> It’s also not the case in 99% of US claims. [...] Surely, there are mistakes made, but there is no standard operating procedure at insurance companies to deny healthcare.
This is so out of sync with the experience of everyone i know that i wonder if you've interacted with the healthcare system at all beyond checkups and occasional antibiotics.
I'll chime in with an opposing anecdote about managing the healthcare for my father with cancer. Dealing with a large insurer, we have no problems with being denied coverage, timely prior approvals, and while some of the copays are high, they are not unreasonable for the plan he chose. Whenever I call, the agents are pleasantly helpful. My main complaint is with providers' fraudulent billing ("cost": $500, "adjustment": $390, insurance: $65, copay: $45), and the worst thing I've had to do was sometimes wait after receiving a billing nastygram, for the claims to settle out.
Of course he is of Medicare age, so this is a Medicare Advantage plan that is still bound by many of the Medicare rules and copay schedules. I can't imagine going through the same thing with my own insurance.
If it was true that insurers are routinely erroneously denying care, then people would be taking advantage of the ACA law that mandates external review of all claims and subjects insurers to the external’s reviewers’ decision.
I’m bipolar and every month I’m dealing with insurance medication denying extreme common, proven, and relatively cheap first-line medications. My insurance constantly requires exemptions and referrals for every step of my treatment. Even for things that have already been approved.
At this point, it would be cheaper and easier to manage everything myself. The only problem is, if I don’t use my insurance, the out of pocket maximum for inpatient treatment would be so expensive I’d refuse treatment and risk killing myself or harming other people. (Which is very much non-zero.)
As a child, my parents constantly fought insurance to get life-threatening allergies treated.
You seriously over-estimate how much people know about their rights and the time they are willing to spend exercising them. But you are right that they should.
That's actually very interesting. Although the article is from Apr 2014, it has some statistics that may be relevant to insurers erroneously denying coverage:
>Insurers say only about three percent of claims are denied.
>California data show about half the time a patient challenges a denied health care service through a third party, the patient wins and gets the health service.
If we assume that denied claims that were overturned were erroneously denied coverage by the insurance company, then half is a huge error proportion, one that would make me think the insurance company is doing it intentionally, or at least intentionally not doing it right.
But maybe the ones that got appealed are closer to being decisions that could go either way and the ones that don't get appealed are black and white cases that were clearly covered or not covered.
It’s easy to lie with statistics. I’d be willing to bet lots of money that it’s 1% because the vast majority of claims are doctors appointments and other very routine things and that major medical procedures, that are less common though more impactful, make up a disproportionate number of denials.
This is so out of sync with the experience of everyone i know that i wonder if you've interacted with the healthcare system at all beyond checkups and occasional antibiotics.