> But the insurer’s defense went even further, to the very meaning of “prior authorization,” which it had granted women like Arch to pursue surgery. The authorization, they said in court, recognized that a procedure was medically necessary, but it also contained a clause that it was “not a guarantee of payment.” Blue Cross was not obliged to pay the center anything, top executives testified. “Let me be clear: The authorization never says we’re going to pay you,” said Steven Udvarhelyi, who was the CEO for the insurer from 2016 to 2024, in a deposition. “That’s why there’s a disclaimer.
> At the trial, Blue Cross revealed that it had never considered any of the appeals — nor had it ever told the center that they were pointless. “An appeal is not available to review an underpayment,” acknowledged Paula Shepherd, a Blue Cross executive vice president. The insurer simply issued an edict — the payment was correct.
> On several occasions, though, Blue Cross executives had signed special one-time deals with the center, known as single case agreements, to pay for their wives’ cancer treatment.
First off, you won't convince me these folks don't belong in jail. I just dont' think anything less than serious criminal penalties is going to get us anywhere anymore.
But at the same time, i guess i'll be contrarian and say the other notable bit to me is that the person wants the absolute best doctors working on her, at the absolute best place possible because they pioneered the technique. I get why. But it's not necessarily reasonable. Obviously, if her cases needs that, she should get it. But it's really unclear from the article - is her case one that any competent surgeon could do, or only these surgeons can do. It does say they pioneered one technique, but that doesn't mean they are the only ones who do it or are good at it. She just says "i want the people who teach other people working on me", which certainly resonates with lots of people (i'm sure that's why it's there), but also, probably too high of a standard?
In the end - the absolute best of everything is expensive. Very expensive. I doubt a system can afford to have that happen for everyone, even if the insurers were not evil fraudsters. So even if we ever fix the insurer side, I think we will also have to fix the patient expectation side around standards of care.
> First off, you won't convince me these folks don't belong in jail. I just dont' think anything less than serious criminal penalties is going to get us anywhere anymore.
Agreed.
Company wise, I’d like to see these things handled like the FDIC handles a bank failure. The Feds come in, wipe out upper management, and have another org take over as caretaker.
Otherwise these fines just get paid out of increased premiums. Which probably makes the folks responsible giggle as they immediately go and do the same thing again.
> In the end - the absolute best of everything is expensive. Very expensive. I doubt a system can afford to have that happen for everyone,
It's not a question of money. If there's one person who's acknowledged as "the best" at something, that puts a hard limit on the number of people who can hire "the best" for that thing in any particular time window. Paying more won't give that one expert more hours in their day.
The point of insurance is that it should not matter. Some providers may charge more, some less, insurance should care about the average. In other countries you may be treated by great doctors and still be covered by statutory insurance.
Patient primary expectation is always to have a doctor they can trust. That can be fixed only when all doctors get the decent money and comfortable work environment and that means several things: the less middlemen the better, the cost of living including housing should be affordable and put them in middle class, the treatment standards should give them enough time and flexibility, etc.
> On several occasions, though, Blue Cross executives had signed special one-time deals with the center, known as single case agreements, to pay for their wives’ cancer treatment.
Just when I thought healthcare reached new lows...
This is the frustration that leads to getting a dictator wanna-be elected President. People are SICK SICK SICK of these shenanigans and seriously want it to change.
How does electing a dictator who promises "Vote for me and I will make it worse" help, though? That's the part I don't get.
If the dictator promised to round up these CEOs and send them to El Salvador without a trial, that would be one thing... but the opposite is true, and I think the electorate understood that well enough.
>but it also contained a clause that it was “not a guarantee of payment.” Blue Cross was not obliged to pay the center anything, top executives testified. “Let me be clear: The authorization never says we’re going to pay you,” said Steven Udvarhelyi, who was the CEO for the insurer from 2016 to 2024, in a deposition. “That’s why there’s a disclaimer.
That quote is far less damning when you consider the surrounding context. The reasoning he gave for why "authorization never says we’re going to pay you" is that there might be deductibles, and out of network deductibles might be higher. That seems totally reasonable to me?
It’s damning when you read the rest of the article. You’re right about the point of the disclaimer - it was not supposed to secretly mean “lol we have no intention of paying for this ever”, but they used it that way.
> They acknowledged that the disclaimer was not meant as a general excuse to free the company from paying bills. A prior authorization “usually” resulted in a payment, testified Brower, who reviewed the center’s bills. He said that the notice was intended for specific situations. For instance, Blue Cross would not cover a woman who dropped out of her insurance before the operation. Nor would it pay anything if a patient had not met her deductible. But otherwise, Brower said, Blue Cross intended to compensate for a procedure that it had authorized. “It’s inappropriate for us as a company to approve a code and then turn around and deny it,” Brower said.
Fuck. These. Monsters. Fuck them and their friends and family. Fuck them to the moon and back. Fuck them until humans evolve to the point that we don't have genitals and then find a new way to fuck them.
I wish more people were asking “why does the hospital charge such absurdly high fees?” instead of “why is Blue Cross trying to not pay those absurdly high fees?”
This. Even if you eliminated all profit margins of insurers you only decrease medical costs in the US by a tiny fraction, still leaving you far worse off than in other countries. They suck, but they're a cheap scapegoat for simpleton populists who don't know or don't want to fix the actual problems.
> Even if you eliminated all profit margins of insurers you only decrease medical costs in the US by a tiny fraction
This is completely wrong.
A general practicioner doctor is unlikely to be making much more than 300K, or $144/hr. But my visit to said doctor costs $450 for 15 minutes, or $1800/hr.
Many people are making a fortune out of the system, the money is not going to the person doing useful work, the doctor. Where is the other $1656/hr disappearing?
Eliminate all those grifters from the loop and I could go see this doctor for $36 per 15min visit. Heck I wouldn't even need insurance, I can pay that out of pocket.
Sure, I'm ignoring rent/utilities/supplies, so it'd be a bit more than $36 but those costs are a tiny percentage. In any case it'd be less than $50, far below the current $450.
I have a very long and maybe ill-formed in-person rant about medical costs in the USA and the cost of higher education in the last 30 years and how these issues are are n-sides of the same n-sided coin but it takes about 8 beers to get through and isn't something I ever have the nerve to put down in an HN comment.
Everyone angry about Big Tech and the like need to know that healthcare was patient zero for the monopolization and enshittification cycle that seems to have consumed everything in the world economy.
Once one industry consolidates, their vendors and customers need to consolidate too, or they don't have any negotiating leverage. If you don't consolidate, you're the deal taker, and that deal will be incredibly garbage. This cycle continues until it reaches the one place where you can't consolidate: end customers. There's no such thing as a "customer union" that can fight back against this bullshit. This turns business into a conspiracy to screw the customer, purely through normal, logical business actions that were already illegal but unenforced.
The problem with merely pinning the blame on one entity is that it doesn't fix the system. You don't care about whether or not it's the hospital's fault or the insurer's fault, you just want the problem fixed. Law enforcement actually has a solution for this: joint and several liability, which is a way of saying "I don't care who did it, someone either fixes it or I'm punishing both of you". Pin the blame on both entities if you want the shenanigans to stop.
Consider their business model. A lot of highly educated employees, a lot of very expensive equipment and furnishings, a high risk of customers dying in their care, and injury lawyers hovering around the exits telling sick and injured people that if they aren’t 100% cured they have a lucrative claim.
Wow great timing, I just got a $22,000 bill 2 hours ago for a surgery that UHC approved 2 months ago (in a written letter from them) because they refused to pay.
I'm on the hook for $128k for a no complications birth and 5 days my newborn had to be on a CPAP machine after blue cross denied the claim. I picked the plan only after confirming all our providers were in network, but failed to check if the building where the delivery was occurring was in network.
The plan at this point is to just ignore it and hope it goes away, since they can't put it on your credit anymore.
>I picked the plan only after confirming all our providers were in network, but failed to check if the building where the delivery was occurring was in network
What?
I'm sorry what kind of kaska-esque system is this?!
I have no idea, I tried calling the number on the bill but it gave me a dialer with 8 options of "if you're calling about a bill from X which is now part of Y, please dial N". When I selected 8, which was "all other" I got a canned message telling me to call between 9-5 on a week day.
Start by calling billing and telling them what happened, and that you effectively don't have insurance and will be self-paying (said for the purpose of negotiation, not what you may or may not actually do). They should discount it by a lot.
Healthcare providers have starting saying it's "insurance fraud" to say that you don't have insurance when you do.
My guess: they know they can get more money from the insurer than the individual (or a combination of both!) so they want to scare you from not allowing them to negotiate with the insurers.
I've called my insurance company to check whether they'll cover certain medical procedures. And they'll actually play a recording before transferring your call - something like "Statements of coverage during this call are estimates, and are not actual guarantees of payment."
I also learned that they have a whole bureaucracy already in place for appealing of payments. (People whose job it is to field all the rejected and then appealed claims, and write multi-page letters explaining their reasoning...) So I took my complaint to my state's consumer complaints department. Let the two bureaucrats explain things to each other.
> So I took my complaint to my state's consumer complaints department. Let the two bureaucrats explain things to each other.
Except that the prevailing direction of the country is to destroy the ability of governments to function effectively. It seems like a well planned move to actively destroy the only entity capable of standing up to big business.
Also happened to an in-law of mine. After they got pre-approved fall bladder surgery, the insurer came back and said the surgery was "elective". They paid after a fight.
Having to fight to get payment for anything major has been more common than not, in my immediate family's experience and from what I've heard from friends and relatives, for a long time.
The tens or even hundreds of hours on hold with insurance providers and hospital billing departments and calling state regulatory agencies and time sorting through the fifty bills scattered over ten months from nine different entities, all for a couple days in the hospital, are a massive unaccounted-for cost of our already-record-settingly-expensive healthcare system.
Tbh the only thing that surprises me about Luigi Mangione is that there hasn't been a thousand more like him over the years. What a farce the US healthcare industry is.
The problem is that most school shooters are angry young men imitating the violent acts they saw on TV. To be clear, I don't mean they're watching violent fiction and reenacting it, I mean they're watching regular ol' news and getting inspiration. I mean, let's be clear here, the news is better at glorifying the acts of violent weirdos than actual writers are, mostly because fiction writers have an actual conscience. And there's a lot of people desperate for some kind of fame, which all these school shooters are getting.
Think about how you didn't really hear about movie theater shootings until someone shot up the one in Aurora. Now they're more common. There is a huge element of social contagion because shooters are very much copying each other's work.
Which would suggest that we would see a rise in CEO assassinations over time[0]. But the thing is, it's also legitimately harder to assassinate a CEO than shoot up a school. Schools are soft targets with predictable schedules for their occupancy. A CEO might be in 20 different countries over the course of a month; you'd have to engage in a LOT of cyberstalking to even have a chance of catching a CEO in your hometown. And not to mention, they usually have security detail specifically to prevent this exact thing from happening.
But who knows. There's a lot of people pissed off about corporate power, in every country, across party lines. It only takes one security fuck-up.
[0] This is what the phrase "propaganda of the deed" refers to
Do you think Luigi's actions fixed anything?
Did the multiple people attempting to assassinate Trump fix anything?
Did Assassinating MLK Jr or JFK fix anything?
No, his actions didn't fix anything, but I doubt there even exists one such action that's capable of resolving the issue. I don't think the next copycat will solve anything either. But what about the 10th?
He moved the needle, people are talking about it, maybe thinking about it a bit more.
Insurers have another weapon: Insurer's preferred telehealth provider is the only one who can process PA(prior authorization). If your PCP prescribes an expensive prescription, PBM(say, optum Rx, owned by UHC) will tell ur pharmacy to have the prescriber get a prior authorization. When your PCP tries to get a prior authorization, insurer will say "the insured party should go through a telehealth provider for treatment". Now that telehealth provider creates more hurdles for patients. For instance, UHC uses Transcarent/join9am.
Insurers will add more and more indirections instead of outright denial. First indirection: get a prior authorization(PA). Second indirection: only a particular telehealth provider has the authority to ask for a prior authorization--and this is a new trend. Expect more layers of indirections.
I understand that healthcare costs are exorbitantly high. The people who have the power to control these costs are politicians, super wealthy, and the elites (lawyers, executives) serving the super wealthy. The latter groups get the care they want without any hurdles. Others just pay all insurance premiums, only to find that they are denied care when they need the most.
It's basically the same unholy finger pointing game as municipal permitting only it's all spread out over multiple entities so it's not like you can just sue the town as a whole like one would do when faced with contradictory approvals/denials.
Readit News
> But the insurer’s defense went even further, to the very meaning of “prior authorization,” which it had granted women like Arch to pursue surgery. The authorization, they said in court, recognized that a procedure was medically necessary, but it also contained a clause that it was “not a guarantee of payment.” Blue Cross was not obliged to pay the center anything, top executives testified. “Let me be clear: The authorization never says we’re going to pay you,” said Steven Udvarhelyi, who was the CEO for the insurer from 2016 to 2024, in a deposition. “That’s why there’s a disclaimer.
> At the trial, Blue Cross revealed that it had never considered any of the appeals — nor had it ever told the center that they were pointless. “An appeal is not available to review an underpayment,” acknowledged Paula Shepherd, a Blue Cross executive vice president. The insurer simply issued an edict — the payment was correct.
> On several occasions, though, Blue Cross executives had signed special one-time deals with the center, known as single case agreements, to pay for their wives’ cancer treatment.
But at the same time, i guess i'll be contrarian and say the other notable bit to me is that the person wants the absolute best doctors working on her, at the absolute best place possible because they pioneered the technique. I get why. But it's not necessarily reasonable. Obviously, if her cases needs that, she should get it. But it's really unclear from the article - is her case one that any competent surgeon could do, or only these surgeons can do. It does say they pioneered one technique, but that doesn't mean they are the only ones who do it or are good at it. She just says "i want the people who teach other people working on me", which certainly resonates with lots of people (i'm sure that's why it's there), but also, probably too high of a standard?
In the end - the absolute best of everything is expensive. Very expensive. I doubt a system can afford to have that happen for everyone, even if the insurers were not evil fraudsters. So even if we ever fix the insurer side, I think we will also have to fix the patient expectation side around standards of care.
Agreed.
Company wise, I’d like to see these things handled like the FDIC handles a bank failure. The Feds come in, wipe out upper management, and have another org take over as caretaker.
Otherwise these fines just get paid out of increased premiums. Which probably makes the folks responsible giggle as they immediately go and do the same thing again.
It's not a question of money. If there's one person who's acknowledged as "the best" at something, that puts a hard limit on the number of people who can hire "the best" for that thing in any particular time window. Paying more won't give that one expert more hours in their day.
Patient primary expectation is always to have a doctor they can trust. That can be fixed only when all doctors get the decent money and comfortable work environment and that means several things: the less middlemen the better, the cost of living including housing should be affordable and put them in middle class, the treatment standards should give them enough time and flexibility, etc.
Just when I thought healthcare reached new lows...
Wow. Just wow.
If the dictator promised to round up these CEOs and send them to El Salvador without a trial, that would be one thing... but the opposite is true, and I think the electorate understood that well enough.
The American people basically legalized fraud and looting for the next four years.
That quote is far less damning when you consider the surrounding context. The reasoning he gave for why "authorization never says we’re going to pay you" is that there might be deductibles, and out of network deductibles might be higher. That seems totally reasonable to me?
[1] https://www.documentcloud.org/documents/25882446-steven-udva...
> They acknowledged that the disclaimer was not meant as a general excuse to free the company from paying bills. A prior authorization “usually” resulted in a payment, testified Brower, who reviewed the center’s bills. He said that the notice was intended for specific situations. For instance, Blue Cross would not cover a woman who dropped out of her insurance before the operation. Nor would it pay anything if a patient had not met her deductible. But otherwise, Brower said, Blue Cross intended to compensate for a procedure that it had authorized. “It’s inappropriate for us as a company to approve a code and then turn around and deny it,” Brower said.
Fuck. These. Monsters. Fuck them and their friends and family. Fuck them to the moon and back. Fuck them until humans evolve to the point that we don't have genitals and then find a new way to fuck them.
But also how is that legal?
https://www.noahpinion.blog/p/insurance-companies-arent-the-...
The big insurers own the PBMs, the specialty pharmacies, the doctors, the urgent care networks. United Healthcare is the country’s single largest employer of physicians. https://www.statnews.com/2025/03/07/unitedhealth-surgery-cen...
They pay their controlled ones higher rates, even. https://www.statnews.com/2024/11/25/unitedhealth-higher-paym...
This is completely wrong.
A general practicioner doctor is unlikely to be making much more than 300K, or $144/hr. But my visit to said doctor costs $450 for 15 minutes, or $1800/hr.
Many people are making a fortune out of the system, the money is not going to the person doing useful work, the doctor. Where is the other $1656/hr disappearing?
Eliminate all those grifters from the loop and I could go see this doctor for $36 per 15min visit. Heck I wouldn't even need insurance, I can pay that out of pocket.
Sure, I'm ignoring rent/utilities/supplies, so it'd be a bit more than $36 but those costs are a tiny percentage. In any case it'd be less than $50, far below the current $450.
Everyone angry about Big Tech and the like need to know that healthcare was patient zero for the monopolization and enshittification cycle that seems to have consumed everything in the world economy.
Once one industry consolidates, their vendors and customers need to consolidate too, or they don't have any negotiating leverage. If you don't consolidate, you're the deal taker, and that deal will be incredibly garbage. This cycle continues until it reaches the one place where you can't consolidate: end customers. There's no such thing as a "customer union" that can fight back against this bullshit. This turns business into a conspiracy to screw the customer, purely through normal, logical business actions that were already illegal but unenforced.
The problem with merely pinning the blame on one entity is that it doesn't fix the system. You don't care about whether or not it's the hospital's fault or the insurer's fault, you just want the problem fixed. Law enforcement actually has a solution for this: joint and several liability, which is a way of saying "I don't care who did it, someone either fixes it or I'm punishing both of you". Pin the blame on both entities if you want the shenanigans to stop.
Does it lead to wait times? Sure! So does the US system!
But of course that has been captured as well
The plan at this point is to just ignore it and hope it goes away, since they can't put it on your credit anymore.
What?
I'm sorry what kind of kaska-esque system is this?!
It might be worth reaching out to your state (local, not federal) rep and also your state’s insurance commissioner.
I'm definitely not paying it
My guess: they know they can get more money from the insurer than the individual (or a combination of both!) so they want to scare you from not allowing them to negotiate with the insurers.
I also learned that they have a whole bureaucracy already in place for appealing of payments. (People whose job it is to field all the rejected and then appealed claims, and write multi-page letters explaining their reasoning...) So I took my complaint to my state's consumer complaints department. Let the two bureaucrats explain things to each other.
And in the end, the insurance company paid me.
Except that the prevailing direction of the country is to destroy the ability of governments to function effectively. It seems like a well planned move to actively destroy the only entity capable of standing up to big business.
The tens or even hundreds of hours on hold with insurance providers and hospital billing departments and calling state regulatory agencies and time sorting through the fifty bills scattered over ten months from nine different entities, all for a couple days in the hospital, are a massive unaccounted-for cost of our already-record-settingly-expensive healthcare system.
Think about how you didn't really hear about movie theater shootings until someone shot up the one in Aurora. Now they're more common. There is a huge element of social contagion because shooters are very much copying each other's work.
Which would suggest that we would see a rise in CEO assassinations over time[0]. But the thing is, it's also legitimately harder to assassinate a CEO than shoot up a school. Schools are soft targets with predictable schedules for their occupancy. A CEO might be in 20 different countries over the course of a month; you'd have to engage in a LOT of cyberstalking to even have a chance of catching a CEO in your hometown. And not to mention, they usually have security detail specifically to prevent this exact thing from happening.
But who knows. There's a lot of people pissed off about corporate power, in every country, across party lines. It only takes one security fuck-up.
[0] This is what the phrase "propaganda of the deed" refers to
He moved the needle, people are talking about it, maybe thinking about it a bit more.
That's incredible.
Insurers will add more and more indirections instead of outright denial. First indirection: get a prior authorization(PA). Second indirection: only a particular telehealth provider has the authority to ask for a prior authorization--and this is a new trend. Expect more layers of indirections.
I understand that healthcare costs are exorbitantly high. The people who have the power to control these costs are politicians, super wealthy, and the elites (lawyers, executives) serving the super wealthy. The latter groups get the care they want without any hurdles. Others just pay all insurance premiums, only to find that they are denied care when they need the most.