Feds help health insurers hide their dirty secret: denials on the rise

https://nypost.com/2024/12/12/opinion/feds-help-health-insurers-hide-dirty-secret-rising-denials/

by mancerayder • 2 years ago

150 279 2 years ago

nypost.com

andrelaszlo• 2 years ago

"No industry malfeasance could ever excuse murder.

Period."

Murdering a murderer to save many innocents could be considered ethical by some?

(Not saying that's the case here, but nypost made an interesting categorical statement.)

no_wizard• 2 years ago

Given the NY Posts leanings I’m not surprised they walked that line by putting it in there.

Media seems to be on an agenda setting tear to disavow the murder, but I think it’s a frankly boot licking response to what is going on here.

I think this spooked a lot of executives (re: “elites” if you will) and there is pressure to ignore the nuance of what the murder means to people and why it isn’t the same as say, stabbing a tech CEO in SF like what happened last year

tossandthrow8• 2 years ago

It is funny that the sentiment that nothing excuses a murder is being circulated in the US - a country that still carried out death sentences.

xyzzy47474• 2 years ago

It's a little different when a jury of your peers convicts you of a crime which was democratically passed by a legislature, versus a lone gunman who feels he is the judge, jury, and executioner.

jimbokun4• 2 years ago

I understand what you're saying.

But a murder carried out by a random citizen is still worse than a death sentence after a fair trial and convicted by a jury of your peers.

TimTheTinker• 2 years ago

In the 20th century, I think the death sentence was only ever applied for first-degree murder and for treason.

A claim denial that results in denial of life-saving treatment could never be counted as either of those charges.

joejohnson• 2 years ago

And which is currently fighting multiple wars around the world, or justifying support of many proxy wars which are killing thousands daily.

seneca2• 2 years ago

The act of killing a human being is not inherently murder. It specifically communicates an unlawful killing, which the death penalty inherently is not.

athenot• 2 years ago

This is because the US is not one homogenous system of thought, but rather a mosaic of people with differing views. (This goes for any other country or population for that matter.)

A more constructive observation would be to consider the overlap in groups of people who (1) hold that murder is indefensible in any case, and (2) hold that death sentences are appropriate for crimes. While not sharing that view myself, I could think of a few factors that may lead others to espouse it, such as:

- an implicit trust in authority and deterrents (follow rule, "or else");

- feeling of being mostly immune to errors in the justice system ("this would never happen to me");

- a propensity to desire revenge but only when it pertains to "others" ("I'm a good person, we must punish the bad people")...

ahupp2• 2 years ago

Murder is by definition an unlawful homicide. This isn’t just pedantry; it’s the most parsimonious explanation for why someone would support the death penalty and object to something like the assassination.

pessimizer2• 2 years ago

Not to mention that we happily do extrajudicial assassinations outside of our borders, and the news falls all over themselves to celebrate them.

Everybody knows that plenty excuses a murder, we live in murderous states and in murderous times. The question is whether this murder is excusable, and one's opinion on it is probably dependent on whether one wishes they had that guy's job. Most people wouldn't do it for any price, but plenty would.

mrbluecoat• 2 years ago

If a cancer patient is denied a claim for life-saving medication because they're 'not sick enough' then dies, is it murder?

JohnFen3• 2 years ago

Yes, in my opinion. It's homicide at the very least.

carlgreene• 2 years ago

I'm trying to figure out if these deaths caused by insurance denials could actually be considered murder. I think they would definitely qualify as being premeditated, but can you consider them "killing"? They are causing death due to omission of expected care, but can the omission of something like medical care be considered the cause of death?

GiorgioG• 2 years ago

Ask yourself this question again when it's your partner/parent/child in the casket.

ziddoap3• 2 years ago

I am not a lawyer, but I would assume that death due to omission of expected care fits pretty neatly under "negligent homicide".

psbp• 2 years ago

There is legal precedent establishing healthcare providers' obligations in life-threatening situations. The same moral responsibility should exist when insurers deny lifesaving care, it's just hidden behind bureaucracy.

TheCondor• 2 years ago

There are direct measures: someone needs a transplant or something of that nature, refusal is effectively shortening their life and some aggressive prosecutors might craft a case. There are less direct things, I expect a lot of them. say people dealing with long recoveries from things, there are good days and bad days and bouts of depression aren’t uncommon; could antidepressants prevent depression on related suicides? That’s an entire can of worms, people have fallen into depression because they’ve become addicted and can’t kick it, what if it was medical pain killers you’re addicted to? Then suppose some company spent half the funds on ED pills and breast augmentation and some more medically things were denied, you can spin that both ways as they might be doing what the bulk of their customers want. That one is interesting, you could break a bone and have surgical reconstruction and hopefully get a full recovery or maybe you just set it and naturally heal and maybe it’s not 100% fixed, only 85%, there is a substantial cost difference there…

For profit medicine and for profit health insurance is just riddled with moral hazard.

pnutjam3• 2 years ago

https://www.sciencedirect.com/science/article/abs/pii/S01651...

ahupp2• 2 years ago

The doctor / hospital that refuses to treat when insurance declines is also involved in the “omission of expected care”. Would they also be guilty of premeditated murder?

harimau7773• 2 years ago

Depends on your philosophy I suppose. For example, Christianity teaches that failing to do good is itself a sin. So that suggests that an omission could be considered to make someone guilty.

I suspect that all modern legal systems have the concept of negligence which could result in someone being considered guilty for someone's death. I imagine in that case whether that's "murder" would come down to whether you mean a legal definition (which might call it something else like "manslaughter") or the colloquial definition.

technothrasher• 2 years ago

Well, if a killing is ethically justified, it isn't murder. So yes, they're at least begging the question with that statement for sure.

ziddoap3• 2 years ago

Well, if a killing is ethically justified, it isn't murder.

Are you saying this as an opinion, or is this an established thing? I thought murder was an "unlawful killing without justification or valid excuse" (paraphrased from Wikipedia), whether one finds it ethical or not is sort of beside the point. Especially because there is no objectively correct ethics.

But, I'm not a lawyer, this is just my understanding.

amarcheschi4• 2 years ago

But now you have another ceo. I'm not suggesting that to fix the issue you would need to - inaudible - again and again

lopalimpa• 2 years ago

"Murdering a murderer to save many innocents could be considered ethical by some?"

This is a heavy statement.

More I read, heavy it gets.

Kill people it never the answer. The ideia that "I" have the power is weak. People, together, have power, however they don't know what to do. In his case the easiest way to win is pressuring the government, with the people, for clear changes.

amarcheschi4• 2 years ago

Killing people is not the answer but somehow another Healthcare company backtracked on not covering anymore long anesthesia.

Perhaps n = 1 is too low of a value? We should research this field more, some people may die but it's a chance I'm willing to take

JKCalhoun2• 2 years ago

I agree with you. But if anything, politically, we are watching the pendulum swing in the opposite direction.

I worry that the future for the U.S. is the malaise that appears to have taken hold of the Russian people.

oulipo2• 2 years ago

Well, in 1789 France, we killed people

It worked beautifully

forgetfreeman2• 2 years ago

I find absolutist stances based on ideology distasteful. History has pretty vividly shown that sometimes killing people is in fact the answer. Something something Nuremburg trials.

christophilus• 2 years ago

Executing a murderer can be defended. “Industry malfeasance” leading to death is indefensible.

jimbokun4• 2 years ago

You would need to prove that murdering a health care CEO will save many innocents, first.

forgetfreeman2• 2 years ago

K. So step 1. murder health insurance CEO (no healthcare involved there), check. Step 2. watch UnitedHealth's refusal rates closely, ongoing.

euroderf• 2 years ago

Zeitgeist graffiti, anyone? "When they wage war, we wage war."

aaomidi• 2 years ago

Consent has been manufactured that if you kill through indirect means then you’re good to go!

OutOfHere7• 2 years ago

Yes, mass media exists to manufacturer consent, and this shooter forced their hand.

oulipo2• 2 years ago

Also without this murder, we could imagine that the NYPost would have never written this article to alert on the malfeasance of healthcare providers...

Why wouldn't they do their part as a news org, and why did they wait for the murder to publish such an article, if that murder was not "needed" for things to change, then?

JohnFen3• 2 years ago

Even if you accept that, it still doesn't excuse it being done by companies or individuals.

The point is also orthogonal to what the insurance industry does.

LiquidSky• 2 years ago

You can't just shoot people and kill them in the street! That's barbaric! You need to do it from behind a desk through a corporate bureaucracy like a civilized person.

refurb7• 2 years ago

One issue is that if denying medical care is murder then every healthcare system is guilty.

In the US it’s insurance companies (or the government through Medicare or Medicaid) but in the UK it’s NICE, in Canada it’s CADTH and the provincial health authorities.

Since there are finite resources spent on healthcare, trade offs are made all the time. If spending $10M on treatment A saved 10,000 lives and $10M on treatment B saves 1,000 lives, then treatment A gets funded and treatment B doesn’t.

The difference is that patients in the US have an up close and personal experience with denial.

In Canada and the UK they don’t because doctors knows what is covered and what isn’t so never bring up life saving options if they aren’t paid for.

In rare circumstances like cystic fibrosis in the UK, patients become aware that they are being denied a life saving drug and protest, but generally it’s pretty rare because patients just don’t know the option exists.

OutOfHere7• 2 years ago

Your argument is completely bogus for multiple reasons. Firstly, people are paying here for insurance, a lot. Secondly, it's the FDA's job to approve treatments which it does. Thirdly, we do not have a uniform privatized determination across the country of what is approvable or not by insurance companies. They deny numerous legitimate treatments and procedures at their whim.

wat100007• 2 years ago

The difference is that patients in the US are being denied by people lining their own pockets with the savings. In sane countries, there’s at least some basis of trying to do the most good with the resources at hand, which sometimes means denying care for person A because those resources would be better spent on person B. With private insurers in the US, it means denying care for person A because they think they can get away with it and it will increase their profits.

stuaxo• 2 years ago

The US spends the most budget per patient for the least amount of care, the rest goes into inefficiency and profit (a second kind of inefficiency).

Medicare per-capita spending is more than NHS per capita spending, but the NHS covers everyone.

Of course healthcare is denied in any system (in other systems this is triage), but nowhere to the level United Health does it: over 30%, it's on a completely different scale.

lubujackson• 2 years ago

I guess we aren't going back in time to kill Hitler any more then?

The media pearl-clutching is extremely heavy this time around, painting Luigi as an unhinged lunatic and all the rest. It feels incongruent and purposefully dismissive to equate this to something like the Oklahoma City Bombing.

kyleblarson• 2 years ago

I hate the way the press and seemingly most people are approaching this but am completely unsurprised: "You are either a heathen who supports murder or you are a virtuous supporter of the people and this man deserved to die." Two things can be correct at the same time. 1) Murder is not OK. 2) The insurance industry is completely broken as it incentivizes terrible behavior and this CEO was a scumbag who perpetuated this behavior while possibly insider trading.

PittleyDunkin• 2 years ago

"No industry malfeasance could ever excuse murder."

AND YET

actionfromafar• 2 years ago

If there wasn't a recent murder of a CEO, that line could be taken as directed towards insurers.

kstrauser8• 2 years ago

That is, the ones who actually convene the “death panels” some politicians pearl-clutched about.

staticautomatic3• 2 years ago

Of course! But maybe …

SauciestGNU7• 2 years ago

Of course not legally, but I think there's a philosophical exercise here for ethicists to debate the boundaries and efficacy of community self defense.

edwinjm• 2 years ago

It's time the US realizes how bad its medical system is.

weberer2• 2 years ago

Everybody knows how bad it is. Everyone wants to change it. But I don't see how it can change as long as both parties are on the payroll

https://www.opensecrets.org/orgs/unitedhealth-group/recipien...

tboyd476• 2 years ago

It can change once Americans break their addiction to "health care."

tossandthrow8• 2 years ago

Well, the events you are seeing unfolding is change around the established systems.

Civil disobeyance is nothing new. The fact that is is so little pronounced currently is probably a signal that there has been alignment for quite a while.

Bit when politicians do not take their jobs seriously, change finds other ways.

jimbokun4• 2 years ago

Everyone wants to change it...until you propose a concrete new system including payment mechanism.

"Give me universal health care...but don't increase my taxes!...and don't take away my current insurance plan!"

shdksjxbcb• 2 years ago

The American people need to stop seeing the other party as the enemy. As long as that’s in place, the parasites at the top will remain in power.

Unfortunately, it’s easy for them to create conditions to perpetuate and widen the American political schisms. And they’ve convinced both sides the common historical solutions (nationalism, limited democracy, religion) are for low IQ bigots. Things are likely too far gone.

paulproteus• 2 years ago

Confusing statement when Republicans are the reason Obamacare shipped without a public option

JKCalhoun2• 2 years ago

Aligning with the other reply, yes, I think it's time US leaders realize how bad the medical system is.

kstrauser8• 2 years ago

Roger that.

I’m against vigilante killings because I don’t want to live in that kind of a society. But a couple days later, Anthem decided to end their insane time limits on anesthesia. I’m hoping the public’s reaction to all these events has put a bug in the ear of politicians who ran partly on the idea of “repeal the ACA”: maybe this isn’t a great time to start slashing coverage. People seem pretty upset about it right now.

wat100007• 2 years ago

They know. They don’t care because they think it doesn’t affect them. They’ve largely been right so far. But this should be their sign to fix it before discontent boils over.

nradov11• 2 years ago

Most people in positions of power realize that it's bad in some ways and good in others. It's bad in cost effectiveness and universal access to affordable primary care. It's (relatively) good at other things like 5-year cancer survival rates, waiting times for elective treatments, trauma care, and drug development. There is little agreement on how to fix the bad while preserving the good.

Bengalilol• 2 years ago

IDK. What puzzles me here is that a NYPost article can be trending on HN.

mancerayder3• 2 years ago

As opposed to a Medium blog? If source material and reputation is the concern.

Many online papers have pay walls. There are similar articles criticizing health care denials from other sources, feel free to post them. They're not all discussion material nor even readable.

And if the writer did a poor job, poke a hole in the argument.

JohnFen3• 2 years ago

That has to be the worst kept dirty secret in the history of dirty secrets.

garciasn3• 2 years ago

I was just denied a colonoscopy as not medically necessary by UHC, coincidentally three days before their CEO was killed, because they don't want me to have anesthesia to do it; they argue I should be awake.

When I called to refute the denial, which was denied, I asked them to find the person, if it was a person, who denied it and shove a tube up their ass without anesthesia and then reassess whether it's medically necessary to have a colonoscopy without it.

I'm 45. Colonoscopies are a thing. I had a friend die at 52 two years ago after he was diagnosed with stage IV during his first colonoscopy. I spent many of his last days watching him struggle to survive; I don't want that to happen to me just because UHC charges me $2000/month in premiums and denies basic service because they need to pay their executives too much money.

tommilburn4• 2 years ago

that's insane! everyone should get a colonoscopy, and i believe they're recommending them for people over 40 if you meet certain risk categories

signed up for an account with my real name to share a doc i've been working on for a long, long time now - i've had UC since high school, and have written an extensive guide of what i've learned, if it helps you or anyone else you know who might be getting scoped:

https://docs.google.com/document/d/1bTW2rdF744woSPpFsUeSaFYa...

hgomersall• 2 years ago

It's estimated by CRUK there are 44,000 bowel cancer cases each year in the UK. Assuming only people over 40 get it, and that's about half the population, the incidence is something like 1 in 800 annually. The rate of "serious complications" for a colonoscopy is about 1 in 300.

Given those numbers, how often should everyone get a colonoscopy?

That's before we get on to the potential harm from a false diagnosis (which is much higher without additional priors).

Yes, absolutely people should pay attention to their bowels and get a colonoscopy when it's indicated. Let's not all rush to get one though unless there's some reason for it.

jbb67• 2 years ago

But it's not usual to have an anesthetic for a colonoscopy is it? I've had two without. I was offered a light sedation but then I couldn't have driven home afterwards. It wasn't particularly awful without.

It's it usual to be asleep? I've not really heard of that. Is it a US thing?

tommilburn4• 2 years ago

i'm not sure if it's a US thing but i think especially if they're going to take biopsies you're put under twilight, which is one step below general - i don't remember anything about any of the ones i've had, and wake up later in a recovery room

garciasn3• 2 years ago

I'm not a medical doctor, nor a clinician that does colonoscopies, so I have no idea. All I know is that the clinic suggested by my primary care physician set everything up and UHC denied it 10 days prior to the procedure, leaving me almost no time to work through any sort of processes to effectively change their decision--if it's even possible.

Without any real evidence except a hunch, I think it's because I've already met my deductible for the year and they don't want to pay for the entire thing and they'll do anything they can to avoid having it happen this year and hope I just go away or do it in another year when I haven't hit my deductible.

runnr_az2• 2 years ago

I dunno if it's unusual? I had mine done recently, 49 years old... seemed like a given that I was going to go under? (I'm pretty sure I prefer it that way?)

Also UHC fwiw, but went through my local provider group, etc...

philamonster• 2 years ago

I'm in US and I've had a single one. It was sedation which induces twilight sleep but I was definitely conscious. I've known many that have had them (ex-partner had stage 3 colon cancer and had/has them on the regular) and it was always sedation.

tedivm2• 2 years ago

Light sedation is anesthesia.

Anesthesia or anaesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia, paralysis, amnesia, and unconsciousness.

"General anesthesia" is probably what you're thinking, which is a specific form of anesthesia where someone is put to sleep.

devilbunny3• 2 years ago

It is extremely common in the US. The only people who get colonoscopies without any sedation are those who want to be able to drive themselves home afterward.

We have people - covered in tattoos - who insist that they are terrified of needles. And that they want drugs before any even mildly painful procedure, like placing an IV.

cjbenedikt• 2 years ago

Same here, just had one in the US and I refused to be sedated as I knew from previous one in EU that it is tolerable. You should have seen the song and dance of the provider trying to convince me to get sedated. In the end they accepted my decision. Afterwards about everybody in the clinic came to see me as if I was a hero of sorts. However,the whole episode gave me a good insight as to why US healthcare is so expensive.

kstrauser8• 2 years ago

Good god. I went to get one, and in the pre-screening, the anesthesiologist asked if I wanted to be awake for it. “Doc, I don’t want to be awake, I don’t want to feel a thing, and I don’t want to remember a thing. Put me out.”

Requiring people to be awake is a good way to guarantee they don’t get the procedure. Which mathematically makes it far more likely for the insurer to incur enormous colon cancer treatment expenses, erasing their profiteering.

caseyohara• 2 years ago

for the insurer to incur enormous colon cancer treatment expenses

This presupposes the insurer isn’t going to deny claims for that treatment, too.

ziddoap3• 2 years ago

Which mathematically makes it far more likely for the insurer to incur enormous colon cancer treatment expenses, erasing their profiteering.

Just find an excuse to deny those claims, too!

voidfunc• 2 years ago

I've done a colonoscopy without anesthesia before... it was a non-event. This is pretty common from what I understand elsewhere in the world. Americans are just super uncomfortable with their bodies so I guess we prefer being put under?

chefandy2• 2 years ago

I've done a colonoscopy without anesthesia before... it was a non-event. This is pretty common from what I understand elsewhere in the world. Americans are just super uncomfortable with their bodies so I guess we prefer being put under?

It depends on what they do while they’re in there. If they’re just taking pictures then it’s fine. If they find anything they usually cut it out immediately. I can tell you from experience that having a piece of inflamed colon cut of and cauterized while you’re conscious isn’t a “non-event” as cool as it might be to watch on the monitor.

harshaw• 2 years ago

They should make anyone who denies anesthesia for a colonoscopy drink that awful orange flavored drink you take the night before. This is just like... basic care.

devilbunny3• 2 years ago

I'm an anesthesiologist. What they denied was paying me to do it. You can still get "moderate sedation" from a nurse - a benzodiazepine and opioid.

Patients strongly prefer having what amounts to a general anesthetic; your chances of recalling anything are low either way, but propofol results in a much faster recovery to full consciousness afterward.

Go gain 100 pounds and develop sleep apnea. Then they'll approve it.

OutOfHere7• 2 years ago

Propofol (or equivalent) is a must. I know people who have had a colonoscopy without it, and have regretted it due to significant pain.

Note that they approved the colonoscopy, just not the anesthetic. Also, to get approval for a colonoscopy, one just needs to have persistent intestinal pain or note that they have a history of polyps.

chefandy2• 2 years ago

They found cancer in my colon during a follow-up for a ruptured appendix, several years before the age for recommended colonoscopies. I recently had one and asked they go light on the anesthesia, so I was in and out. They removed a polyp while I was awake and it was pretty uncomfortable. The idea that you shouldn’t even have that much anesthesia is insane. These people are morally bankrupt and frankly I don’t care what it takes to stop them.

Noumenon72• 2 years ago

You were not denied a colonoscopy, but anesthesia during a colonoscopy, which is not medically necessary[1]. Tough line to draw though.

1: https://www.mayoclinichealthsystem.org/hometown-health/speak....

MichaelZuo• 2 years ago

It does seem like the parent is confused.

I haven't heard of any jurisdiction where putting someone under for colonoscopies, outside of extreme cases, is the standard expectation.

Not even for fancy private hospitals, way too high of a risk-reward ratio.

OutOfHere7• 2 years ago

Sedation 100% is a medical necessity. Firstly, it hurts a lot without it. Secondly, if you need polyp removal, that's going to burn like hell.

timr4• 2 years ago

I was just denied a colonoscopy as not medically necessary by UHC, coincidentally three days before their CEO was killed, because they don't want me to have anesthesia to do it; they argue I should be awake.

It sounds like something is getting lost in translation. Presence or absence of anesthesia does not change the medical necessity of the procedure.

I'm 45. Colonoscopies are a thing. I had a friend die at 52 two years ago after he was diagnosed with stage IV during his first colonoscopy.

Without wading into the specifics of your situation, there's not great evidence justifying colonoscopy for normal people without family history at age 45. The USPSTF just kinda lowered the threshold based on crappy (pun not intended) observational data. And if you look at their recommendations, they actually don't recommend colonoscopy, specifically -- they just recommend "screening" [1] which includes FIT, DNA testing (again: not great evidence here), or flex sig, which is done without anesthesia, and all of which are cheaper than colonoscopy. It's a huge debate.

Anyway, I absolutely don't want to reflexively defend the health insurance industry in the US, but one the reasons we have skyrocketing health care costs in this country is because people are doing expensive procedures when cheaper ones would suffice.

[1] https://www.uspreventiveservicestaskforce.org/uspstf/recomme...

garciasn3• 2 years ago

My father's mother had it. My mother's father died of it early. I am predisposed.

seanmcdirmid4• 2 years ago

When my doctor recommended mine, she said that they could do screening but if they found anything, they would have to do a colonoscopy and then it wouldn’t just be covered as screening (since it was an incident rather than preventive at that point). She said it was better just to get the colonoscopy due to health insurer rules.

scarecrowbob• 2 years ago

"Anyway, I absolutely don't want to reflexively defend the health insurance industry in the US, but ..."

I am glad you are able to recognize behaviors that you don't like doing, as that's the first step in not doing them.

pnutjam3• 2 years ago

Did they give you an option to poop in a box? I went with that.

astura• 2 years ago

Cologuard?

itishappy2• 2 years ago

Occult blood stool sample? Colonoscopies are a lot more accurate. Something on the order of 50% vs 90%.

bufferoverflow• 2 years ago

I'm going to be a bit contrarian and say that drinking that awful liquid the evening before the procedure is 100x worse than not doing it with anesthesia. I did my colonoscopy without any anesthesia, and while it's not very pleasant, it's not painful, it's just a very weird sensation.

MiguelX4132• 2 years ago

False dilemma.

Invictus0• 2 years ago

Not saying this article is wrong but it is clearly written in a sensational style and does not belong on HN.

65• 2 years ago

The one sentence paragraph writing style drives me nuts.

toast03• 2 years ago

I think we need more thorough analysis. Are the denied claims denied in error? The appeals success rate probably indicates that most of the appealed denied claims were denied in error... but appealed claims are a biased sample of denied claims, so it doesn't tell us much about the overall denied claims.

In my experience, I've seen some denied claims, because the provider submitted a wrong code. Then the provider submits a new claim with the correct code and it goes through.

Given the proliferation of plans, and their sometimes conflicting requirements on medicial coding, I could see that being a big driver of denials increasing over time. As well as a driver of increased administrative costs for providers and insurance companies.

OutOfHere7• 2 years ago

That's just code gaming. It's not necessarily an error. Also, numerous legitimate legitimate claims are denied no matter their code.

toast03• 2 years ago

I don't doubt that numerous doubly legitimate claims are denied.

What I want is a sense of what the breakdown of the denied claims.

Ex: company sends a list of all denied claims. Auditor picks 100 randomly, gets the files for each and researches those denials to classify the denial as reasonable or not and whatever other categories apply.

timmytokyo• 2 years ago

"A key congressional committee asked insurance giant Cigna on Tuesday to provide corporate documents so that lawmakers can examine the company’s practice of denying health care claims without ever opening a patient file."

https://www.propublica.org/article/cigna-health-insurance-de...

adleyjulian2• 2 years ago

Some procedures are considered never medically necessary or only approved with prior authorization.

Acupuncture has a CPT code and can be billed; do you think a patients file is required to deny it?

Removing a skin tag is considered cosmetic unless it's causing significant issues or is suspected to be cancerous.

wat100007• 2 years ago

From the patient’s point of view, it all looks the same. Treatment that should be covered gets denied.

It sounds like the insurance companies have a strong incentive to make their coding and requirements as complicated as possible to increase the error rate so they can deny coverage. I don’t think they should get a pass for those denials.

dheera3• 2 years ago

Just leaving this here for reference:

In 2022 I was denied full insurance payment of a routine, preventative echocardiogram at Stanford Healthcare to monitor my heart issues. I was balance billed $5000+. The insurance company was HealthNet. The policy clearly indicated full coverage of preventative procedures, without a deductible. They said they did not recognize the procedure as preventative. Fuck them, I know better about what's preventative and what's not than them.

I argued the shit out of it, dozens of e-mails, hours of phone calls, and it was eventually sent to debt collectors. I wrote back to the debt collectors that it wasn't my debt and to stop contacting me. I reported it to a couple of government agencies as well to give them more headaches. I did not pay.

In 2024 it was written off as uncollectible.

(a) Use a virtual mailbox with your health provider so that they don't send debt collectors to your residence. Do not give them your residential address.

(b) Use a virtual phone number with your health provider so that the debt collectors can't call you. Their only option will be mail and that leaves a paper trail which you DO want. NEVER communicate with a debt collector by phone.

(c) Freeze your credit reports with all 3 bureaus so that they cannot use your mailing address to find your residential address.

(d) If they do somehow find your residential address, do NOT answer. Only communicate by mail.

Disclaimer: IANAL, account of personal experience only

AdmiralAsshat2• 2 years ago

That might have gotten them to stop bugging you, but I imagine your credit score still took a hit?

dheera3• 2 years ago

It didn't show up on my credit score at all.

I also wasn't too concerned about that because

(a) I believe medical debts don't affect credit scores for a long time.

(b) I believe medical debts are required to have complete erasure from a credit report if cleared so if I actually needed my credit score to buy a house or whatever I could take the $5K hit to restore the credit score at that time.

(c) I sent them a formal letter disputing the debt, which I assumed means they can't just take it to the credit agency, they'd have to go to court with me first. (Again IANAL, I don't know how accurate this is.) In any case I was mentally prepared to spend $10K on lawyers and court and give them a absolute hell of a time than pay $5K to pay for healthcare I shouldn't need to pay for. I made it VERY CLEAR to the debt collectors that I was ready to pay for lawyers.

(d) For the forseeable future I don't think I need my credit score for anything. I don't plan to borrow money.

foundart2• 2 years ago

Thanks for the tips.

I do have a question about one thing you said:

I know better about what's preventative and what's not than them.

How is that? From your profile I don't see any medical training.

dheera3• 2 years ago

The insurance companies don't have medical training either. I know far, far more about my body's medical situation than them.

Doctors and medical research may supply me with additional medical knowledge, but the insurance company can go to hell. They don't know a damn thing about any of this.

nradov11• 2 years ago

Under the Affordable Care Act (Obamacare), there is a very limited and specific definition of preventive care services which health plans are required to cover. An echocardiogram is not on the list.

https://www.healthcare.gov/coverage/preventive-care-benefits...

In your particular case it might have been medically necessary, but not legally classified as preventive. This is a huge hassle for patients because the nuances aren't obvious or clearly documented. It's likely that Stanford Healthcare erred by failing to obtain the necessary prior authorization from HealthNet before performing the procedure.

Since 2022 there are some legal protections against balance billing. Although those might not have helped in your case.

https://www.cms.gov/newsroom/fact-sheets/no-surprises-unders...

Miner49er• 2 years ago

It shouldn't even be legal for health insurance providers to deny claims. It's essentially them practicing medicine without a license, because they're making calls about what healthcare a person needs or doesn't need, only a person's doctor(s) should be able to make those decisions.

kstrauser8• 2 years ago

That’s the crux of it. I didn’t visit with any of my insurer’s staff, like I did with my own doctor. How are they making treatment decisions without ever having seen the patient?

dboreham• 2 years ago

Otoh some medical providers like to over bill and over treat.

drewbug01• 2 years ago

Otoh some medical providers like to over bill and over treat.

This is true to some extent, but the share of medical providers that over-bill and over-treat really doesn't justify the way the insurance industry does business. It's a false equivalence.

kstrauser8• 2 years ago

Crack down on them, but don’t use it to justify denying healthcare to patients.

harimau7773• 2 years ago

It seems to me that should then be handled by the legal system or perhaps the licensing boards. That is to say, the insurance companies should be forbidden from denying coverage and if they believe that something is going on then they can alert the police or take the doctor to court.

ubnvfft• 2 years ago

Stop speciously muddying the waters by either intentionally or accidentally making spurious arguments for these unethical sociopaths.

I’ve seen this argument made on this website a lot, and it always conveniently omits the vertical integration of these insurers wherein they are the providers too.

The DOJ is literally, actively, suing to block a merger between united healthcare and a provider.

https://www.justice.gov/opa/pr/justice-department-sues-block...

fny2• 2 years ago

Yes, insurance companies deny claims, but this is mostly because they don't have the money to pay for things most of their money is spent on care in the first place: they're forced to optimize and people get hurt in the process. Providers do far more damage.

UHCs profit margins are only 6%, their operating costs are extremely low[0], and if you look across G7 insurers in the US pay more than the government does in every country but France![1] Compare this to HCA which makes an average margin of 10% with far higher administrative costs. The CEO of HCA makes $20M, Brian Thompson made $10M by contrast.

This is not to say we (and insurance companies) don't spend astronomically more than other countries: providers are to blame for this, and I have seen their nonsense first hand:

- They keep people alive overnight to charge insurance more

- Some hospitals use ML (!) to optimize ICD codes for billing. Most do this by hand: there's literally a job and training to be an ICD coder.

- They allow people to deteriorate (e.g. dialysis) to charge more (no preventative care.) I have seen a hospital only provide preemptive care to patients at risk of dialysis because they were part of their own insurance pool

- Their administraive expenses are far higher.

- They test and provide unnecessary care.

- Physician shortage is in part caused by limited residency spots, a dumb bachelors requirement, and high tuition costs. These barriers to entry are imposed by physicians.

- Uneccesary tech and equipment upgrades (e.g. we need to replace your knee with a new knee)

- Having to deal with tons of different insurance companies: not their fault but they don't know how to handle this efficiently.

[0] https://www.reddit.com/r/dataisbeautiful/comments/194wucn/oc...

[1] https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_pr...

mancerayder3• 2 years ago

Yes, but in my opinion it falls to the patient to figure out the details and absorb the risk. That's the messed up part. That insurance providers and medical services might disagree on pricing or whatnot is an inevitability. What's not fair is throwing ordinary people under the bus to deal with it, which for many reasons is risky and can ruin lives.

DennisP2• 2 years ago

Agreed. France, Germany, and Japan have health systems similar to the ACA, with the following differences: insurance is nonprofit with an effective mandate, there's a national price list for medical services, and claim denials are prohibited for anything on the list. Germany has an especially effective digital system that guarantees payment within a week.

All three systems get better health results than the US, by measures like survival time after diagnosis of major disease. And all three spend a significantly lower percentage of their GDP on healthcare.

Source: The Healing of America by T.R. Reid.

nradov11• 2 years ago

The other side of that is that some expensive services and drugs are simply unavailable in other countries, or are very tightly rationed. The USA has higher 5-year survival rates for most types of cancer than France, Germany, and Japan. I'm not saying that the US system is better overall, but it does do some things extremely well. We should make sure that any reforms don't sacrifice our unique advantages.

https://doi.org/10.1016/S0140-6736(17)33326-3

josh_cutler• 2 years ago

All large health insurers employ many physicians. You're not wrong that they may not have all of the evidence but there is a lot of licensed medical knowledge available to all Payors.

ASalazarMX• 2 years ago

I'm glad to see this phrased this way, because that was something I felt but hadn't articulated consciously. It's literally private accountants making healthcare decisions.

refurb7• 2 years ago

This makes no sense.

Plenty of healthcare is not covered by insurance. Cosmetic procedures are healthcare and not covered.

Not to mention errors in claims, claims that include care well outside guidelines, etc.

You’d expect a pretty consistent level of denials even if all medically necessary claims are approved.

drweevil2• 2 years ago

"An appeal means coaxing your doctor and staff to spend hours filling out forms and making repeated phone calls to joust with an insurance company employee."

The hospital where I receive my cancer treatments once told me "don't worry, our Denial Team is handling this."

They have a Denial Team. That is to say, insurance companies are imposing cost overheads on providers and patients due to their illegitimate profit boosting tactics. And our government can't be bothered to enforce the ACA's basic requirement to track and report denial rates.

"No industry malfeasance could ever excuse murder.

"Period."

And yet, that's what it took for our media to start reporting on this? We have some real problems in this country, and a corporate news media asleep at the switch, or at worst complicit, is one of the most serious.

dogboat2• 2 years ago

"industry malfeasance" is 1984-esque lanuage.

IED airbags, HIV injections, babies without limbs, etc. are industry malfesance.

So the phrase implies:

No acts of corporate greed including profiting by killing people could ever excuse murder.

codegeek2• 2 years ago

My solution to this mess:

- Health "Insurance" middleman mafia should not be the default b/w me and my doctor - Health Insurance should only exisit for Catastrophic events (big surgery, cancer etc) - Get rid of the regular Premiums, CoPays, Deductible, CoInsurnace, In network/Out network Bullshit. - For catastrophic events, we pay a premium (much smaller than now) - All hospitals and Doctors must offer an advertised/displayed Cash Price. No exceptions. Fine heavily if they hide - Let me pay cash for a regular doc visit. - Govt can subsidize for poor people (exdtension to medicare etc ??)

That's it. Problem Solved. This will remove so much BS, middleman stuff, overhead and with a competitive market, prices will drop significantly. Doctors will be happy not dealing with Insurance for everything.

Tell me why I am wrong.

__m• 2 years ago

People will probably avoid going to the doctor if they have to pay cash, missing the opportunity to detect the big things early.

codegeek2• 2 years ago

I would argue that people already dread going to the doctor because you still have to deal with all the insurance garbage. Remember that even with a copay, you still could get a bill after the visit depending on deductible.

i_love_retros• 2 years ago

How do we stop this?

lapcat3• 2 years ago

Worth noting: neither major Presidential candidate, nor the news media, made health care a focus of the recent election. The issue was almost ignored. And neither major political party offers much: the Democratic establishment will defend the Affordable Care Act to the death (literally in this case), despite the fact that it's not particularly affordable, becoming more unaffordable over time, and it continues to enshrine and subsizide the ruthless for-profit insurance companies. On the other hand, the Republicans paint any kind of government involvement in health care as "Communist", despite the fact that the entire rest of the civilized world have more efficient, effective, and compassionate health care systems heavily regulated by the government.

I think it's a sign of deep American corruption that we can't even have this public debate without a salacious murder occurring.

lofenfew• 2 years ago

The affordable care act is the most reasonable path from the current american system to a system on par with other first world countries. This especially given the sort of republican opposition it's liable to face. It's current form is due in substantial part to the republicans gutting it, so you can't really blame the dems for it not working very well.

lapcat3• 2 years ago

The Affordable Care Act received precisely zero Republican votes in Congress. It was entirely a Democratic product.

onionisafruit• 2 years ago

She says that you can’t find denial rates for specific providers then she gives denial rates for specific providers. I’m not sure if she cited a source. I’m curious where her data comes from.

amarcheschi4• 2 years ago

I don't know what happened but this super duper upvoted post disappeared from the home of hn. perhaps moderators temporarily shadow content that is upvoted too much? Or else?

techdmn• 2 years ago

Also curious about this. Several other posts of similar age and with fewer points are in top spots on the front page. This post is still gathering comments, but seems to be hidden.

siliconc0w• 2 years ago

We should just have single payer if we have to constantly police these companies.

foundart2• 2 years ago

This is an opinion piece. Its main claim is that the ACA requires denial rates to be available to consumers but they aren't.

Additionally, it reports that denial rates have increased 10x in 10 years, based on the following chain:

- "UnitedHealthcare nixed 1.1%, Humana 1.9%, Aetna 1.5% in 2013, per the American Medical Association."

- "By 2022, major insurers were refusing to pay, on average, 15% of claims, according to a national survey of hospitals and health-care providers by Premier, an insurance consultant."

- "The figure continues to shoot upward, with some companies today denying almost _half_ of all claims, according to researchers at the Kaiser Family Foundation."

Furthermore, "few people appeal, but of those that do 41% obtain a reversal", which suggests the denials may be unfair.

I certainly would like to know the denial rates when selecting an insurance provider. As the article says, "You aren't really insured if your insurer can deny valid claims with impunity."

Given that the ACA requires this information be provided, it certainly ought to be provided. Then we'd have a much clearer picture.

It's an opinion piece on a news site known for inflammatory articles but it reports some interesting information. It would be much nicer if it included references to the research it's based on, but it seems pretty reasonable to me.

leereeves• 2 years ago

Excellent summary. I'd like to address the denials in particular.

As the article says: "No industry malfeasance could ever excuse murder."

With that in mind, we should remember that every death that happens because a valid lifesaving claim was denied is a kind of murder, and no amount of fraud could ever excuse denying valid lifesaving claims.

The stakes are too high: all claims should be approved, then adjudicated later. Fraud should of course be punished severely (with prison, not merely returning the money), but no one should die to protect insurance companies from fraud.

nradov11• 2 years ago

I think you're mixing up terminology here. When a claim is submitted the care (lifesaving or otherwise) was already delivered. You might be thinking of prior authorization, where a provider asks an insurer for advance approval before delivering care. If a payer denies a prior authorization request then some providers will refuse to deliver care unless the patient has another form of payment.

Fraud is only a small part of the systemic problems. There is an enormous amount of waste and abuse by providers who deliver treatments that are ineffective or unnecessary or excessively expensive. The dominant fee-for-service financial model incentivizes over treatment. We can argue about where to draw the line but payers (whether commercial or government) have to push back on this to keep the system from collapsing. Healthcare is already ~20% of the US economy. It can't continue expanding, we simply don't have the resources to pay any more. Every other country rations care in some way; no country delivers unlimited lifesaving care to everyone.

https://peterattiamd.com/saumsutaria/

https://www.npr.org/sections/health-shots/2019/10/22/7673763...

johnohara• 2 years ago

In December 2021, the American Hospital Association issued the following statement regarding United Healthcare's plans to closely scrutinize medical claims for ER visits. [0]

UHC subsequently reversed itself and delayed the plan for 6 months. That was in 2021-2022. It's now 2024-2025.

Around that time many insurers, not just UHC, began implementing AI-assisted claims adjudication. It was a bumpy ride with a steep learning curve and probably took a couple of years to fine-tune the algorithms and learning models.

Especially as the Covid-19 claims tsunami subsides.

No matter tho', every claim paid is considered a loss by insurers. Every claim denied is considered a small step towards mitigating those losses.

In the U.S., medical reimbursement is a push and shove, shove and push battle fought inch by inch with high-speed data systems. It has been that way for a long time.

[0] https://www.aha.org/special-bulletin/2021-12-29-aha-expresse...

nradov11• 2 years ago

That's simply not how the system works. For the most part, medical insurers no longer provide much real "insurance" in the sense of bearing risk. Instead they mostly act as administrators for employer self-funded health plans. Since insurers are subject to an 85% minimum medical loss ratio, every paid claim is actually a gain because they get to take up to 15% from a larger revenue stream. The majority of the pressure to tighten coverage rules actually comes from those large employers since they're the ones ultimately paying the bills.

https://www.cms.gov/marketplace/private-health-insurance/med...

If anyone wants to see real reform then eliminating employer sponsored health plans is one potential way to get the incentives more properly aligned.

ethbr15• 2 years ago

There's an easy solution to this that the Federal Employee Program (aka FEP) [0] uses -- regular, external accuracy audits.

The relevant metric to customers isn't "What percentage of claims are denied?" given the substantial amounts of medical claim fraud.

It's "What percentage of claims are denied... that should have been approved?"

So you regularly audit a random sampling of denials, publish the results of that audit transparently, and provide a financial incentive for insurers to keep their numbers below a certain threshold.

It's worked pretty well for FEP -- to the extent that FEP insurers typically have segregated operations from the rest of the company and do much better on denial accuracy and other metrics.

[0] https://en.m.wikipedia.org/wiki/Federal_Employees_Health_Ben...

adleyjulian2• 2 years ago

It's a question of what we want to measure. There's a metric that represents how much a claimant sees in unexpected costs due to denied claims vs impact on care from the insurer.

A denied prior auth results in no unexpected costs but perhaps a change or delay in care.

A denied claim to an in network hospital may result in the provider losing revenue but nothing for the claimant.

Eddy_Viscosity22• 2 years ago

The auditors would either be captured or rendered powerless in short order. There is a great deal of money that can be used for effective lobbying.

ethbr15• 2 years ago

Hasn't in the FEP program. Mostly because there's no incentive: doing so helps your competitors as much as you. And it's more profitable to invest those dollars in hitting KPIs.

SauciestGNU7• 2 years ago

Wrongful care denial should be considered a serious felony on par with assault with intent to do grave bodily harm. It should be a veil piercing crime that exposes every insurance company employee involved in denial to personal legal jeopardy should they wrongly deny claims. Reasons for denials must should be required to be extremely detailed and provided to the institutions requesting coverage. Upon receiving a denial, the health care institution should be able to evaluate the denial for validity and choose to refer the denial to local prosecuting attorneys if the denial is medically unsound.

consteval5• 2 years ago

These "bolt on" type of solutions work but they also raise the costs. Already the administration costs of insurance are through the roof. The system is as inefficient as humanly possible. Hospitals needs hundreds of administrators and billing specialists just to make insurance work - never mind the patient and doctor time lost.

And now, we also pay to audit insurance? It's too much money burning.

This shouldn't be done by the private sector, period. The reason our costs are so insanely high is because of insurance the sheer inefficiency it brings to care.

ethbr15• 2 years ago

Do you have a source for the administrative costs being larger than they could/should be?

Obviously they'd be lower with single payer, especially on the provider side, but outside of that the system runs pretty efficiently for what it is.

On the provider side, they're going to have to code up a claim.

But once they're submitted, the majority of claims automatically flow through the rest of the system with low human touch.

That's literally the only way insurance companies can function under ACA admin cost caps.

When that generates a denial... then obviously there's a lot more touch during the back and forth.

mancerayder3• 2 years ago

Let the health insurance companies deny claims. But then let the medical providers duke it out behind the scenes! Leave patients alone and don't send them bills six months later.

refurb7• 2 years ago

This is actually key.

The problem today is the insurers, hospitals and doctors put the patients at the center of the fight.

Insurance denied? You pay patient.

Insurance didn’t pay doctor enough? You pay patient.

Hospital not in network? You pay patient.

I think patients would see it as an improvement if hospital said upfront to go somewhere else as insurance won’t pay. If they knew insurance would pay at the right hospital than it would be better than today’s situation.

dogboat2• 2 years ago

Assuming you are a coder lets see how that works for you..

Someone comes to you saying they need a website. You say "absolutely ... clearly you need one!". So you build it.

The decision to pay you however comes from some 3rd party who says "denied". Now the customer keeps their site and you don't get paid.

Will you stay in this coding business?

The real solution is a public health system. Which has issues (apply queuing theory, because you will have to wait for the limited resources you are niw denied) overall it is better though since it can in theory be optimized as a whole.

antisthenes3• 2 years ago

They deny claims. I deny paying my medical bills.

benterix• 2 years ago

It's insane that someone needs to die for a serious discussion about it to take place.

caeril• 2 years ago

Denial policy should be very very simple:

If you're seeking coverage for lung cancer, but you chose to smoke, denied.

If you're seeking coverage for type II diabetes, but you weigh 400lbs, denied.

If you're seeking coverage for cancer because you got unlucky with a cosmic ray incident on your DNA, approved.

If you're seeking coverage for a liver transplant because you refused to put down the bottle, denied.

If you're seeking coverage for injuries from an auto accident that was not your fault, approved.

I will NEVER understand why this type of blanket policy is so controversial. Cover bad luck, do NOT cover personal choices. It will fix not only costs, but the moral hazard endemic to the current system.

Or, AT THE VERY LEAST, allow prejudicial adjustments to premiums for fatties, smokers, and alcoholics.

byecancer21• 2 years ago

The German state is also helping public health insurers hide their dirty secret: in hundreds of thousands of cases, denials were legally flawed and the cases have to be reviewed. They refuse to do so on the behest of politics as a small number of cases will turn out to be intentionally negligent homicides caused by public officials.

A site properly presenting the facts is due for launch in the lead up to Germany's upcoming federal election. Until then, you can find a teaser here:

https://de.wickepedia.org

Any claim related to outpatient treatment which outside the ordinary requires prior approval there. You cannot opt to pay in advance and seek reimbursement later.

In the state of Bavaria the doctors at a government agency have been practicing without a medical license going back many years because their supervisor let this slide. I discovered her problem randomly in the course of litigation and it impacts probably a million case.

The person responsible for her staff of hundreds lacking a current medical license was later hired to lead the qualifications department at the medical board. That is, after I got her fired from her position and then from a job at a hospital (a felonious psychologist is unacceptable risk for patients). Politics would prefer to see her problem covered up.

beej71• 2 years ago

Do these numbers include denials when a provider bills more than the negotiated rate? I see this happen all the time with my insurer.

EasyMark• 2 years ago

One thing that will help greatly is to regulate hospitals into having an umbrella of "services" that allows "private" operators BUT those operators have to be covered by any insurance that wants to work with the hospital rather than these 3 nurses in one pay center, this surgeon in another, assistant surgeons in a third, and the anesthesiologist so far out of network he laughs and isn't part of any HMO, PPO or anything else.

Feds help health insurers hide their dirty secret: denials on the rise

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