Cigna saves millions by having its doctors reject claims without reading them

https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims

by metadat • 3 years ago

564 414 3 years ago

stathibus• 3 years ago

This reminds me of the US patent approval system. There are too many claims to properly vet them all, so just "click and submit" and only put effort into the ones that come back to complain. (Except the PTO is biased toward approval and not rejection, of course.)

AnthonyMouse4• 3 years ago

Not exactly. The US PTO rejects a large proportion of patent claims. It can be quite expensive / time consuming to get a US patent as an individual inventor. But you can appeal the rejections, and large corporations and patent trolls have staff attorneys who do that all day long, so then tons of garbage patents get approved too.

woohoo76762• 3 years ago

This has been happening to me for the past several months.

1. Cigna will not tell you for any reason, why the claim is denied

2. Reps will not help at all other than "Oh I see the issue, will reprocess" which often just results in another denial

3. The issue that a helpful rep finally disclosed: Cigna's own claim form for providers has a box that is overloaded for procedure code and equipment code; apparently the CPT code for therapy is the same as the equipment code for injections.

So one claim processor decided that the claim was for injections and denied it. Then every subsequent claim has been denied under the same reason.

4. At this point the only option for me is for my provider to appeal every single claim (which takes months), as this is the only way to get someone to actually read the claim and make an intelligent decision.

An absolute nightmare :(

kurikuri• 3 years ago

I always wonder if small claims court could be somewhat viable. In the instances where I’ve fought and gotten approval, I’ve spent my own time, my own money, and had my health deteriorate. Ideally, I’d like to be compensated for the time I’ve spent defending myself to this company, and I’d like some form of remuneration (somewhat for retribution, somewhat as a negative incentive to the company) for my now diminished health…

Kye• 3 years ago

There needs to be something like the CFPB for health care. I couldn't get an actual human to acknowledge me when dealing with PNC when they ate up my bank, but one CFPB complaint got them to do exactly what I asked. That way you never get to the point of burning time, money, and health because they're afraid of action from the agency.

firstlink6• 3 years ago

If you have health insurance from your employer, it's probably covered under ERISA. This is federal, so no help from your state insurance agency and no small claims, and I have found that there are few lawyers who will touch it even in a large city.

indymike3• 3 years ago

1. Cigna will not tell you for any reason, why the claim is denied

Of course not. Fight fire with fire. Get care providers to sign a letter to Cigna saying the procedure is medically necessary Going through the process will not work and will go slow. But putting them on notice by having licensed, local care providers say something is medically necessary and urgent will work almost 100% of the time.

bombcar• 3 years ago

And blatantly copy your state's insurance regulatory department. Insurers LOVE that.

blakesterz• 3 years ago

  “We thought it might fall into a legal gray zone,” said the former Cigna official, who helped conceive the program. “We sent the idea to legal, and they sent it back saying it was OK.”

Reading this article is just maddening. I've been dealing with different insurers for the past 7 years or so, and it's my experience they must all do something similar. Anyone with any kind of serious health condition is regularly driven CRAZY dealing with insurance. It's just an insane and broken system.

kurthr3• 3 years ago

Wife is a nurse. Required surgery for lifesaving/severe disability (inherited congenital, killed her father). Insurance was Aetna and Hospital Self Insured. Surgery recommended by world class surgeon she worked with.

Finally pre-approved on 3rd appeal after 8 months and 150pages of documentation of every piece of every single communication (who, when, response, expected next contact) only weeks before surgery scheduled >6 months before. First rejection was automatic, second was revealed to be a dermatologist, third was a gynecologist. (They really hated that we figured out who the person was, their specialty, the state they worked in, and pending disciplinary actions).

Standard answer is we can't tell you why you were rejected (code only) because the criteria are from a third party and their review document is proprietary. When you find an online leaked document with the same code it says "unnecessary cosmetic surgery". Wrong contact numbers are provided, people go on vacation and do not respond for weeks, "that person doesn't work here".

If you're not a professional in the field with time on your hands and a detail oriented A-hole, you will be denied anything expensive that isn't considered immediately lifesaving at a trauma ICU recommended by the attending.

After pre-approved surgery with excessive blood loss and an extra 12 hours in recovery... Overcharge/All-claims-denied. Multiple appeals until involving Hospital CFO who agrees to split the extra (self-insured) cost of the insurer and get the final insurance reimbursement check... it is $3k less than promised (hospital paid the correct amount). Surgeon was going to start charging late fees and interest or send it to collection after 4 months.

Is it worth fighting any more? No.

anigbrowl2• 3 years ago

Standard answer is we can't tell you why you were rejected

How did you find out about the automatic rejection/identity of the reviewers?

ClumsyPilot3• 3 years ago

Standard answer is we can't tell you why you were rejected (code only) because the criteria are from a third party and their review document is proprietary

So you paid for a service, and you don't get the service you paid for, and you will not be told why?

If I did this in my line of work, I would be in prison for fraud.

anonuser1234562• 3 years ago

The sneaky thing to do is have your attorney send a letter to the insurance carrier's liability insurance provider, detailing everything you uncover and that they will be on the hook for the malpractice claim. That will get you an highly aggressive advocate with teeth.

theGnuMe5• 3 years ago

Insurance was Aetna and Hospital Self Insured

Does this mean that the hospital self-insured and provided the surgery? As in why have Aetna involved at all then?

geerlingguy2• 3 years ago

I have Crohn's disease, and I'm fairly certain dealing with health insurance's ineptitude directly led to multiple hospitalizations and a major surgery last year.

Had it not been for their constant denials of a drug I had been on for over two years prior, I might still be taking that medication instead of having developed antibodies for the 6 months they denied.

My doctors office gave me free samples as long as they were able, but in 2022 they were wiped out as all patients that were on that drug were being denied coverage.

Worse still, insurance recommended "use drug X, which is similar"... but I couldn't because I was on drug X—until I had anaphylaxis from it!

magila2• 3 years ago

I also have Crohn's and am going through this right now. Months of delays and denials for a new drug lead to two hospitalizations. I'm currently on TPN (IV nutrition) while I taper my Prednisone dose as low as possible prior to surgery.

The funny/sad thing is: between my hospitalizations, TPN and related home health care, and surgery, this is all going to cost my insurance far more than the drug they were denying would have. One would hope this provides them with motivation to better judge the necessity of treatments, but I'm not holding my breath.

Centigonal3• 3 years ago

Situations like this are infuriating to me. Our healthcare system needs to have some kind of provision for "this patient needs to be on treatment X probably for life. They are authorized for this treatment and subsequent claims will be approved unless there is a qualifying event (e.g. a recall, condition changes, patient and their doctor switch treatment, etc)."

I have UC that's well-controlled with mesalamine, and I've had a few scares (my insurance rolls out a new prior auth every year, and I have to call my provider to have them sign it for some reason, or the new insurance only covers the name brand (not generics) because of PBM antics). The thought of having to come off of mesalamine for even a week is terrifying. I really feel for you because your condition seems much more severe/hard to control.

Why do I need a new prior auth every year? My medication hasn't changed, and neither has my condition. It's a bureaucratic hoop, and if I don't jump through it I get to spend my whole day on top of a toilet. That's a terrible way to treat a human being.

Even from a purely amoral capitalist perspective, I know the cost of my medication is a small fraction of the dollar value that doesn't get generated if I can't take it. I don't benefit and society doesn't benefit if I'm sick - the only group who benefits is the insurance company who gets to pocket my premiums and avoid paying out. It makes me furious.

indymike3• 3 years ago

When someone in my family does not get pre-approved for care, I write a letter and and ask my physician to sign, and ask the other doctors at his practice to sign a letter that goes like this:

"I beleive this procedure _____________ is medically necessary for __________. Time is of the essence, and this procedure should be performed as close to immediately as possible."

In the signature block, I include the degree, specialty and medical school of the doctor. I then fax the letter in, and within 30-40 minutes, I have a phone call apologizing for rejecting and giving me pre-approval for the care. I learned about this when my (at the time) 15 year old was rejected for a cardiac procedure and the billing person pulled out a pre-printed deck of letters that was pre-signed by every department head at the hospital. The one thing the insurance people fear most is risk.

firstlink6• 3 years ago

This must have been before insurers adopted the mantra "we aren't denying care, only paying for the care!" With that legal magic wand, there is no risk to the insurer.

ridgeguy4• 3 years ago

Noted and saved for future use. Thanks for this.

stouset4• 3 years ago

Counterpoint.

I have an Aetna PPO and experienced a stroke last year. $100,000+ hospital stay and insurance just… covered it. I paid $1,100 out of pocket.

I had a $100,000+ surgery a few weeks ago to repair a heart issue that may have led to it. They just covered it. No fuss, no hassle. I paid $3,300, which was the remainder of my total annual out-of-pocket, and now I will pay $0 for healthcare for the rest of the year.

For the surgery, I called in advance to double check that it was covered and after five minutes on the phone with a concierge they confirmed that it would be covered.

Obviously I am only a single data point and I can’t speak towards other conditions or procedures. But Aetna has done right by me, at least from within the perspective of our insane for-profit healthcare system.

Centigonal3• 3 years ago

I'm glad you had such a good experience. Not a counterpoint, though.

Healthcare is like running water, bridges, or banking systems - a high-volume system with extremely high stakes. We need many nines of consistency as protection against preventable harm.

There are around ~35M hospital admissions in the US every year. Even if 9/10 patient experiences are like yours, that means more than 3.5 million people had a sub-par experience that year - that's the entire population of LA. We need to strive for a much higher bar of quality and consistency.

alpaca128• 3 years ago

I paid $3,300, which was the remainder of my total annual out-of-pocket

So with insurance you paid more than a European without insurance would, and you call that a counterpoint?

danielschonfeld• 3 years ago

And the cost of your Aetna PPO per year?

Also this is anecdotal. I too have an Aetna PPO and can tell you of horrid stories and countless hours on repeated phone calls with them.

Not saying you just did this (you obv did not) but as a whole in this country we need to start dropping the “it didn’t happen to me so something must be wrong with you” mentality. It is pervasive in the healthcare topic and unfortunately in many other facets of American life.

Germans in WWII that enjoyed the fruits of the regime have sang its praises - that didn’t mean the war machine on the whole wasn’t decimating the people and their country. We shouldn’t lose focus of how our country is being decimated by our collective ineptitude.

IG_Semmelweiss5• 3 years ago

As long as insurance is subsidized by our tax dollars and is regulated to include (forcefully) everything, then theres no way out.

For the record, to comprehend what this means from the doctors side, this means that Doctors (and billers) must be aware of every possible permutation that is "allowed" for billing by every insurer, for every CPT (procedure code).

I did some quick math to measure:

A) There are ~12000 valid CPT codes. (I could not google the exact number but CPT codes go from 0xxxx to 99xxx, plus therr are also S codes (Sxxxx), J codes (Jxxxx) etc.)

B) There are 155,000 ICD-10 diagnosis codes [1].

There are roughly 900 payors in USA. [2]

This means there are 1.67 x 10^12 rules a doctor billing insurance must know.

Even if you consider the narrow view that a doctor of X specialty may bill only top 100 cpt codes, for maybe 50 payors, thats still a huge number (25M!!!) because diagnosis DX (I.e. ICD-10) is not narrow and requires knowledge of related conditions - billing z11 is different result vs billing z11.26 and you must know that.

Its insane to think anyone will memorize 25 million combinations to know what to bill or not bill. And this calc does not consider modifiers OR primary DX....

[1] https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2021-03/I...

[2] https://collectivemedical.com/resources/payers/

bushbaba• 3 years ago

Yep happened to me. Worst is when you have two insurance providers and they both claim to be secondary and refuse to pay the bill.

dafelst• 3 years ago

Privatized health care as a person's sole option for care is an absolute dystopian nightmare. Any system that requires balancing human suffering against profitability is inevitably going to optimize for profitability.

The fact that this is even a thing is mind boggling.

xwdv4• 3 years ago

Public health care can be similarly dystopian in other ways: Very long wait times due to limited resources, subpar medical care, limited prescription options and drugs, beauracracy.

No matter what society you live, the advice is the same: try not to get sick.

PicassoCTs• 3 years ago

Ah, yes, have a privatized public sector, use the gained funds to lobby in other countries, pushing a ideology that destroys public sector/services, use the result of ones own actions to push the conversion to more privatized public sector. The ultimate glider gun ideology.

weaksauce• 3 years ago

Very long wait times due to limited resources, subpar medical care, limited prescription options and drugs, beauracracy.

those are all there because the people that created the system did not think paying for it was good enough. it doesn't have to be that way. and even with wait times being long you still eventually get it. in the privatized system if you are poor and have bad health care you don't get it at all.

harshalizee• 3 years ago

I moved from a third world country with both socialized and private healthcare, to the United States. I pay vastly more for worse healthcare than anywhere I've lived. The fact that you, your doctor can agree that a certain procedure is required, only to be denied by a third party with no medical qualification is absolutely dystopian.

illiarian2• 3 years ago

Very long wait times due to limited resources, subpar medical care, limited prescription options and drugs,

You realize we're discussing the US which has all this?

beauracracy.

It's funny you mention this, because the US spends vastly more on bureaucracy in its health systems than other developed nations.

nathan_compton3• 3 years ago

This might be true, but as someone who has lived in the U.S. and Europe I can say utterly unequivocally that I preferred Health Care in Europe. I wasn't even in one of the European countries with a great reputation for Health Care.

Health Care in the U.S. isn't just bad, its outright fucking brutal. An elderly friend of mine recently fell and went to an urgent care where they couldn't get him into the x-ray machine. They told him to go to an emergency room where he waited for _13_ fucking hours with a broken pelvis. I'm basically 100% sure that such emergency room bullshit literally kills people from stress or exposing them to other sick people. You can't even wait in your damn car and just have them text you - they just force you to sit in this horrible room with a ton of sick people for hours on end.

The U.S. Health Care system absolutely fucking blows.

xenospn• 3 years ago

As someone who grew up in israel, I can confirm your statement is factually incorrect.

cmurf2• 3 years ago

Sounds exactly like my private for profit health care provider.

firstlink6• 3 years ago

All claims being reviewed by big health insurance conglomerates is the antithesis of privatized healthcare. It incorporates the worst part of public healthcare and destroys the best potential benefit of privatized healthcare.

emodendroket2• 3 years ago

How is that so? The health insurance conglomerates are in private hands.

specialist4• 3 years ago

What are some real world examples of beneficial privatized healthcare?

harvey9• 3 years ago

The best potential benefit of privatised healthcare comes to those wealthy enough to just pay cash for what they need.

cmurf2• 3 years ago

This is not properly referred to as health insurance. It is a sickness, aging, and death payment plan. There's no such thing as major medical anymore.

It was private healthcare that backed public law forcing minimum coverage. Why? Because their pool was shrinking. They were getting sick people who needed care, but with premiums skyrocketing, what benefit is there for healthy people to buy in?

But I agree that the private for profit health care system is an abomination only made much worse by making it public law requiring we buy into it. Instead of Medicare for all.

gentoo• 3 years ago

it's funny how whenever a big company does something bad that's actually an example of how socialism is bad

glenstein3• 3 years ago

What part of public healthcare is incorporated into health insurance conglomerates? And what potential benefits of privatized healthcare are we missing out on?

winrid4• 3 years ago

I have literally spent years trying to get an MRI for my knee after an accident. Both Kaiser and Anthem won't cover it.

t344344• 3 years ago

I had MRI in EU, it was 160 euro for scan, and another 50 euro for specialist consultation. Public insurance would not cover it, so I paid it myself.

Not sure what is holding you back, but health should be a priority!

rsyring• 3 years ago

My family has received multiple radiology procedures including x-ray, MRI, and ultrasound from private radiology businesses (I.e. not the hospital). They are typically 10x give or take less expensive. Last MRI was $600.

Doesn't help if you are stuck in the hospital. But, it's an option otherwise.

slaw• 3 years ago

MRI accessibility is regulated at the state level, which determines the number of MRI machines available to the public. I was able to obtain an MRI while on vacation in Europe without any appointment or referral from a physician. The process was straightforward; I explained my needs to the receptionist, and a technician conducted the MRI. The cost was 180 euros.

matwood• 3 years ago

I know it's still not cheap, but I needed an MRI a few years ago and it was $350. Talk to your doctor and let them know you want to pay cash. Mine suggested a place.

Don't get one in the hospital if you can help it. They charge 1-2k because they have a full set of people who can't go anywhere else.

rr8083• 3 years ago

Privatized health care as a person's sole option for care is an absolute dystopian nightmare.

Dont exaggerate. I've lived in 3 European countries and Australia. My American healthcare is easily better than those. Sure I'm lucky to have a good job that pays for it, but you can't say its terrible without looking at how those public systems are really struggling right now.

walls• 3 years ago

Oh, well as long as you personally have not yet had a problem.

Everything is fine everyone, no need to worry.

jfengel• 3 years ago

The article suggests that your health care isn't as good as you think it is. You never know if you'll be one of those cases where they make you fight for every bit of care you get.

Some Americans do get excellent care with a minimum of grief. Others think their insurance is fine while they're healthy and only discover later that it doesn't really cover what they imagine it does. And the difference is entirely arbitrary.

The fundamental problem of health insurance is that you cannot know what you will need, and there is no way to make an informed consumer choice, but your need when you have it is absolute. It's pathologically pessimal as a free market. And you usually don't know until it's too late.

ryanSrich• 3 years ago

Yeah this is a very common sentiment. I feel like most people in the US haven’t actually talked to someone that has experience with socialized healthcare at scale. I had a German professor that was very clear about just how much better healthcare is in the US.

hayst4ck3• 3 years ago

Do you think your health care experience represents the median healthcare experience in all 5 countries?

If we divide up people into percentiles based on wealth, 25, 50, 75, 95, how do you think people fare in the different countries? How do you think they the median experience is in America?

interstice• 3 years ago

An ironic use of the phrase survivorship bias springs to mind

EnglishRobin962• 3 years ago

Having lived the opposite, I have to strongly disagree. I lived the nightmare of US healthcare, where my provider decided to stop working in my state, which meant that I no longer had access to any doctors under health insurance despite it being paid for by my company.

The UK was amazing - no questions asked care for my health was a massive improvement over what I had in the US. Free access to a doctor at any time is more life changing that you can think - every health issue I had I could talk to a medical professional and get guidance. Even free mental health care.

Moved to Ireland last year, with a mixed public/private system, and my health is now slipping a bit. Going to a GP, trying to file for reimbursements, and knowing that every time I have a health concern, it will cost me money, is a powerful suppressing force. I miss the NHS.

ugh123• 3 years ago

a good job that pays for it

If that's whats necessary to get decent health care in this country, then something isn't right.

CogitoCogito5• 3 years ago

My personal healthcare in Sweden has been higher quality (considering both personal cost and state cost) than my healthcare in US. I have heard complaints the other way of course.

Regardless of our personal experiences, the US spends so an enormous amount on healthcare and gets very little in return by basically all international measurements. Americans who think American healthcare seem to me too insecure to accept that their system is just plain bad. But yes Americans with a lot of money have access to better healthcare than average Americans. That said, this is essentially true in all countries so it's not that relevant really.

mertd• 3 years ago

We need to realize that publicized healthcare is the only option. Then we can focus on how to make it more efficient.

globalise83• 3 years ago

The important question is: have you ever made a large claim for a serious long-term illness? If not, you aren't yet in a position to judge the two systems.

mavelikara• 3 years ago

Sure I'm lucky to have a good job that pays for it,

That is not where you are lucky.

You are lucky to be healthy enough that you can hold on to that job. Once your health takes a bad turn, and you are unable to work, when you really need your healthcare, that's when you are better positioned to judge the quality of healthcare.

casenmgreen• 3 years ago

I may be completely wrong, but I understand in the US normally people have health care through their employer? so they are not themselves paying the insurer, and cannot change insurer.

If this is the case, then it is no wonder the insurer has no particular care for them. It is the power of the consumer to change provider which gives them influence over the provider.

dboreham2• 3 years ago

Even if not employer provided, there's usually little choice in carriers due to anticompetitive practices and regulatory capture.

lumb632• 3 years ago

This is the case, and is, IMO, the central problem with American healthcare. Folks in both political parties argue for or against socialized healthcare, and ignore that a huge amount of the problems could be solved by having an actual free market.

My opinion is that providing healthcare as a benefit should be banned. Employees who have healthcare today should be provided the amount the employer would have spent on health care in wages/salary. The fine details are hard to work out, but I think it is a good starting point.

ClumsyPilot3• 3 years ago

Can anyone name any usefull innovation that has come from private health INSURANCE in the past 100 years?

Not private hospitals/drug manufacturers - those are arguable - just insurance. What do they contribute?

They got bailed out in Covid, they take money out of the system in good times, they deny you care in the bad times.

Best I can tell they serve no usefull function

kevviiinn4• 3 years ago

Capitalism is all about rent seeking and having middle men that contribute nothing where they only exist to suck money and resources out of the system

paulddraper• 3 years ago

I knew I was going to see this comment.

As if Medicare didn't reject millions of claims too.

A number of physicians just don't accept Medicare because it's subpar.

slackfan• 3 years ago

I see you've never had to do a major procedure in a "public" system.

Heh.

thallium20510• 3 years ago

So then what are your thoughts on those who get denied on a Medicaid plan?

lotsofpulp6• 3 years ago

And still Cigna’s profit margins are low single digit percentages.

https://www.macrotrends.net/stocks/charts/CI/cigna-group/pro...

Wonder what premiums and out of pocket maximums would have to be if there were fewer denials.

OrvalWintermute• 3 years ago

If they are paying out huge sums to their c-suite, giving them stock left and right, and enriching the company through stock schemes or dividend payouts, unjustly, perhaps their compensation shouldn't be so rich?

https://www.statnews.com/2022/05/12/health-insurance-ceos-ra...

candiddevmike• 3 years ago

C-suite, board members, a bunch of "foundations", probably some for-profit contracting services for IT and accounting (also managed by the c-suite, probably). Unraveling health insurance admin costs is probably similar to Panama Papers level of financial engineering, especially after the ACA capped profit margins, the companies just turned to malicious compliance.

vkou• 3 years ago

I think we can just go a step further and kill their entire toxic business model. After decades of observing how it behaves, it should be pretty clear that it's always going to devolve down to privately-ran death panels.

lotsofpulp6• 3 years ago

Is their pay out of line with executives in any other similar sized businesses?

As far as I can tell from the financial reports, profit margins are so low simply because expenses are that high, and its across at least 7 publicly listed health insurers.

The main cause of low profit margins that I can tell is high healthcare expenses (and lots of competition and state regulation so they cannot increase premiums more).

GiorgioG• 3 years ago

15 years ago I worked for a "non-profit" health insurance company that was a Blue Cross Blue Shield affiliate/franchise. The CEO made $2.1m/year while the other VPs were raking in > $1m. The IT organization was as backward as they come - 200+ full time employees. I got in trouble for trying to introduce using source control to their developers. Beyond that, they used Excel spreadsheets as the source of truth for their healthcare plans...and the spreadsheets fed the claims processing system. There were 20 dedicated employees to managing Excel spreadsheets.

eapressoandcats2• 3 years ago

For all the crappy stuff insurance does, their medical loss ratio for group insurance is pretty good. The actual problem is that healthcare costs way more in the US than most other countries. Health insurance just ends up getting the blame for that.

missedthecue• 3 years ago

I tend to agree. People love to blame insurers for the difference in price between US and (other country) healthcare prices, without any mention of facts like US nurses earning 4 to 8 times as much as an average NHS nurse, or that half a trillion dollars goes to end of life care in the US every year, i.e. spending $70,000 to extend an 85 year life 3 more months.

Income = expenditure. They are one and the same. Every dollar spent on healthcare in the US is someone else's income and looking at the profit margins, 'someone else' doesn't seem to be the insurers.

cmiles743• 3 years ago

IMHO, the push-and-pull between insurance companies and hospitals is a big problem here. They seem to be in a co-dependent battle to consistently raise the costs of everything. I don't think any solution to managing cost will succeed unless we're altering the incentives for both insurance companies and hospitals.

prophesi• 3 years ago

I wish I was surprised. Automated decision-making with little to no human oversight is the dream of risky bets (policing, insurance, loans, etc).

hestefisk3• 3 years ago

This is the reason we need universal public healthcare.

luckylion• 3 years ago

That won't help you there. Germany's public healthcare system denies plenty of things too, and will only pay for treatment when you sue (or know someone who works there). Germany's private healthcare system on the other hand is usually better (I'm sure there are exceptions and some insurance company that sucks).

hestefisk3• 3 years ago

You can have good public healthcare without the need of the notion of 'claims'. The Scandinavian healthcare system is a good example (https://en.wikipedia.org/wiki/Healthcare_in_Denmark).

p_l• 3 years ago

Having worked tangentially on AI that approved payments for outpatient ops for one of the companies involved in handling German health system...

The very basic design goal was that the AI system could only approve, not reject. The goal was that obvious cases should be auto-approved, and anything where the AI returned below a certain confidence value was booted back to human to make a decision (same as pre-AI).

So at least you get that.

loeg• 3 years ago

His claim was just one of roughly 60,000 that Dopke denied in a single month last year

60,000 / 20 workdays in a month / 8 hours in a workday => this guy rejected about 375 claims per hour, on average. Over six claims a minute. He spent less than 10 seconds on each claim, for a full month of work time.

Centigonal3• 3 years ago

Less than 10s/claim is actually an upper bound, since chances are there's meetings, coffee breaks, and other overhead.

prepend• 3 years ago

I mean supposedly the doctor also approved some so their review rate is even higher.

SapporoChris• 3 years ago

"A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments."

"Cigna said its review system was created to “accelerate payment of claims for certain routine screenings,”

This sounds like simple automation with an error rate that is acceptable by Cigna. Of course it's not acceptable to anyone wrongfully denied a claim.

Now that's an issue I don't see in the article. How many claims were wrongfully denied? I can't get worked up about the situation when critical information is missing.

ahi• 3 years ago

They are not legally allowed to automate this. These cases MUST be reviewed by qualified medical personnel.

magicalist2• 3 years ago

Now that's an issue I don't see in the article. How many claims were wrongfully denied?

Well gee, to actually estimate that you'd need a medical expert to review the claims.

IG_Semmelweiss5• 3 years ago

Not only the automation is a problem. Cigna is the only one that knows the rule set.

This forces the patient or biller to try out multiple combination of codes until he strikes told. This is why healthcare is so expensive. Remove cpts and icds and the admin overhead syatem goes away

But that requires insurances to be there for catastrophic care only (I.e. reverse lottery) , and this is not palatable with the govt crowd

colordrops• 3 years ago

This rate is pretty ridiculous. I wouldn't be surprised if there is automated software or a farm of non-medical staff working behind the name of the doctor, similar to how shady contractors will "rent" the license of a legitimate but retired contractor.

itsTyrion• 3 years ago

... it literally says in the article they have a program that goes over claims, says deny if it "thinks" it's "not needed" and humans confirm it in batches of 50.

hotpotamus• 3 years ago

I wonder how many claims a minute GPT4 will be able to achieve?

CogitoCogito5• 3 years ago

Dr. Cheryl Dopke should lose her medical license.

kwhitefoot5• 3 years ago

Her employer should be jailed as well, all the way to the top of the company. Such behaviour cannot exist without at least the tacit agreement of everyone higher in the chain of command.

conductr3• 3 years ago

Yep. This may be legal but has to be against the hippocratic oath

01100011• 3 years ago

Soon, a GPT/LLM will auto-deny an order of magnitude more than that!

dragonwriter2• 3 years ago

They are already being autodenied, the human is in the loop only for superficial compliance with rules requiring a qualified medical professional “reviewing” before denying.

conductr3• 3 years ago

This alone should be grounds for a class action lawsuit. It’s ridiculous they do this in an obviously automated way. If they want to raise the bar on requirements of “submitting a claim “ that’s fine, our healthcare admins can figure it out. But patients should be allowed to be dragged through the mud like this.

throwawaylinux• 3 years ago

It's funny when it comes to the law including civil disputes, us commoners are always told "oh no the judges look at the intent behind the deal, and consider what a reasonable person would expect" when it comes to explaining why bank errors and such don't work in our favor.

No reasonable person would ever enter into a contract for health insurance with a company that would reject their claim after a doctor looks at it for literally 10 seconds, but apparently when it comes to the big end of town, the exact letters of the law become much more important.

courseofaction• 3 years ago

Jail the executives.

RainbowFriends• 3 years ago

Revoke the medical licenses of the doctors who rubber stamp the denials.

dragonwriter2• 3 years ago

In addition, states (as the pirnary regulators of insurance) should adopt a rule that if an insurer has a policy which directs, incentivizes, or which managenment knows or should reasonably know results in denials without good faith review, the state then has a cause of action against the insurer for damages of equal to triple the amount originally denied without appropriate review (whether or not later paid), and will, if necessary, pierce the corporate veil to recover it and, separately, each medical reviewer who is found to have denied a claim without good faith review shall be fined an amount equal to the value of claims so denied and prohibited (regardless of whether their medical license may later be restored) from being responsible for medical review of insurance claims in the state in the future.

ncallaway4• 3 years ago

I genuinely think every health insurance denial should have to come from a named doctor at the health insurance company who is personally and professionally liable for the health outcomes from a denial.

Deny someone life-saving care without a sound medical reason? That’s a malpractice lawsuit and a potential loss of their medical license.

theGnuMe5• 3 years ago

There's some doc on twitter who was denied by insurance and he filed a board complaint against the insurance doc claiming malpractice. I think he won.

d1str03• 3 years ago

Know any more details? This seems rather promising.

ncallaway4• 3 years ago

Yep, basically we should make it much easier to identify the specific doctor that is responsible for the denial (to make them easier to sue personally, and discipline professionally), and we should make the liability for such a denial extremely explicit.

kube-system3• 3 years ago

That doesn’t make any sense.

Insurance claims are submitted to insurers after providers have already performed the care.

thallium20510• 3 years ago

What about prior authorizations?

IG_Semmelweiss5• 3 years ago

A claim denial will result in patient responsibility, which ends up with a service but costing patients a lot of $$.

OR in this case, the pa was denied for the cpts requested. In which case care may be denies by the provider or facility

ncallaway4• 3 years ago

More and more often care is gated by prior authorizations by insurance. This is because insurance companies have more and more often required many procedures to have a prior authorization before hand and will refuse to pay bills if a prior auth wasn’t obtained.

My proposed policy would apply both to prior authorizations and post care claims.

Post care claim denials can be serious too. If you need repeated treatments a denial to a claim can have an impact on your ability to receive subsequent treatments.

I have a dear friend that was suddenly paralyzed, and now needs ongoing PT from specialists to work to regain use of their limbs. Their insurance has tried to get out of paying the bills several times (they’ve gotten it done so far, but each of the claims has been… a near thing). If one of those bills doesn’t go through, their ability to continue PT at this facility would almost certainly be impacted.

So, yes, a claim denial may impact ongoing care in similar manner to a prior authorization denial.

———

Finally, I’d actually want to add criminal liability for what was described in this particular article.

“We literally click and submit,” one former Cigna doctor said. “It takes all of 10 seconds to do 50 at a time.”

A doctor working for an insurance company issuing medical denials in this kind of a scheme should be facing jail time, not just personal liability or professional discipline.

conductr3• 3 years ago

In a way, a denial is accusing the ordering/prescribing of trying to commit some type of insurance fraud. I agree if you’re trying to override a doctor that knows me, has cared for me, likely already done some labs/scans/etc to make their order, well - the burden should be yours to prove it’s not necessary.

electrondood• 3 years ago

For anyone who is against government regulation... this is another perfect example of the kind of perverse financial incentives unregulated capitalism results in.

Blanket denial without consideration lowers your costs as an insurance provider, because it acts like a filter on people who care enough to appeal repeatedly.

whatthesmack3• 3 years ago

This is not unregulated capitalism. This is crony capitalism or corruption. It is government regulation that allows a monopoly of large corporations to remain the powerful health insurance companies they are, and ObamaCare gave them even more power.

If this was a free, unregulated market, healthcare in the US would be cheaper.

mdmglr• 3 years ago

Maybe to speed things up patients can opt to have ChatGPT read the claim and make a decision. /s

readme• 3 years ago

it would probably benefit patients

Ekaros• 3 years ago

AIs are wrong at least some of the time... That means they will approve some claims. Not deny all of them.

pontifier• 3 years ago

Automatic rejection is a tactic used by all sorts of con artists.

If they say no and you never come back then they don't have to worry about you anymore.

lostmsu3• 3 years ago

I am surprised commenters here did not read into the nuance:

A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments. Company doctors then sign off on the denials in batches, according to interviews with former employees who spoke on condition of anonymity.

Before grabbing the pitchforks, it is important to be sure if their policy is reasonable or not. Whose fault is it if doctors ask clients to perform expensive tests, because they can't be bothered to actually think and figure out what test would be the most optimal?

Now even if the doctors really overprescribe tests, I don't think the client should be responsible. Instead, the insurance should pay, but kick the doctor out of their network.

sidlls• 3 years ago

I don’t think we should trust the soundness of their algorithm. I’ve worked in the healthcare space before, and the perverse incentives involved should make everyone extremely skeptical of insurance companies’ motivations, procedures, and algorithms.

lostmsu3• 3 years ago

From the description it sounded like something trivial. E.g. given the diagnosis, there might be a cheaper known way to get to it. I am a layman, but for instance that could be ordering an MRI when an ultrasound would suffice.

salawat• 3 years ago

Fuck that.

You know what that incentivizes?

Not testing at all. You know what that leads to? Bad outcomes. I'm all for selection pressure toward more efficacious, less invasive, less dangerous tests. Writing an insurer a blank check to blanket deny millions of claims without checking or reading up though? Nah. That's profiteering.

You want to run that algo in parallel and dift through the claims that would change, individually weeding out the actual false positives? Kosher. Just YOLO'ing it on prod and trottingbit out in front of investors? Hell no.

soared• 3 years ago

It’s insane to trust an insurance company to make healthcare decisions. I was denied an MRI when I tore my hamstring off the bone, and so my doctor had zero info on what my treatment options should be. I went to physical therapy when I possibly should have had surgery.

I’d so much rather 10% of people overpay for unnecessary tests than the other 10% of people be denied potentially necessary care.

lostmsu3• 3 years ago

Oh, you can have that. Just pay 10x for insurance to cover your 10x more expensive tests.

vfclists• 3 years ago

There a few points to be made here:

1. The doctors who signed of on those batches should be sued for medical malpractice and negligence. Where is the AMA on this issue?

2. Why are the tests so expensive? All it requires is to add some chemicals to the blood sample or whatever and see if it changes color or something? $1000 of dollars?

3. Isn't there a trust relationship between Cigna and the doctors who authorize the tests? Does Cigna believe that some of its doctors have a relationship with the testing companies where they receive kickbacks for authorizing the tests?

4. The patients whose tests were signed of in batches must file a class action lawsuits against each doctor separately and Sigma. The doctors and Cigna are colluding in medical fraud. Even if subsequent indepth evaluations indicate that declining a tests was justified they should still be sued as they signed off the tests without actually doing the tests for real.

5. I think American doctors, their healthcare institutions and their medical schools have a serious problem with the medical ethics if so many doctors are that criminally minded.

camhart2• 3 years ago

Why can't healthcare be fixed?

I'm self employed, pay a crap ton of money for "good" insurance, and it's horrible. It's very difficult to find good doctors in network. Everything gets rejected from insurance and the Dr has to appeal it multiple times in order to sometimes get them to budge. It's absolutely broken, and even more so for those on individual and family plans (ie not through an employer).

Last year I was with United Healthcare, this year Blue Cross blue shield. Both are horrible. Both are massive companies.

javajosh• 3 years ago

Why can't healthcare be fixed?

Because doctors and patients won't fix it. Doctors can charge whatever they want. They could see more patients, charge less, and charge cash. They could do their own diagnostics during the visit. People from other countries will be shocked to know that US doctors never do their own diagnostics, and instead refer patients to other providers, which require their own payment and paperwork, another round of appointments.

Putting the patient through all that for an ultrasound is "standard practice", which also happens to be maximally profitable for multiple providers and their associated office staffs, and the enormous industries that exist to service this deeply problematic "standard practice".

olliej3• 3 years ago

No doctors cannot charge whatever they want. They can charge what insurance companies specify.

Doctors in other countries don't do their own diagnostics: a GP isn't a radiologist, isn't a microbiologist, isn't a lab technician, etc.

kofejnik• 3 years ago

It is working as intended. All parts of the system co-evolved to extract maximum value from you.

eapressoandcats2• 3 years ago

In the US at least the underlying problem is that we pay more for basically every medical procedure, drug, and device, so you end up paying more to get less. Largely this is due to having engineered a shortage of doctors combined with no negotiation on drug and medical device prices.

ratg132• 3 years ago

Once you get rich or in politics, healthcare is no longer a problem, so you don’t see it.

Even this thread is full of Americans trying to tell other Americans that the US system is “better” than Europe

camhart2• 3 years ago

Europe's healthcare isn't perfect like many Americans make it out to be. It has its own list of cons. Although it is very nice when you go to a Dr there and talking about money isn't even a thing.

My wife is German. There are Dr's that refuse to work with insurance altogether. There are procedures not covered at all. The employer pays for half the insurance, the state (aka taxes... so you) pay for the other half. Self employed people who failed to pay their "half" can still end up with life crushing bills (personal experience in the family). Not sure what happens if unemployed (I assume the State does step in there to cover it 100%?).

d1str03• 3 years ago

Not trying to be a shill, and would happily discuss my entire healthcare experience with Kaiser, but I highly recommend them if you have the option. Obviously, don’t change unless you do research etc. and again happy to discuss my experience with them for anyone interested.

adrr2• 3 years ago

What do you mean by fixed? Affordable? That means we would have to lower medical professional income and we have a shortage of them. Insurance have tried to push down their rates but they just stop taking insurance so we have to pay more to see a decent doctor. We could be more punitive to insurance companies for denying claims but the cost of insurance would become even higher.

There is no easy fix.

pyrelight• 3 years ago

I doubt you'll find many other industries that have as many unnecessary employees as you would in healthcare.

Given that they're for-profit, they have every incentive to hire as many people as possible to answer phones and create a bureaucratic nest of people who go to work to literally make it hard to use the insurance you're paying for.

Compare to car insurance, where many companies tout how "easy" it is to file a claim, and in most cases it is pretty easy to get your car fixed, get a rental car in the meantime, and get back on the road in a few days. Everybody in the process gets paid, you can shop around every 6 months for cheaper rates, etc. By all accounts, car insurance is profitable.

If healthcare was made simpler, with standard prices for procedures across all hospital systems and insurance carriers, and actual doctors who aren't of the same caliber of the ones prescribing Viagra from some random site in Albania, we could start to fix the system.

As it stands now, and I'm sorry for the people involved who work these jobs, but if health insurance reduced it's bloat of unnecessary workers, many of whom go to work to specifically answer calls from people whose claims are denied, we could lower costs, cover more people's procedures, and keep physician pay the same.

As it stands now, nurses do most of the work in the healthcare system, whether it's in the doctor's office or in the hospital, and unless you're in a niche field of nursing, they get paid less than an entry level PHP developer.

A nurse can lose their license if they make a horrible mistake at work. Hospitals see nurses are replaceable and that's why many of them burnt out during COVID when staffing ratios were thrown to the wayside, raises and department transfers were halted, and techs and other low-skilled nursing positions were eliminated, increasing the burden on RN's.

It's not correct that in order to lower healthcare costs, we have to lower physician pay. Healthcare is just not a business that can be left to the free market.

dennis_jeeves13• 3 years ago

A true free market is when anyone should be allowed to practice medicine including your barber. That would give your regular doctor a run for their money and have them perform better that the barber.

Similar goes for pharmaceuticals, a true free market does not exist.

fzeroracer• 3 years ago

This already exists and we know what the outcome of it is. It's alternative medicine. Insurers will gladly and gleefully let you do holistic woo bullshit because it saves them money.

A 'free market' as you state just results in people falling for bullshit care.

olliej3• 3 years ago

It can be. You make it a public service. Much like roads, public health a "loss making" industry, so the options are "a public service that treats everyone" or "a for profit industry that works to avoid treating people while charging as much as possible".

tim333• 3 years ago

Dunno exactly but pretty much every country on earth seems to get by without these sort of stories. American politics?

snozolli• 3 years ago

“Put yourself in the shoes of the insurer,” Howrigon said. “Why not just deny them all and see which ones come back on appeal? From a cost perspective, it makes sense.”

Something about "do no harm" comes to mind.

knodi123• 3 years ago

was it the hypocritic oath, "second, do no harm"?

daviddever23box• 3 years ago

There is a curious irony regarding retirement funds that invest in health insurance companies: if one is healthy and pays into the system, the insurers will reap ample profits, and one's retirement plan will reap the benefits. Get sick, and one may never make it to retirement....

sheeeep86• 3 years ago

You can attack the management, but also you should look at the people doing the action. If medical doctors participate in such a scheme I feel that the medical schools should strongly consider revocation of degrees as an option. Clearly these doctors are violating their oaths.

catchnear4321• 3 years ago

Any “health insurance” in the States do otherwise?

throwawayce• 3 years ago

I work for Cigna, and recently went through cancer treatment. They rejected every scan and treatment until my doctor challenged. My first doctor couldn't figure out how to challenge and it set back my initial treatment.

Then last year the CEO did a town hall with a tear jerker clip show about how evicore is helping cancer patients. But evicore is the part of Cigna that kept rejecting my treatment. It was incredibly insulting, and I've been ashamed to work there since.

nine_zeros3• 3 years ago

Brutal.

Once you get the treatment and feel better, please share it with your local news stations. This is the kind of story that should take the company out of business.

borissk3• 3 years ago

The local news station probably receives a big part of it's budget and profits from medical ads. It won't run any material that can threaten it's main income.

throw737away2• 3 years ago

That is sick. I'm sorry.

I remember that town hall.

I know people at evicore. Some of them even seem to take pleasure in the fact that patients and doctors call them EvilCore.

They're very convinced that evicore delivers superior outcome at lower cost.

I quit Cigna late last year. Couldn't take the place anymore.

olliej3• 3 years ago

They're very convinced that evicore delivers superior outcome at lower cost.

A superior outcome by what measure? Non-treatment with a cheaper life insurance payout than cost of treatment is "superior". Treatment with a worse long term outcome that is cheaper overall is "superior".

diebeforei485• 3 years ago

Obama gave the insurers (who are big donors/lobbyists) way too much power.

binarymax• 3 years ago

The fictional story “The Rainmaker” is about a fictional insurance company with a secret internal policy to deny all claims on first submission, and only fulfill some claims on appeal.

It was meant to be fiction, but I suppose it’s not. This whole company should go down for fraud.

theGnuMe5• 3 years ago

Yeah that's basically a true story, also before the ACA there were plans that would deny your insurance claiming that you lied during the underwriting process if you used the insurance. It was big news at the time and lots of state action against those plans.

I think Cigna needs to be sued class action style for denials. I think it would probably work in the case where Cigna is operating as the claims administrator which is where your company self-insures (so they pay the claims) but Cigna just deals with the paperwork. I would not be surprised if Cigna advertises its services to large companies as "cost effective" etc...

d1str03• 3 years ago

I’m not familiar with class-actions, but I assume they would not work well for a class pool that has an extremely wide ranging list of claim value, and background evidence/ailments.

rgblambda• 3 years ago

So the law says a Doctor must review the claim. An algorithm does what effectively is a pre-review of each claim and the Doctor just clicks accept without even checking a single sample in each batch of pre-reviewed claims. This cannot possibly be legal.

dcow4• 3 years ago

What would be the problem with requiring all healthcare to be non-for-profit? You can still have it privatized, but you can’t ever be in a situation where you’re trying to maximize profits. Someone poke holes in the idea…

AnthonyMouse4• 3 years ago

The incentive to maximize profits (i.e. minimize costs and maximize number of customers) is the benefit of a privatized market. The profit-minimizing mechanism is supposed to be competition, because then people switch away from plans that have a poor balance between price and rejecting claims. But because most plans are tied to employers, that part doesn't work.

If you had a non-profit with no competition it would be little different than the government, i.e. susceptible to regulatory capture and with poor incentives to constrain bureaucratic inefficiency.

Non-profits in a competitive market would be better, but so would for-profit insurers in a competitive market. The problem isn't that somebody is making money -- a service is being provided and somebody is getting paid one way or another -- the problem is it's too hard to switch so bad providers proliferate.

dcow4• 3 years ago

I understand what you’re saying but I don't think it’s so simple when you involve human lives. When you have shareholders and a board demanding profits, fucked up things happen like you don’t get the new MRI machine because it’s bad for the bottom line. Or you pass on the state of the art surgical robot because it won’t pay for itself quick enough. Both examples would increase outcomes for patients but don't happen because the board chooses profits. I am from a family of primarily doctors for multiple generations so I have 2nd hand experience with this crap.

I think as a society it would be totally reasonable for us to say “we don't want profiteering in healthcare”. If you set out to take care of people then your business may only cover costs, which includes reinvesting into the business and your employees. You can never be in a situation where you’re weighing profits against patient care because the conflict of interests is considered unacceptable. I would love to see more people advocate for that stance.

Nihilartikel• 3 years ago

Sounds great, but to make it happen on a legal level, the public would have to mobilize enough money to out lobby the vast interests already enjoying complete regulatory capture. Also every advertisement block would have a 2 minute propaganda segment showing a grandmother suffering due to 'sclerotic non-profit ineptitude' that is inevitable when the god given American profit motive is stripped away.

switch007• 3 years ago

“Put yourself in the shoes of the insurer,” Howrigon said. “Why not just deny them all and see which ones come back on appeal? From a cost perspective, it makes sense.”

This is more or less how the UK government handles benefits (welfare) applications.

It’s cruel and demeaning and damaging to health in many many cases.

moogly• 3 years ago

The title is missing "of Dollars". Right now one might mistakenly think it implies "of People".

honkycat• 3 years ago

But hey: at least they owned the libs this month by passing a disgusting anti-trans bill.

That is what is important right? Not stopping the massive corruption from every mega-corporation in every sector that is making our earth uninhabitable and our lives miserable. Lets hyper focus on people's sexuality.

elromulous• 3 years ago

I interpreted "saves millions" as "saves millions of lives". I couldn't have been more wrong.

SkeuomorphicBee• 3 years ago

The USA medical insurance system is missing a "stick" for such bogus rejections. Unduly denying a claim should result in a fine big enough to be felt in the company balance sheet, that is the only way to change companies' behaviours.

, missing some kind of harsh

avidiax• 3 years ago

What if we just don't have a stick. The government or a company they hire is the party that reviews claims. The insurance contacts must have standardized terms and conditions.

This probably wouldn't even really hurt the insurance companies. They would not need to compete with each other by denying claims on the backend to provide lower prices on the frontend.

The current system is a race to the bottom.

thallium20510• 3 years ago

The terms and conditions (usual and customary) are already there. People just don’t know what they are.

Logans_Run• 3 years ago

Free Market, Self-Regulation, Share-Holder Value.

My Friends, The Revolution is near. There comes a time when the common man can no longer stand idly by and watch as their brothers and sisters (and themselves) continue to be screwed over.

There are many amongst you that fear speaking out in the vain hope that some day that they will get their share of 'the Good Life'. I regret to inform you that if it was going to happen, it would have happened to you by now.

Don't remain silent nor inactive in fear of rocking the boat, the 'they' are mocking you and holding out a carrot on a stick while you blindly plod on in the hope of 'some day'.

Do what you can, when you can. Even the smallest ant can overcome an elephant.

Do not be discouraged nor disheartened if you feel there is nothing you can do. That is what the 'they' count on.

Enough of this Shit!

whatthesmack3• 3 years ago

There's no free market for healthcare in the US. What you mean is crony capitalism and corruption. If there was a free market for healthcare and health insurance in the US, it wouldn't be so expensive.

duxup2• 3 years ago

I was on a jury on a civil case that involved medical claims.

The insurance company doctor seemed like a doctor who sort of plodded his way through jobs and eventually just found a place where he could be a doctor and just reject insurance claims.

Dude didn't seem to actually know all the medical claims involved in the case, seemed confused about what kind of care was done ... just not at all on the ball.

When we deliberated and reviewed the evidence absolutely nobody on the jury had any faith in the insurance company's doctor and we disregarded his testimony entirely.

I honestly felt like there should be some consequences for someone acting as a "doctor" testifying in a court case and having very little clue what was going on, but choosing to testify.

kwhitefoot5• 3 years ago

there should be some consequences for someone acting as a "doctor" testifying in a court case and having very little clue what was going on, but choosing to testify.

It will make no difference. It is the people higher up and the investors in the company who are responsible. The doctors in question don't behave as they do just because they want to, they do it because that is what the company that employs them demands.

duxup2• 3 years ago

I'd like to see the doctor be at least at risk of losing his license. It's a serious profession and should be held to standards.

Osiris• 3 years ago

My insurance is denying mental health care for my teenager who has Autism. They also rejected prescriptions given by my doctor for reasons that the doctor would already have taken into account.

Both rejections came with a note to “not stop getting care”.

In my opinion, insurance companies should not be able to override a doctor.

32kfjh23• 3 years ago

vD is stored in the bones? Author needs to get facts straight as that’s the first thing you read. Is ProPublica quality going down?

charles_f• 3 years ago

I somewhat get why you'd build such a system when on the other side you've got pharma and labs pulling for useless medication and tests through doctor presents and "seminars". What's beyond me* is how health insurances get to be the deciding entity when there's such a blatant conflict of interest in the matter, which gets abused as it is here demonstrated.

If you get a home insurance claim, at least here in Canada the insurance company has to use an external adjuster. Even though it's not perfect, it seems a widely better solution to handling claims.

* it's not beyond me, it's probably just the result of lobbying

pcurve• 3 years ago

I’ve been working in the industry for 20 years. All companies do this. I don’t think this is even the worst example of rule driven coverage review

smsm42• 3 years ago

Imagine spending years studying medicine and ending up doing this.

thallium20510• 3 years ago

Insurance companies deny medical necessity claims because the procedure and diagnosis code combinations don't align with what is pre-determined to be medically necessary. One of the big reasons why this happens that nobody ever talks about is because the doctors office does not code the claim correctly and it gets denied. The patient is pissed and blames the insurance company, the doctor is pissed and blames the insurance company, but in reality its the biller/coder in the back office who screwed it up.

borissk3• 3 years ago

All right, US insurance companies deny millions of valid claims not because of greed, but because "the doctors office does not code the claim correctly". It's just an unforeseen side effect that said insurance companies end up with billions of annual profits and patients sometime die...

Your post remains me of how Russians often react on their forums to posts regarding the corruption in Russia. There are undeniable proofs of how corrupted Putin regime is. All ministers, members of president administration, local administration, judges, generals, etc. end up owning multi-million properties both in Russia and Europe/USA, but many regular people find the stupidest excuses of how the system is fair and just, but "the doctors office does not code the claim correctly".

thallium20510• 3 years ago

I’ve worked in healthcare revenue cycle management for over a decade. If you don’t accurately tell the insurance company what you’re doing and why you’re getting denied. Doesn’t matter if it’s health, auto, home, etc. There are thousands of codes, millions of combinations, and all being mostly hand coded by minimum wage workers. There are constant fuck ups most of which don’t require anyone but a computer to review to know it’s wrong. But okay cool conspiracy.

darrin• 3 years ago

If all insurance companies published all the code combinations covered for every procedure/diagnosis, I might buy this argument. But they don't. I've asked Blue Cross and they said they don't disclose those details. Many billing codes are open to some interpretation. So if insurance companies aren't transparent about what codes are or are not covered, why are the doctors' offices at fault when something is denied? Why isn't the default response from every insurer "code X isn't covered in combination with code Y. <some clarifying questions, explanation, and related codes>"? Why is it a black box?

thallium20510• 3 years ago

They aren’t allowed to publish them.

And they do use denial and remark codes to indicate the services don’t justify the diagnosis.

https://x12.org/codes/claim-adjustment-reason-codes

https://x12.org/codes/remittance-advice-remark-codes

jc_811• 3 years ago

Wow. This is almost the exact plot of The Rainmaker by John Grisham[1] that came out in 1995:

“Rudy uncovers a scheme by Great Benefit to deny every insurance claim submitted, regardless of validity. Great Benefit was playing the odds that the insured would not consult an attorney. A former employee of Great Benefit testifies that the scheme generated an extra $40 million in revenue for the company.”

[1] https://en.m.wikipedia.org/wiki/The_Rainmaker_(novel)

hughw• 3 years ago

Where are the professional bodies for physicians in all this? These doctors seem to be using their medical credentials to get paid for fake work.

more_corn• 3 years ago

This country sucks. They’re literally killing us for increased profit margins. It is sickening. Perfectly legal, will not fix.

PuppyTailWags• 3 years ago

There's a viral case going around where a doctor whose lost his license due to replacing a hip backwards is now making his living denying insurance claims. It's not just that claims are being denied unread, but when they are read, it's not exactly the medical cream of the crop doing the work.

babbledabbler• 3 years ago

Somebody should make an AI service that automatically files appeals. I suspect that the cost of the appeals process would negate the savings they make from auto-denying claims.

xtracto• 3 years ago

I keep and keep saying that health insurance is a scam. Paying to a company for a service when their explicit objective is to AVOID providing that service or to minimize the money they spend is plain wrong.

Even medical professionals are angry at the system (check r/medicine) . We are two parties in a transaction being screwed by a third party which only value is to extract profit as an intermediary... even a lending setup (instead of a insurance) would be better. Or imho better yet, socialized medicine.

Jensson• 3 years ago

Problem is that neither the patients nor the doctors choose health insurance so they both get screwed over. Your company CFO chooses your health insurance and the hospital managers chooses what health insurances to collaborate with.

engineer_22• 3 years ago

Government intervention is clearly necessary, but having government take over the industry is obviously the most drastic step we can propose.

sublinear• 3 years ago

Imagine how much more ruthless it would be if it was run by "AI"

amai• 3 years ago

Why should a blood test for Vitamin D cost $350?

In Germany blood test for vitamine D are also not covered by the insurance. But they cost 16€. I believe the algorithm might be right in the example given in the text. The costs for such a simple test are excessive and the case should be rejected.

It sounds to me what is described here is simply an algorithm for fraud detection, which many companies use.

ThePowerOfFuet• 3 years ago

As a physician, van Terheyden said, he’s dumbfounded by the company’s policies.
“It’s not good medicine. It’s not caring for patients. You end up asking yourself: Why would they do this if their ultimate goal is to care for the patient?” he said.

Because their ultimate goal is to make money, as with the entire health "care" system in the US.

Yet another reason blue card trumps green card.

mmranger• 3 years ago

I worked customer service for years with a cell carrier in the US. It was tiring hearing everyone's problems with their luxury devices(at that time). I left and got a job at Aetna customer service 6 weeks of training and I walked in the first week on the job. After getting off a call with an elderly gentleman trying to figure out why we weren't paying for his wife's medical care. And all I could say was the plan you have well not cover that because you didn't jump through some ridiculous hoop. A hip that as a young adult I would have struggled to complete let alone a very old person who doesn't understand what is required and there is no one to help him.

bithead• 3 years ago

I am a T1 diabetic, and worked for UnitedHealth Group. During that time they decided to stop paying for my insulin with no substitute for it, in spite of several cheaper substitutes existing. Thank god for Canada mail pharmacies.

No amount of oversight of health insurance is too much. Health insurance companies should be forbidden from owning or otherwise influencing any health care provider (sounds like a RICO thing now that I type it out). Mandatory prison time for CEO's and any other corporate officers if they knew about the offense and failed to notify authorities. Also fines base on gross revenues, at least 10%. Make shareholders pay as well. Also mandatory incarceration of corporate officers while investigations take place.

consultSKI• 3 years ago

#sad

norswap• 3 years ago

I thought the headline was about saving millions of lifes and got really confused for a hot minute.

thewileyone• 3 years ago

Insurance companies are scum of the earth. A relative, who's a Prudential agent, bragged that Prudential had billions in their war-chest. I replied that's because ya'll don't payout any claims.

Cigna saves millions by having its doctors reject claims without reading them

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