitalist markets to be efficient, but have the primary goal of maximizing human well-being
this kind of “communism” will never work in the US of A long-term :)
Just look at the all the stuff they pulled over COVID. It would usher in a terrible era where everything you do is free for someone else to say no to, because "we all pay for that".
I give it 10 years under such a system until we have a similar supreme Court ruling to the one we got for interstate trade. Except this time blowing out their scope of power to anything and everything, with no more limits
Yes I greatly prefer the current era, where everything you do is expensive and someone else can still say no.
https://en.m.wikipedia.org/wiki/File:Life_expectancy_vs_heal...
And what actions do you think companies might take to benefit customers if not for government involvement?
In fact us out of pocket spending is low compared to OECD, and overhead while relatively high is not huge. It's that the doctors and hospitals in the US are paid much more.
[0] https://x.com/mcuban/status/1666973561108725760