
A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims - fern12
https://splinternews.com/a-glimpse-into-the-bureaucratic-hell-of-denying-health-1823560356
======
tptacek
If you're a tech entrepreneur, it's the first story in here that should alarm
you the most. It's about denying coverage altogether, not about denying
individual claims. Outside of the "guaranteed issue" ACA market, there is
virtually no due process for coverage denial. You can be denied on a whim,
with little recourse.

The list of conditions for which insurance outside the ACA will be denied is
long and opaque. The story makes it sound as if they're looking for reliably
diagnosed conditions like diabetes. No. They're looking for _indicators_ of a
long list of _potential_ conditions. If you or your spouse has a functioning
female reproductive system, the chance of your family being denied is high,
even without a diagnosed or treated condition. We were denied for something
like that, and also because my daughter had an unexplained seizure when she
was 4 (she's now 16 and just fine). To get insurance for the first couple
years of Matasano, my wife had to take a crappy full-time job with group
coverage.

Without insurance, a typical working family is one major medical incident away
from zeroing themselves out. My daughter has never met a pickleball net that
didn't break her ankle (she has met one pickleball net). Even with insurance,
the cost of that injury was high single-digit thousands of dollars. Without
it? The cost of a pretty decent car. Find a friend who's had an appendectomy
some time and try to find out how much the insurance company was (nominally)
billed for it. A down payment on a house.

If you work in this industry, intend ever to start your own business and
potentially have a family at the same time, you should be extremely alarmed at
the prospect of guaranteed issue regulated health insurance (the ACA) being
replaced.

~~~
mobilefriendly
ACA is horrendous, unless you're receiving a government subsidy. I'm self-
employed and we have one option of insurance provider, and the cheapest plan
for my family last year was $18,000 a year with a huge deductible. That's
after tax, out of pocket, for a healthy family with no pre-existing. Like all
self-employed people I know (who aren't getting government subsidy), I moved
my family to Christian Medishare, which is basically catastrophic coverage for
about $3,000 year that was grandfathered in when Obamacare was passed. However
it isn't truly insurance, it isn't regulated for soundness. I'm seriously
considering returning to wage employment for health care benefits.

~~~
tptacek
The rate of increase for health insurance prices went _down_ after the ACA was
enacted. The motivation for enacting the ACA was, in large part, the untenable
increase in insurance prices in the 10 years leading up to it.

People have a bad habit of blaming the ACA for insurance prices. The ACA
failed at its goal of making individual health insurance affordable, that is
true. But it didn't _cause_ that problem, and it did something extremely
important to mitigate it.

~~~
ethagknight
Health insurance for my healthy young family of 4 spiraled out of control WITH
ACA, so much so that I didn’t purchase proper health insurance in 2017, while
also underfunding my income tax in hopes that ACA cannot legally “send me a
bill” for 2.5% of my household income. (I mean shit, in a red blooded
patriotic American, but that penalty made me absolutely furious) All this
while paying cash for prenatal visits for our next child, still far cheaper
than paying for a $15,000/yr policy + 15,000/yr deductible. In my decade of
buying family insurance, I watched my family policy increase by nearly
$1000/mo combined with a staggering decrease in value provided via super high
deductible... oh, and no legal way out.

I know ACA is good for some, but goodness did it remove my interest in
remaining insured. I’m sure you can cite data that tells a different story,
but my experience, as well as that of my peers, says ACA has been very bad for
those actually paying the bill unsubsidized. I fully blame ACA for this.

~~~
tptacek
You have a young family of four, and can barely afford insurance premiums.
Basically, without insurance, every single year you're hitting on a blackjack
17 against bankruptcy. You see the ACA penalty, and you see the insurance
premium cost, but you're not factoring in the 5-digit cost of virtually any
significant medical expense.

 _Rising insurance premiums_ aren't good for anyone. The ACA set out to fix
the problem of rising insurance premiums and (I think) pretty much failed. But
it didn't _create_ that problem; 5-digit annual premiums for a family of four
were a reality prior to the ACA --- or, at least, they were in Chicago on the
small group market.

The subtext to these discussions though is whether we'd be better off without
the ACA. No, we would not be. We would lose guaranteed-issue insurance, so a
sizable fraction of families wouldn't be able to get insurance at all, and,
from the available evidence, we would _at least_ have the same rate problems
we have now, and (according to some studies) have _worse_ rates. Obviously,
this subtext is about the GOP's health care rhetoric, and I'm not wild about
opening up a political salient in this thread, but let's at least be clear:
the idea that you can repeal the ACA, do nothing else, and get lower health
insurance premiums for real coverage is sleight of hand.

~~~
whatshisface
If enough people didn't have access to insurance, then there would be pressure
on hospitals to find ways to reduce prices (so that their volume could go up).
As it stands the medical industry is allowed to hold the poor for ransom
("accept our increased costs or they won't get treated") against the US's deep
but finite pockets.

Before, we had the (very poor) demand elasticity of people paying everything
they had and then maxing out every credit source, and predictably prices rose
to around that point. Now, we have no demand elasticity at all, and prices can
be expected to rise well above the average person's net worth + credit access.

If you look at any microeconomic equilibrium chart, you'll see that the price
is held in a balance between people buying and people holding off due to
price. When the good is healthcare, the human cost of "holding off" is very
high, and usually involves inability to pay. Unfortunately our economic system
tends to fly off the rails if this balance is disrupted, no matter how noble
or urgent the cause.

~~~
komali2
>pressure on hospitals to reduce prices

Elsewhere it has been said: choosing between bankruptcy for your family or
cancer care for your child isn't an actual choice, it's two loaded guns
pointed at your skull. One held by the hospital, the other by the insurance
company.

The reason first world countries choose universal healthcare is that
healthcare is a human right. Full stop. It is not an economic issue. If you
want to get economic about it though you'll lose because as it turns out a
healthy educated populace is more productive than one that loses productive
families here and there to lances of bankruptcy from the unpredictable nest of
human disease.

~~~
AFNobody
I'm not sure its fair to argue that universal healthcare is a human right
despite the fact it makes economic sense.

Humanity survived just fine without real healthcare and healthcare is not
essential to a fair balance of power b/t the government and its citizenry.

Universal healthcare needs to be argued on the economics of the issue because
that is the only practical way to make it sustainable. The "feel good" stuff
about it being a human right will fail when stress is applied to America and
stress is coming. The US, frankly, has peaked and it is all downhill from
here.

~~~
whatshisface
You also have to watch out that asserting positive rights that are sometimes
impossible to provide (like healthcare) will confuse people when governments
attempt to claim that other, deeper rights are "impossible to give." (For
example, they might try to argue that they can't afford to not torture,
comparing it to how their impoverished country can't give everyone free
internet.)

~~~
dragonwriter
As anyone who lived through the more recent Bush Administration witnessed
nearly daily, people claim “not torturing” is an impossible right to give
while denying all positive rights—and acted on that argument—so I fail to see
the relationship.

~~~
whatshisface
Denying every right is the _last_ step of the manuver I'm describing, the
first step is to re-define right to mean comfort. Bush-era politics just went
straight to step 2 and it didn't work on us.

I suspect that the current UN rights council may be an example of this in
action. See: the track record of the members on negative rights, the number of
positive rights on their list of rights.

------
aaavl2821
This is a good article, but it only shows a few parts of a much more complex
whole, and extrapolating from these anecdotes to a broader system is not
really accurate

Many hospitals lose money on every Medicare and Medicaid patient. The only
reason they survive is because they can charge private insurance companies
more. So hospitals and health systems have been consolidating to strengthen
their negotiating position against insurers

This article paints Medicare as the good guy, private insurance as evil, and
hospitals as mixed. The reality is more complicated, and more regional, but
overall healthcare is a zero sum game today between payers and providers
fighting for dollars, and power comes largely from scale. In geographies where
payers are bigger and stronger, they push hospitals and force many to
consolidate or die. In areas where hospitals are stronger, they basically
dictate price and rates can skyrocket

There's a lot of bad stuff happening on all sides, and it isn't clear that
private insurance is always evil. If we become a single payer society, small
providers that are struggling to survive will probably be the first to die,
and providers will probably consolidate much more aggressively into massive
national chains, like the Walmart of healthcare

The cause of a lot of healthcare issues is not one particular party
(insurance, Medicare, hospitals) but a system that encourages monopoly seeking
behavior without any good mechanism for regulating this

~~~
maxerickson
I think it'd be a good sport to make hospitals eat denied claims. If two giant
institutions want to argue about whether something is covered, the patient
should not be the loser.

We should also better fund Medicare and Medicaid. Taxes should be apparent.

~~~
Spooky23
It’s more complex. Medicare is outcome-based. Providers who do a shitty job
don’t get paid, which is why hospitals complain about reimbursement.

Medicaid is like an ATM machine for providers in many states. There is usually
little or no correlation between outcome and payment, and poor fraud controls.
That’s why you always hear about providers in NYC and Miami who “visit” 900
patients a day. Additionally, you have the institutional racism aspect of
Medicaid where services are unavailable in some red states.

IMO, the biggest issues in healthcare are for profit institutions and insurers
and the trade guild practices associated with Doctors.

Single payer or regional systems supported by taxes are the way to go.
Medicaid should be an institution that is replaced by something better.

~~~
ianai
The market would work better if everyone was paying the same prices without
"denial-based" inflation.

I think the solution would be to give citizens disease/disorder "endowments."
i.e. a yearly health stipend account - it's money they can spend at doctors,
but they can't spend on unrelated goods/services (i.e. food). On top of that,
additional "stipends" for major life ailments. The trick would be in finding
budgets for those stipends. Once individuals have money, though, they have the
ability to do the relative value assessment for various treatments.

~~~
snaily
You may want to read up on Singapore's Central Provident Fund system, as a
real-life implementation of something similar:
[https://en.wikipedia.org/wiki/Central_Provident_Fund](https://en.wikipedia.org/wiki/Central_Provident_Fund)

------
downandout
This story is couched in terms of how bad things were _before_ Obamacare, but
I’d like to point out that things aren’t great now either. To prevent
Obamacare from bankrupting them, insurance companies are resorting to legally
dubious mass-denials, one of which affected me personally.

A few months ago, I woke up the next morning after eating some fast food and
began vomiting. I couldn’t stop throwing up, and I couldn’t eat anything, for
2 straight days. I had a 101 degree fever at the worst point. At the beginning
of day 3, when I vomited so hard that I passed out for a few seconds and fell
on the floor, I went to the ER. They gave me IV fluids and anti-nausea
medication, which worked.

About 2 months later, I received a letter from my insurance company (Anthem).
They had determined that my situation didn’t qualify as an “emergency,” and
therefore they were denying the entire bill for this ER visit. I have
appealed, and so far it has not been overturned. I am now on the hook for
thousands of dollars, even though I had already covered my entire deductible
for the year.

I thought that this had to simply be a mistake, but then I learned this is
actually a new policy that insurance companies are implementing in the era of
Obamacare [1]. Patients are expected to self-diagnose whether or not their
situation meets their insurance company's definition of an “emergency,” and
are rolling the dice as to whether or not an ER visit will be covered.

[1] [https://www.vox.com/policy-and-
politics/2018/1/29/16906558/a...](https://www.vox.com/policy-and-
politics/2018/1/29/16906558/anthem-emergency-room-coverage-denials-
inappropriate)

~~~
magicalist
> _To prevent Obamacare from bankrupting them, insurance companies are
> resorting to legally dubious mass-denials, one of which affected me
> personally._

What does the policy has to do with Obamacare? Completely unfair denials
obviously happened before the ACA (see: this article), and the idea that
Anthem is doing this to stave off bankruptcy is laughable (just see their
financials since the ACA was enacted).

~~~
downandout
It seems to be happening more and more post-Obamacare. Further, this is an
actual policy now, and this policy was created post-Obamacare (my incident
occurred in Nevada, where they have not received permission to deny these
claims like they have in other states, so apparently they feel the need to
roll it out nationwide without telling anyone). There was no need for the
policy before, but now apparently there is in an Obamacare world. But they
can't expect people to diagnose themselves and determine whether or not a
situation is an "emergency" under insurance company rules, since the symptoms
of many non-life threatening conditions feel like they may be life
threatening.

Unfortunately, in capitalist economies, when you use the law to put the hurt
on companies, they will pass that hurt onto unsuspecting consumers. The money
will come from somewhere, and it's not coming out of executives' pockets.
Perhaps this is why Nancy Pelosi urged lawmakers and the public not to read
Affordable Care Act before it was passed it into law [1]. Had everyone read
it, they would have known that problems like this would eventually arise.

[1]
[https://www.youtube.com/watch?v=hV-05TLiiLU](https://www.youtube.com/watch?v=hV-05TLiiLU)

------
maxxxxx
It's hard to believe that the country is putting up with a system that can
bankrupt you any time you get sick and there is pretty much nothing you can do
other than being lucky or having a lot of money already. The actual medical
care is fine but the billing practices are just ridiculous. I would call them
fraudulent in a lot of cases.

~~~
ModernMech
Is it really hard to believe though? The ones who are lucky and have the money
are fine with the situation. The unlucky ones with no money are too busy
fighting diseases, insurance companies, and bill collectors, they don't have
time to change the system. Dealing with insurance when you have a serious
illness is a full time job. The people who need change most are literally
fighting for their lives. Meanwhile, healthy people in America think "Gee, why
should I have to use my money to pay for someone else's healthcare? What do I
get out of it? I'm rich and lucky after all".

The richest don't even understand what health insurance is as a concept. I
mean, just look at what our own President Billionaire has to say: "Because you
are basically saying from the moment the insurance, you're 21 years old, you
start working and you're paying $12 a year for insurance, and by the time
you're 70, you get a nice plan." [1] What does that even mean? Or our Speaker
of the House: "The whole idea of Obamacare is...the people who are healthy pay
for the...sick. It's not working, & that's why it's in a death spiral" [2].
That's literally the entire point of health insurance. This is what we're
dealing with here.

[1] [https://www.cnbc.com/2017/07/20/trump-thinks-young-people-
pa...](https://www.cnbc.com/2017/07/20/trump-thinks-young-people-pay-12-for-
health-insurance.html) [2]
[https://www.washingtonpost.com/news/politics/wp/2017/03/09/e...](https://www.washingtonpost.com/news/politics/wp/2017/03/09/either-
paul-ryan-doesnt-understand-insurance-or-you-dont-understand-paul-ryan/)

~~~
maxxxxx
"The whole idea of Obamacare is...the people who are healthy pay for
the...sick"

This is the whole point of health insurance! What a stupid idiot (I am overly
nice to Paul Ryan. His budget plan was the most ridiculous thing I have ever
read).

~~~
powera
That is the whole point of _socialized medicine_. The point of _insurance_ is
that you pay slightly more than the expected value of your claims. So if you
know you need $5000 worth of medical treatment for asthma, your insurance
premium should be definitely more than $5000.

This bizarre obsession with using the phrase "insurance" and insisting on a
product that is not at all insurance is probably why the US health-care system
is so fucked.

~~~
ModernMech
> That is the whole point of socialized medicine. The point of insurance is
> that you pay slightly more than the expected value of your claims. So if you
> know you need $5000 worth of medical treatment for asthma, your insurance
> premium should be definitely more than $5000.

How does that make sense? If I knew I needed $5000 worth of medical treatment
for asthma, and I pay an appropriate premium based on that, but then I get
cancer..... well then someone else is going to have to pay for that, because
my premiums certainly won't cover the cost of cancer treatment.

~~~
twoodfin
You’d pay the 99% chance of asthma * $5,000 + 1% chance of cancer * $50,000
(or whatever the probability you get cancer * the estimate of cancer treatment
costs).

If you do get cancer, the other 99% of folks who didn’t get it are covering
your costs.

~~~
ModernMech
> If you do get cancer, the other 99% of folks who didn’t get it are covering
> your costs.

This is exactly my point, but it's this mechanism Paul Ryan said wasn't
working. @powera claimed this is not the point of insurance. These things seem
like exactly the same thing to me, so help me understand the nuance.

~~~
twoodfin
It’s the asthma for which you are near-guaranteed to need $5,000 worth of
treatment for that’s the issue, not the small chance you get cancer.

You’re not looking to insure against the chance you get asthma: You have
asthma, and you’re looking for someone healthy to help pay for it. If too few
healthy people sign up for Obamacare relative to the sick (and remember, all
else equal, they have to be charged the same regardless of their health) those
healthy folks will get an increasingly bad deal as their premiums are covering
the costs of more and more sick enrollees and more and more healthy folk drop
out of the exchanges. That’s the “death spiral”.

------
sykh
Every health care system rations care since no current system has enough
resources to care for everyone without some form of waiting. The U.S. health
care system rations care in the most immoral way of the advanced nations. A
person should not profit by denying care to someone else.

As a nation we should try optimizing for a more moral, just system. As I see
it that would be something like Medicare for all but I'm open to
suggestions/solutions.

~~~
pg_bot
There is no silver bullet in health care. The field is too large for any one
single solution to cover everyone (3 Trillion USD per year is spent on health
care). There needs to be a lot of innovation in a lot of different areas in
order to solve the problem.

I started a company with my brother that is attempting to drastically lower
costs for primary care. ([https://scalpel.com](https://scalpel.com)) We build
software that allows physicians to set up their own direct primary care
clinics. Our beta clinic in South Carolina charges $49 / month for unlimited
visits and charges people at cost for things like labs and procedures. So
instead of dealing with a labyrinthine medical system people are just working
directly with a doctor. We really only care about making money off our
memberships which we charge what we believe is a reasonable amount.

~~~
bbddg
I think there's plenty of room for innovation but we should start from the
principal that everyone gets full access to medical treatment regardless of
their ability to pay.

~~~
pg_bot
We technically have this in the United States (for emergencies). It is illegal
for someone to be denied emergency services regardless of ability to pay.[0]
No government system guarantees "full access" to medical treatment there is
some form of rationing everywhere.

[https://www.cms.gov/Regulations-and-
Guidance/Legislation/EMT...](https://www.cms.gov/Regulations-and-
Guidance/Legislation/EMTALA/index.html?redirect=/EMTALA/)

~~~
sykh
Emergency rooms are required to stabilize a patient, not treat them or cure
them. This is not universal care and it not giving everyone access to the
medical system. One does not got the ER for things like cancer screenings.

From the link you provided:

 _Hospitals are then required to provide stabilizing treatment for patients
with EMCs._

~~~
pg_bot
Access is a function of cost. If medical care is affordable for people near
the poverty line then we will be able to solve the access problem entirely.
(this is my goal) Governments, charities, and businesses will pick up the
slack as they already do.

------
pjdemers
I'm old and deal with the health "care" system more than anyone else here.
What I've learned: 1) You are responsible for your own health. Eat less, eat
better, and exercise more. Get enough sleep. Don't over worry. Don't drink too
much. Don't touch recreational drugs. Your own health must be your number one
priority. Teach your children this, too. 2) ACA, for whatever problems it
caused, will save many of us from bankruptcy. "Us" being everyone who is or
wants to be a founder. 3) The biggest problem with health cost is lack of
transparency. If I could shop around, even a little, I could save tens of
thousands of dollars a year. But it's hard to negotiate for price when nobody
knows what anything really costs, or what you actually get for that cost; even
the people selling it. 5) Every day you are in good health is a good day.
Thank God, nature, or other deity(s) of your choice for your lack of health
problems.

------
justinmk
I've begun to suspect is that "universal healthcare" means "you weren't
denied, you're just on a waiting list, and every physician is an
interchangeable cog".

I often wonder why health insurance companies don't use a similar tactic.

Edit: Try finding a pediatrician in Berlin. (Seriously, I would love to hear
recommendations)

~~~
dboreham
Because doctors will happily tell you that whatever they plan to do will be
covered by your insurance. So the work gets done, the money spent, before they
get a chance to screw with you.

------
John_KZ
That's a very interesting insight into the world of American healthcare and
privatized healthcare in general. Previously I thought that all these
statements about the US healthcare system were seriously exaggerated, but I
guess I was wrong. It's kind of terrifying that being sick excludes you from
access to healthcare. In my experince, public healthcare has many problems,
but you get what you need.

------
hestefisk
This is why I prefer Europe over US: we have realised healthcare is a human
right, not a business.

------
oldandtired
Healthcare is a basic infrastructure problem, not that it is considered this.
As a basic infrastructure problem, there are many who see a profit to be made
in supplying services. Each country views healthcare from a specific point of
view and that dictates how they will, as a country, provide the general
healthcare service.

A country like the USA see this in the light of healthcare as a business, make
as big a profit as you can, irrespective of the actual services that you
provide. In other countries where the relevant governments provide universal
service they allow private businesses to dictate the price that the government
pays for the supplies required.

So, we have general commodities when supplied into the healthcare system being
charged at 10x or greater for on item which, if not used in a healthcare
environment, is charged a much lower price. This applied to things like
computers, phones, chairs, tissues, matches, paper, toilet paper, gloves, etc,

The suppliers get away with this because of the perception that these goods
are of a higher quality. These goods often come off the same production lines
as those sold in a normal commercial market.

I have seen up to date medical equipment that cost a large fortune that looked
pretty, but if you actually looked at the basic equipment was technology that
was anything up to 10 years old and was superseded by stuff your could get
commercially.

The amount of money charged for drugs is based on the amount of money spent of
research, which if you actually looked at the figures thrown about were spent
by the public purse not the private.

It is a captive market and those supplying into it want it that way to
maximises their profits. Morality questions are not considered to be important
unless it has regulatory considerations that will significant reduce your
profit margins if you fail to live up to them.

The problems within the healthcare system (insurance included) will not be
solved any time soon. Even if there was a revolution that changed the entire
basis of how and when healthcare was supplied, it will soon return to what we
see today as greed is the basic motivator for society as a whole.

To bring about real change requires people really changing and this will not
happen because we are basically looking out for ourselves and our own. This
occurs on the local level, on the regional level, on the state level and on
the national world levels.

The healthcare system is an area that needs a complete overhaul worldwide. It
is not going to happen since most people do not have the ability to see past
their local situation.

------
audio1001
This is a sickening and inhumane system

------
audio1001
This is sickening

