- 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.
- 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:
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.
- 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...
- 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.
- 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...
- 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.
- 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.
- 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.
- 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.
- "No industry malfeasance could ever excuse murder."
AND YET
- That has to be the worst kept dirty secret in the history of dirty secrets.
- It's insane that someone needs to die for a serious discussion about it to take place.
- 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.
- >"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.
- 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.
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- Do these numbers include denials when a provider bills more than the negotiated rate? I see this happen all the time with my insurer.
- 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.
- They deny claims. I deny paying my medical bills.
- Not saying this article is wrong but it is clearly written in a sensational style and does not belong on HN.
- 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
- We should just have single payer if we have to constantly police these companies.
- IDK. What puzzles me here is that a NYPost article can be trending on HN.
- How do we stop this?
- 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.
- "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.)
- It's time the US realizes how bad its medical system is.
- 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?
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