This is some of the best hacking I've seen on Hacker News in a long time!
My son broke his arm skiing a few months ago and we went to the clinic that is at the ski resort. They x-rayed him, set the bone a little (thankfully it didn't need much), put on a splint, and put his arm in a sling. Straightforward simple stuff.
The clinic is not on our insurance so we filed a claim with them after the fact ourselves using the detailed receipt the clinic provided. It was out of network so they didn't pay for most of it (for some reason they did pay the $12 or whatever for the sling), but they applied the cost to our out-of-network deductible. Except not the cost the clinic charged, the cost they thought the clinic should have charged, which was of course about $150 less. What?? I'd love more insight into how all that makes sense in someone's mind.
Emergencies are always considered In-Network by law *.
For example, if you are traveling Out of Area (OOA) and skiing in Colorado, and you have a medical emergency, emergency room care is considered In-Network. Any financial responsibility you have under your health plan (coinsurance, copay) should be calculated as part of In-Network.
* If you have an HMO or EPO plan, it is black and white language. If you have a PPO plan, legally it is a bit squishy because of the already provided for out of network (OON) access. BUT - generally - any emergency is considered in network no matter what product you have and where you are.
He went to a clinic, while you, me and he may all agree it fits the definition of an emergency, he didn't go to the ER.
Getting emergency care:
In an emergency, you should get care from the closest hospital that can help you. That hospital will treat you regardless of whether you have insurance. Your insurance company can't charge you more for getting emergency room services at an out-of-network hospital.
For something fairly simple like a cast, that can still end up more expensive than the clinic option though, depending on your insurance. ER co-pays and co-insurance can be pretty high. For example, a typical ACA/Obamacare "Silver" level plan in my area has 20-40% co-insurance on an ER visit (until the $5k-10k annual out-of-pocket max), which can easily be more than whatever you'd end up paying for the non-ER option to set a broken arm.
Your health insurance doesn't want to pay for it because they deem what the clinic charged as "too expensive" or another reason there isn't a pre negotiated contract in place between provider and insurer. The clinic can extract what it can from your because your insurance didn't cover it, sending you to collections if you don't pay [1] [2].
Many folks harp about how government insurance doesn't pay enough, and there is some validity to that argument, but without cost controls or other guardrails, the patient is always caught between the payer (private insurance) and the provider. Both are attempting to maximize their profits, the former through "cost plus" accounting, the latter at point of sale/purchase/care.
Tangentially, this is why global/nomad/world traveller health insurance typically excludes the US specifically from coverage and visitors to the US in many cases will fly home for urgent medical emergencies vs receiving care in country; the economics are simply unpalatable.
Insurer tries to get away with: the provider is not in network, but not strictly out of network (because they know that would be covered by the law), so they call them "participating", a 50% coinsurance applies and patient owes 121K.
(Resolved in patient's favor after state government got involved and media coverage about it).
More of a federal Medicare problem because the government runs an insurance plan that fails to throw its heft around and negotiate beyond “you can’t charge us more than other insurers”.
Gets very opaque fast.
Edit: lots of (I assume) correct points below about hospital/procedure charges, but it’s only in 2026 that Medicare will start negotiating drug prices, and just for 10 medications in the first year:
> For the first time, Medicare will be able to negotiate prices directly with drug companies, ensuring lower prices on some of the costliest prescription drugs
> More of a federal Medicare problem because the government runs an insurance plan that fails to throw its heft around and negotiate beyond “you can’t charge us more than other insurers”.
You've got it backwards. Medicare does negotiate, in some cases reimbursing less than COGS. Hospitals and providers make up for it by charging private insurers more (that's why private insurance contracts always state that they reimburse X% of the Medicare Allowable Rate, where X > 100).
> Looks like it’s only starting for drugs in 2026. But until now, they paid whatever list price the manufacturers dreamed up:
We're not talking about prescription drugs - the entire thread so far has been about inpatient and outpatient care.
Medicare does not negotiate prices for prescription drugs at the moment, but that's because pharmaceutical coverage for Medicare is provided by private insurers, and those private insurers are responsible for negotiating the rates.
> There are Reference Based Pricing plans available in the commercial medical insurance world now.
> So yes you can "pay what medicare pays" be prepared to have some pissed off doctors and balance billing.
You're not wrong but your description is conflating two different things.
What you're describing - "pay what Medicare pays" is more or less how private insurance typically works for in-network providers. The provider gets paid X% of the Medicare Allowable Rate (where X > 100), and that comes either from the patient or the insurer (depending on any applicable deductible, copay, OOP max, etc.)
Reference-based pricing applies that to all providers, including out-of-network providers. However, except for care received in the emergency room, the provider is allowed to bill the patient for the difference between what the insurer allows and what the provider charges. Some plans will actually allow in-network providers to bill patients for the balance. In that case, everyone wins except the patient: the insurer/employer has a fixed cap on their costs per service, and the hospital/provider doesn't have to settle for a lower rate.
>>"Reference-based pricing applies that to all providers, including out-of-network providers."
RBP is a multiple of standard Medicare rates, say 140%, often is substantially less than a negotiated rate from a Carrier, hence balance billing and not so happy provider. Basically a take it or leave it option for the provider, many of which simply take it and move on. Not claiming right or wrong, just stating facts.
> RBP is a multiple of standard Medicare rates, say 140%, often is substantially less than a negotiated rate from a Carrier, hence balance billing and not so happy provider.
Negotiated rates are also themselves set as multiples of the Medicare Allowable Rate. Both are set as multiples of Medicare rates; that's not something unique to reference-based pricing.
I had a buddy who figured out a hack to the US medical system after being hit over the head with a poolstick and being unable to remember his identity. If you don't give a real name at the ER, they don't have anyone to attach liability to.
These are simple explanations to a complex topic. I shared the nuance as to why you can be held hostage in a medical emergency in the United States. Please disregard my comment if you're not getting value from it.
No you are claiming the carrier "doesn't want to pay for it because they deem what the clinic charged as "too expensive"".
That is not nuance, that is an knee jerk unsubstantiated misleading claim. You have 0 details into what chassis the plan is carried on, what the plan design is, who the carrier is etc.
>>"this is why global/nomad/world traveller health insurance typically excludes the US specifically from coverage and visitors to the US in many cases will fly home for urgent medical emergencies vs receiving care in country; the economics are simply unpalatable."
Again misleading, there are expatriate plans specifically for visitors to the USA, and frankly, it's great coverage.
The point is that you have to specifically opt for US coverage, rather than the default global coverage, because of the eyewatering expense of medical care in the US.
You can try an appeal that the network did not have adequate coverage in the area in which your son was injured in which case they would treat it as were in network, or see if it might have been covered under their emergency room benefit instead of as out of network.
I work in this industry and can provide some insight.
Every payer has the concept of "UCR Rates" or "Usual, Customary, and Reasonable Rates" for every procedure code, for every ZIP code. For example, the median cost of an X-ray should be a certain dollar amount in Topeka, Kansas and a different (higher) dollar amount in Manhattan, NY.
When a provider is out-of-network, they'll bill as much as they possibly can to see what the insurance company will pay — the insurance company will only pay up to the "UCR Rate" for the treatments (or in your case, apply that to the deductible before the payments start to kick in). Whatever the difference is between the UCR rate and the requested amount is almost always ignored, since the doctors' motivation for the high requested rate was to try and maximize payment from the insurance company. In your case, since you paid out of pocket, you're unfortunately on the hook for that difference. In other situations the provider might also invoice the patient for that difference, but it's relatively rare.
In contrast, when a provider is in-network, they have contracted rates for all of the procedures (also typically varies by ZIP code). These are called the "fee schedule" rates, and every payer (including Medicare/Medicaid) has their fee schedule rates defined and agreed upon with the physicians/providers.
It sounds like pure fantasy to come up with a number they should charge and it is the same for every provider in a zip code. Different hospitals, clinics and offices would pay different rents, staffing expenses, supplies, marketing, utilities, and the list goes on. Not even McDonalds charges the same price for the same meal in every location in a zip code. Malls, airports, entertainment venues are easy examples of divergent pricing.
Right, the UCR is usually pegged at the 75th percentile price for that ZIP code — though that can vary from payer to payer, some can even go up to 90th percentile — it's usually determined by actuaries. It's basically a guidance that conveys "we've never met you before, but you're asking us to reimburse for a treatment, and we as an insurance company think this is the highest reasonable amount to charge for that treatment". It's also important to note that payers don't advertise whether they're doing 75th percentile or 90th percentile or 50th percentile or whatever, because then it just becomes an incentive for providers to anchor at that amount, even if it may be higher than they would otherwise bill for that treatment — they'd just submit a claim for that amount and say "cool, thanks, pay me". In single-payer countries in which the state is a monopsony buyer, there is only 1 rate (sometimes a narrow range), often per location.
In either case, the goal is to try to keep prices down, and in many cases to prevent so called "upcoding" by providers. You'd be surprised how prevalent upcoding is among providers. I've been on the phone with a provider that included in a claim an $80 line item for "oral hygiene instructions", which is a fancy way of saying "instructing the patient to floss more". I've seen another claim that asked for $300 for sign language because the patient was deaf. I've seen yet another claim that asked for $200 for a swaddle for an infant patient. In all 3 of those cases, I personally informed the clinical administrator on the other end "this is not covered", and their response was something to the tune of "oh yeah that's okay, we just put that on there to see who covers it, you can go ahead and ignore that line item".
All of this is characteristic of the fee-for-service model, which is increasingly being seen as quite flawed, regardless of whether it's done by the public sector or the private sector.
And people wonder why health care in America costs so much. You have two businesses (at least one of which is totally removed from the services being provided) trying to scam each other every time someone goes to the doctor.
How long are people in the US going to put up with this insanity? Some we have managed to create an extremely cruel, bureaucratic, expensive and unreliable system that produces below average outcomes compared to other countries at exorbitant cost.
If it was for the people to decide, we’d have something like Medicare for All a long time ago. But America is a wildly corrupt oligarchy, so the answer to your question is “forever.” If the George Floyd protests didn’t change anything anything meaningful about policing, I can’t imagine the level of unrest that would be needed to change something with so much money and back room dealing involved as the healthcare industry.
Oddly standarduser and mikestew aren't asking for details regarding your statement so I am. What kinds of services treatments and facilities did you recieve while visiting south Asia?
>>"so much money and back room dealing involved as the healthcare industry."
I think you’re mixing up my comment with another one, but go look at things like the “speaking fee” racket. US politicians get paid hundreds of thousands of dollars by healthcare industry companies to deliver the most banal speeches imaginable as a form of bribery.
Agreed, I am planning on moving overseas because of how horrific our healthcare system is, I can go to Vietnam, Thailand, or any number "developing" countries and receive better care at their private clinics than in the USA. If the US wants to operate on a market system for healthcare, give me a better product. And with respect to experimental treatments, Singapore and Japan have advanced medical technology and treatments at a fraction of the price. The US system manages to have the worst of single payer and market systems while providing none of the benefits of either approach.
"Do you know how many people from Countries such as Canada Germany and the UK come to the US for treatment because they cant get it at home?"
Do you know how many people from the US can't go for treatments in the US because they can't afford it? Many.
I am from Germany and I can tell you that I have never heard of anybody going to the US for treatment. Maybe some millionaires do this but certainly not the average citizen. Do you know how many people are in medical debt in the US vs Germany? Do you know which country has higher life expectancy?
How many and for what treatments? I want details and specific numbers. And how does that compare to the number of people who go to Eastern Europe and Latin American for medical care they can't afford in the US?
Drive into any cancer clinic in south Florida and count the number of Canadian vehicle plates (most of them are very nice cars so these are people with means). Single payer systems doesnt mean equal access. Quite the contrary actually.
Don't most Canadians carry some form of private insurance? Why would they do that if healthcare is "free"?
If you're truly committed to defending insurance companies, so be it, but you should try to offering something other than anecdotes about some cars you see. Medical debt is a huge burden in this country, not only in terms of families struggling financially, but in terms of people avoiding or postponing needed treatments due to cost.
Drive to any supermarket and you'll see the same Canadian plates. They don't come all the way to the US for the food. South Florida is a vacation destination for Canadians; while a few may come for medical treatment, the vast majority come for the warm weather.
Standarduser, can you answer my question as to who administers the plans? I'll wait patiently. Maybe that will shine light on my 50 statement for you.
As for your other statements, where's your proof? I offered plenty of proof for my comments.
edit: 1 hour, no answer from Standardtroll. The answer is private companies such as Centene and Humana. The common element in the answer is each State regulates Medicaid and Medicare. Federal Government reimburses States via the issuance of debt. Medicaid is Free or extremely low cost. So for all the Europoors, you can have your cake here too!
You're offering nothing but false choices and strawmen. No data, no coherent argument, just a vague list of inefficiencies and concerns and some literal nonsense about license plates. Dozens of wealthy nations have healthcare systems that provide better outcomes with minimal debt. To not look at those systems for a better way to craft out own system would be idiotic.
And what is the cryptic "Fifty Sovereign States" supposed to mean exactly?
Do you know how many people from Countries such as Canada Germany and the UK come to the US for treatment because they cant get it at home?
No, I do not. Do you? I ask because every person, to a woman and a man, who says something along these lines has yet to even try and provide a number ("well...it's a lot.").
I mean, I see folks on this very page mentioning some medical tourism to SE Asia. But I'm trying to remember if I've ever seen someone mention travel to the U. S. for medical treatment because the medical system in their shitty European socialist hellscape is lacking.
There's about 6 times as many hospitals in the US as in Canada, including some of the best research hospitals in the world, so naturally those with means would seek specialized treatment in many cases. But it's just one little piece of the puzzle. What about the many Americans who travel overseas for healthcare?
There you go about time you coughed up some links. Please be my guest go to a third world country for cheap care. Unfortunately your precious big government throw's caution to that wind!
Your second link, I'd love to see what access is restricted. Nearly all restrictions in the US are because of the FDA.
Most medical tourism is for cosmetic surgery (which is elective and therefore not covered, I don't care what country or insurance plan you have, generally not covered). I don't need that, I'll stay in the States, thanks.
There was an article in the news today. Woman with stage 4 cancer got treatment denied by her insurance company because the treatment only had a 30% chance of succes. The operation would cost 150k out of pocket. She was, and I quote "not profitable enough". It took them 9 weeks to tell her this news. It is a death sentence to her. In the video you can hear her 5 month old baby in the background.
Is this in the USA or Europe? I think it's important to point out given how widespread blatantly false information is given by leftist Americans when comparing US health insurance to European Health insurance.
It depends on the specifics of her situation. If the 30% is the chance of it being curative (as opposed to just dealing with the currently known tumors), then even if the treatment "failed," it might still allow her to live several additional years and/or be in better health for her time remaining.
> Changing it, a Cigna employee estimated, could save more than $98,000. (Cigna spokesperson Justine Sessions said the insurer only suggests changes when clinically appropriate and that cost is never the sole determining factor. She said Cigna does not directly benefit from such savings.)
Emphasis mine.
Can... someone explain how that makes any sense at all?
Insurance companies must pay out at least 80% of premiums to claims. Any excess gets refunded to policy holders.
This means that it is, counterintuitivly, in there interest to spend more on claims, as it makes the 20% profit they are allowed to take bigger. At least until they start to lose clients.
And yet, all large publicly listed health insurers, for the last decade+, play in the 2% to 4% profit margin range, except for UNH which does about 6%.
Yes, that is the point. Business owners generally do not like employees to pay excess expenses so that the owners’ profits are less, even if the owners are shareholders in publicly listed companies.
No, but it's a small number. Approximately 13% of people with employer-provided plans have grandfathered plans[0]. That number is also steadily decreasing over time.
That's specifically looking at people who get their insurance through their own employer, so the denominator doesn't include, for example, people on Medicare or Medicaid.
The 80% claims rule doesn't apply to every individual plan, but it's widespread enough that it drives the overall structure of how insurance companies operate these days. They're not optimizing their organizational workflow for plans which comprise a tiny - and shrinking - fraction of their revenue.
Any plan worth having does. If you are offered non ACA compliant health insurance, you should value it at $0, especially since there is no penalty for not having health insurance.
>For Rate Review: These requirements don’t apply to grandfathered plans. Check your plan’s materials or ask your employer or your benefits administrator to find out if your health plan is grandfathered.
>For the 80/20 Rule: These rights apply to all individual, small group, and large group health plans, whether your plan is grandfathered or not.
I assume grandfathered plans are not ACA compliant, and hence do not have all the provisions that make health insurance worth having (such as out of pocket maximums and zero cost preventative care and appeals processes and other things that set a floor on the quality of healthcare covered by the insurance).
Some states are 85/15. Did you know that? However, the plans you are referring to are Marketplace plans. I am not referring to Marketplace plans, nor community rated employer plans. I'm referring to self funded employer based commercial plans. These same type of plans are commonly offered not only in the US, but UK, Canada and Germany.
Large employers are often self-insured. But since they lack the expertise and large network of negotiated rates and providers, they typically hire a company in the insurance business to administer their plan. Thus, the employer bears the risk of the claims, and also is the party that benefits when expenditures are reduced.
.... which leads to excellent situations where employers try to get rid of employees who have expensive health problems. Especially if a smaller employer is self-insuring because a decision maker read some blog post about it and thought it sounded neat.
Sorry about the cancer!! please go die somewhere that I cant see it thanks.
If the employer doesn't self insure, then their insurer will raise their rates because their employees have a history of expensive health problems. Which still leads to pressure to get rid of those employees. (Unless the employer based coverage is priced like marketplace plans, where only age, sex, and smoking are available to set prices; but I don't think that's the case for most?)
Even the age factor is bounded by the highest risk age having to be only 3x the lowest risk age (i.e. a subsidy from young to old). The lack of ability to price based on pre existing health conditions is a subsidy from healthy to sick.
And for political reasons, we can afford to discriminate against tobacco use, but not sugar or alcohol or sat fats or lack of exercise.
> Does that page apply to employer based plans? It's not clear that it's not just discussing marketplace plans.
It applies to all non-Medicare, non-Medicaid, non-grandfathered[0] plans for people under the age of 65.
Ironically, once you turn 65, all bets are off: insurers can factor your age into your premiums, and people often get a massive rate hike then (usually prompting them to switch to Medicare).
[0] A small percentage of employer-provided pre-ACA plans are grandfathered in, but they're few in number and decreasing over time. If you have a grandfathered plan, you probably know it, because it's required to be disclosed visibly in the plan documents when you enroll.
>>The only factors allowed to price insurance is age, location, and tobacco use.
Not necessarily.
Self funded plans are underwritten. Fully Insured over 50 fte plans are underwritten. A carrier will underwrite based upon Medical History. Individual Short Term Medical plans are also underwritten.
>>It applies to all non-Medicare, non-Medicaid, non-grandfathered[0] plans for people under the age of 65.
Incorrect, see above.
>>Ironically, once you turn 65, all bets are off: insurers can factor your age into your premiums, and people often get a massive rate hike then (usually prompting them to switch to Medicare).
Again, not necessarily, Nearly all Americans over 65 have Medicare, as part A is required. The States regulate these plans so each state may be different in some way. Medicare supplements are often underwritten, but can be guarantee issue, again depends on the State.
>>A small percentage of employer-provided pre-ACA plans are grandfathered
Correct, these are getting priced out. They are underwritten. If you are on a GF/GM plan, then switching to LFP or similar is likely a smart move.
>>Which still leads to pressure to get rid of those employees.
Can you give a source to this statement or is this an ad hominem?
>>but I don't think that's the case for most?
Great question, generally the larger the company the better the case for self funding. Keep in mind there are different types of self funding, such as graded funding and level funding. Most employees on employer based health insurance are likely to be on a self funded chassis however that is changing. Not all states provide that data, without that, it's hard to pinpoint an exact number of how many is on what chassis.
"She said Cigna does not directly benefit from such savings."
The quote indicates that the employer group was self-insured, and Cigna was the plan administrator. This means that Cigna is not insuring the health plan. Cigna is probably paid a per member per month (PMPM) fee for third party administration (TPA). The actual medical claims and associated costs are directly paid by the self-insured entity (the employer group).
Self-insurance can make actuarial sense for companies with >2,000 employees.
In addition there is likely specific and aggregate stop loss coverage carried by a reinsurance carrier, such as AXA, Lloyds or even Cigna papers reinsurance often on their self funded plans.
My guess is that they increase premiums to cover payouts; so the cost of payout is amortized away. The indirect benefit is that their prices are more competitive the less they pay out.
Maybe. They've got payout minimums these days, too, but it seems like finding ways they could tweak payouts lower to get as close as possible to that line if they have room to is a pretty direct benefit.
[EDIT] I mean I guess what I'm getting at is that if they decide to make the adjustment in treatment, it's going to be because it makes them more money, even if they can't afford to make all of those adjustments they might, or it'd push payouts too low and they'd have to give some money back—finding the option to do so doesn't increase profit immediately, but if they choose to make the change, it's surely because it'll make them more money.
My sister has severe MS that has been progressing rapidly, and the most common treatments have failed to halt or slow progression. Her neurologist who specializes in MS wanted to put her on a new, but expensive drug that has shown significant promise. Her insurance denied it, insisting that she should be put on a different medication that has never so much as been studied, much less approved for treating MS. Multiple appeals, by my sister, by the doctor, and by the hospitals insurance specialists were all denied. A lawyer advised that legal action would be prohibitively expensive and have no guarantee of results.
Mind you MS is a progressive disease,. causing permanent brain and neurological damage. There is no "recovering". Once the damage has been done, it's permanent, treatment only hopes to stop or slow progression, so experiment with another drug isn't something you can do, then later decide it's not working and go with something else. Permanent damage has been done, while your wasting time with treatments that have no expectations of working.
The semi-good news is the insurance company did approve the drug 6 months later after she ended up in the ER and had a 4-day stay, and she believes she hasn't experienced progression since starting the drug. I cannot fathom however why we as US citizens allow this cruel practice of private industry insurance to continue.
>>insisting that she should be put on a different medication that has never so much as been studied, much less approved for treating MS.
I find this hard to believe and would be very interested in seeing details.
Ironically, Cigna has a very good speciality Rx program for MS.
>>I cannot fathom however why we as US citizens allow this cruel practice of private industry insurance to continue.
Did she find a Country where she was comfortable getting the denied treatment? What do you recommend besides "Government paying for everything"? What makes you think that "Medicare for all or whatever" will get the declined drug approved? Do you realize Canadians commonly get denied for things too? God forbid you have Rectal Cancer in Germany, generally not covered by the Government plan.
Pepto bismal is cheap, but we don't try treating a lung cancer with it just because of that. Again the drug they wanted her taking had NEVER been so much as studied for treating MS, and she had already exhausted a number of cheaper treatments including diet, PT and a number of other drugs, and a couple clinical trials. It's not like they jumped to the most expensive option. As for a second opinion, she is working with the only neurologist in the area who specializes in MS. Even if she wasn't I'm not sure why you think a second neurologist saying the same thing would change anything.
> Did she find a Country where she was comfortable getting the denied treatment?
No, no one researched hypotheticals. It's not like she can travel to another country and get treated under their healthcare plan. These generally only cover citizens and even if not she will need treatment for the rest of her life. This isn't a one time surgery where it might be cheaper to go to another country, then come home.
> What do you recommend besides "Government paying for everything"?
Well I do recommend single payer, because I'm of the radical mind that even the poor and unemployed deserve health care, but if that's off the table how about some actual oversight? We have an insurance company overriding a doctor who specializes in this disease insisting on a treatment that has NEVER been studied for this disease. This should not be legal. And yet the only recourse is to ask the same insurance company who already made this bad decision if they'd pretty please reconsider, or to find out if you can afford to pay lawyers for longer than they can. Maybe we should have an independent board one can appeal to. Make the consequences for incorrectly denying treatment dire. Like take away their license to operate if it happens to frequently dire. For many people delays can have serious consequences including death, if we are going to let these companies make such important decisions they should be held to a very high standard.
> Do you realize Canadians commonly get denied for things too?
Sure. Government can be fucked. Call me an optimist however, but I have a lot more confidence in my ability to drive meaningful change in my government than within Blue Cross.
> God forbid you have Rectal Cancer in Germany, generally not covered by the Government plan.
Does it not? Booking health (the Link you provided) appears to be a site for finding the best specialists around the world. The fact that it has a price list just implies to me that it has a cost for non German citizens. The article below the list even talks about getting "your cancer treatment in Germany for lower cost" which implies to me it's aimed at non-german residents. You may be correct, but I was not able to find any sources corroborating your claim with a quick search. Even if so, again as broken as government can be, I have a lot more say there than a private insurance company.
>>Pepto bismal is cheap, but we don't try treating a lung cancer with it just because of that.
What? I'm sorry that is not a reasonable statement. I have no idea what point you are trying to make.
>>Again the drug they wanted her taking had NEVER been so much as studied for treating MS
Again, without specifics I find that extremely difficult to believe.
>> because I'm of the radical mind that even the poor and unemployed deserve health care
I believe you are confusing administrators and payors. Even wealthy families get subsidized health insurance on the Marketplace. Medicaid is nearly free and medicare is for over 65 individuals. Do you know who administers Medicaid and Medicare?
>>This should not be legal.
It isn't which is why I'm having a difficult time believing your story.
>>Blue Cross
Which Blue Cross? What is the plan design? Was it employer based? What is the PBM?
>>appears to be a site for finding the best specialists around the world.
And yet that has nothing to do with the fact that healthcare is not free in Germany, and not single payer either, contrary to what 'radicals' like to claim.
>>I have a lot more say there than a private insurance company.
>> Pepto bismal is cheap, but we don't try treating a lung cancer with it just because of that.
> What? I'm sorry that is not a reasonable statement. I have no idea what point you are trying to make.
You stated that the insurance insisting on a non-related drug was step therapy, which is where one explores cheaper and less invasive treatments before exploring more expensive/invasive options. The point was step therapy does not include exploring treatment that there is no reasonable expectation will help.
> Again, without specifics I find that extremely difficult to believe.
I'm sorry. I'm not going to make my sister send me the drug names for a random internet discussion, and given the names of these things I unsurprisingly don't remember them. If you think I'm lying so be it, frankly I don't see how knowing the specific drugs involved would make that less likely.
FWIW it was a Parkinson's drug they wanted her to take, which might seem like it makes sense given the similarities between the diseases symptoms, but only if one doesn't understand the difference in cause and progression.
>> This should not be legal.
> It isn't which is why I'm having a difficult time believing your story.
The fact that you have a hard time believing that an insurance company might illegally deny a drug feels pretty shocking to me. The lawyer essentially agreed, it's probably not legal, but advised that fighting it would be extremely expensive and the best case outcome would be that she gets the drug, but it's more likely she runs out of money long before then. There are essentially no consequences when insurance companies do this, so of course they do. The worst case for them is they have to pay for the treatment eventually and most of the time it saves money.
> And yet that has nothing to do with the fact that healthcare is not free in Germany, and not single payer either, contrary to what 'radicals' like to claim.
I made no claim about Germany. I have no idea why you brought it up. I thought you were pointing out flaws in single payer systems, but now you tell me it isn't single payer?
>> I have a lot more say there than a private insurance company.
> Specifically, how so?
Voting, writing my senator/congressman, etc. Our government is broken in a lot of ways but are you really asserting we have zero influence? Because that's what I have with private companies.
>>The fact that you have a hard time believing that an insurance company might illegally deny a drug
No, I find it hard to believe, as you alluded to, Blue Cross were trying to get her on the equivalent of pepto for cancer. A Parkinson's drug likely has a correlation and is hardly pepto which is over the counter. Sounds like you acknowledge that even...
>>Voting, writing my senator/congressman, etc. Our government is broken in a lot of ways but are you really asserting we have zero influence? Because that's what I have with private companies.
You want to get an insurance company to respond quickly? Each State has an insurance commission with a phone line, email etc. I wish you the best of luck with Congress.
Please pay careful attention to the section on what information to include.
It takes at least three pieces of info to positively ID the correct policy for a large (national) insurance company. It's a HIPAA violation if they send you the wrong files.
If you have a common name, have a relative with a similar name, etc, it's especially important to make sure to include things like policy numbers and claim numbers.
I wish this sort of article were not necessary. This is not how it should work, though I don't know how to fix this mess.
I think the most absurd case of this was getting an insurance claim denied for relatively boring treatment. I had some wounds cleaned after an accident. I call and talk to the insurance representative. I am informed that they'll resubmit it and it will be approved. No additional information needed, no evidence, etc. They literally just deny most claims outright because most individuals are not going to call them about it.
I'm pretty sure I've experienced this as well, and the pressure must be pretty high to do that sort of thing "accidentally". It's basically free money for them.
It doesn't have to be a policy. Large beaurocracies naturally tend toward certain behaviors due to natural incentives. You must have policies/regulations to specifically counteract these tendencies.
Seems like the kind of thing that is probably illegal if they're overt enough, but I don't know. It's definitely not ethical or moral or admirable in any way.
I recently discovered how completely arbitrary healthcare pricing is. I got services from an out-of-network clinic, and ended up receiving a very large bill. I called my health insurer, and the conversation went like this:
- What's up with this $2000 bill?
- You went to an out-of-network clinic.
- I didn't know it was out-of-network; my doctor recommended it to me.
- [...pause...] How about $200?
And that was it. My $2000 bill became $200 for a completely unknown reason. I didn't ask for a price reduction; I didn't even know that was possible.
The whole situation was, and still is, bizarre to me. What is the pricing based on, if it can be dropped so drastically without explanation?
We're all victims in waiting. But, just like with other arbitrary systems such as the enforcement of victimless crimes or traffic laws, most of us don't suffer too much most of the time, so the systems endure despite the inherent incoherency and unfairness. It's just the occasional poor sucker having their life ruined, but never enough to create a meaningful backlash.
Maybe for you being a victim, that's your problem. Don't lump me into your issues. I prefer to create my own destiny. I am not a victim. I can handle myself. I have the ability to ask for help when needed.
As a matter of fact I'd say most of my circle of friends colleagues and acquaintances would agree with not being a victim. Probably be offended by your statement actually.
I have an app from my health insurance company to see if a hospital is contracted with them (similar to what they call "in network" in the USA). It's as simple as typing in the procedure and my zipcode and it shows me contracted hospitals near me. I always check it before I schedule an appointment.
Alternatively I could also get insured with a company that covers all hospitals but those have higher premiums (around €50 per month extra).
I do too. I'm in the USA. Most US carriers provide an app. My app also shows Prescriptions, how much of my deductible is left, provider search, my ID card, EOBs claims and treatment cost estimates.
>>Alternatively I could also get insured with a company that covers all hospitals but those have higher premiums
Whoah we in America thought all insurance and healthcare is free in eurolands! (i'm being sarcastic, some of us realize the truth, some on the left dont.)
Which insurer was this? It makes no sense to me that they would care about reducing the price you owe to a third party.
You do not owe the insurance company $2,000, and the insurance company does not send you bills. So what is their incentive to pay the healthcare provider the $1,800, or otherwise engage with them to reduce how much the healthcare provider charged you who has no contract with them (since they are out of network)?
the pricing is based on what the suckers will pay. I've seen similar 10-15x cost reductions on significant procedures with hospital stays like childbirth.
My son broke his arm skiing a few months ago and we went to the clinic that is at the ski resort. They x-rayed him, set the bone a little (thankfully it didn't need much), put on a splint, and put his arm in a sling. Straightforward simple stuff.
The clinic is not on our insurance so we filed a claim with them after the fact ourselves using the detailed receipt the clinic provided. It was out of network so they didn't pay for most of it (for some reason they did pay the $12 or whatever for the sling), but they applied the cost to our out-of-network deductible. Except not the cost the clinic charged, the cost they thought the clinic should have charged, which was of course about $150 less. What?? I'd love more insight into how all that makes sense in someone's mind.