tl;dr: It doesn’t.
America is one of the richest countries, but life expectancy is so low because of all these inequalities and shootings.
So here is a question:
A medical professional examined the person IN PERSON and has a requirement.
In comes the insurance to tell you your doctor is wrong and that you’re perfectly fine, your doctor is basically lying to you.
Question: how the fuck did any of this ever become legal?
You do need some checks and balances because what’s to stop a hospital from profiting off the insurance companies by asking for a CT scan/whatever of every single patient just because they can.
I suppose we could have the government run the hospitals too. But noooooo, that’s never going to work out because communism or something.
Maybe we should try effective altruism and accelerationism instead? Let’s just hand over all our money to a few tech bros and then we can go beg them to pay for the scans. And if they don’t pay for it, surely someone will come up with a cheaper technology to do the same. Yes, that’ll definitely work.
Yes, it’s clear why it’s legal and necessary to some extent. In a for-profit system, a doctor’s office or hospital, every procedure or test the doctor can order (and have the patient pay for) will generate profit. Doctors have an incentive to order as many tests as possible. I assume that most doctors are somewhat honorable and won’t abuse this too much, but they’ll probably still err on the side of ordering as many tests as possible not necessarily because of profits, but because more tests gives them more information.
Meanwhile, in a for-profit system, an insurance company will generate the most profit by agreeing to as few tests and procedures as possible. So, they will have an adversarial relationship with doctors and will try to arrange as few tests and procedures as possible. My guess is that the average insurance company is less ethical than the average doctor, so they’re probably more likely to refuse to allow tests that are actually medically necessary.
In a sane system, there would be a neutral referee, the government, who would resolve disputes and severely punish any actor in the system that was behaving badly. But, AFAIK that only rarely happens in the US, where the idea is that the “invisible hand of the free market” will magically make it all work.
Doctors do not directly profit from ordering tests. They get paid whether they order a test or not.
You want to know who profits from over testing? Quest Diagnostics.
https://bergermontague.com/quest-diagnostics-pay-1-79-million-settle-false-claims
These guys literally defrauded the government, but everyone points their fingers at poor people, doctors, liberals, ethnic minorities, lgtbq people, ect. The problem is corrupt businesses and their CEO’s hoovering up as much money as they can so they can shove it up their ass.
You could just get rid of the for-profit medical industry entirely and then there would be no incentive to over treat patients.
Question: how the fuck did any of this ever become legal?
I would guess lobbying.
Politics are dumb but very important.
Had surgery to correct an underbite a few years ago after prepping for it with braces for years. For context, I was still young enough to be on my parents’ insurance. The surgery involved moving my upper jaw forward and my lower jaw back because the underbite was so severe. The insurance denied the claim. My parents (I love them so much for this) decided beforehand that, if the claim and the appeal were denied, they would instead “gift” me the money out of their own retirement savings and have me pay for it. The procedure alone cost, I believe, $16k out of pocket. (I don’t remember the specific reason why they gifted me the money instead of paying for it outright.)
It might be that you HAD to be the one to pay for it. When I hit a certain age, all the insurance cheques were made out to me, and I had to deposit them and transfer the money to my parents.
(Though this was insurance for therapy, so maybe it’s different?)
Insurance wasn’t involved when it came time to pay for the surgery. By then, they’d already denied the claim and the appeal, so they were paying completely out of pocket for the surgery.
Prior authorization should 100% be outlawed. It’s either insurance adjusters practicing medicine without a license, or insurance doctors making diagnoses without examining a patient, both of which are unethical or illegal.
Though I think the real solution is a system where every time a prior authorization denial is overruled by the DOO or a court, the insurance company has to pay punitive damages of at least $200,000 to the patient.
Everyone should also remember that it’s going to get worse. People, especially nurses, are leaving the medical field. GPs are becoming scarce, and boomers are taking more and more of the medical resources available as they age. It’s going to get harder and harder to get timely medical care at all, let alone getting it without bankruptcy.
Think we could make Lemmy a household name by having the C suite of companies that do this SWATed? The government doesn’t work so we’re going to have to do this ourselves.
don’t joke about that, you might cut into their profits if it happened. /s
American health insurance in a nutshell: https://youtu.be/llx-SaGq4Fs?si=eDIny0fqcGYFkB2a
And before non-Americans ask, yes, that’s actually how it is. The humor in this video isn’t from exaggeration, the comedy derives from the unexpectedly clear way the absurdity of the system is explained.
it seriously blows my mind that the overwhelming majority of my fellow americans tolerate this system, that is if they don’t downright approve of it. The issues mentioned in that video are not isolated incidents. They are common, everyday, business-as-usual practices that almost all of us deal with.
Yep! The last bit is more of a joke, but the rest is pretty spot on with how the stupid system works. Here’s another example of a video explaining US Healthcare.
The episode of South park where they walk into this 22nd century insurance building and ask to make a claim. They get sent to the “claims office” and it’s like they went back in time to the 1980s with dot matrix printers, rotary dial phones, and fax machines.
Here is the link if anyone is interested: https://www.youtube.com/watch?v=VAfy26xs6e0
I love BDG, everything he makes is fantastic
They hire doctors who can’t handle being practicing doctors to prop up their delusions. I’ve only had one on the line in a dispute and he acted quite offended when I asked for his license to prove he was a real doctor. Turns out he was barely a doctor at all. He decided instead of practicing medicine and killing people he would work for a insurance company and kill them that way.
My insurance that I pay a ridiculous sum of money for has started doing this neat new thing. When the doctor orders imaging, they mark it as “requested more information but never received any”, and reject the claim. They don’t actually request any additional information, and they ignore me when I contest their decision. So glad that I pay like $400 per month for this coverage.
I file a complaint with the department of insurance instantly when they deny anything. I don’t negotiate with them for 3 months first, I jump straight to sicking the Feds on them and my doctors have always provided me every bit of data I need and cheered me on.
And I’ve won every time. It annoys me that I have to do it, but I enjoy that it costs the insurance extra every time.
I didn’t even know that was an option. Thank you! I will do that from now on.
Yes, I think that’s exactly what my doctor was trying to describe. He said if they’re at that point, they basically have to guess what information they’re looking for other than “I’m a qualified physician that has run diagnostic tests and determined this is the best course of treatment. Here are those tests and why it indicates X and therefore requires Y.”
I’ve had to do unnecessary labs to prove an ailment wasn’t something else that some person hundreds or thousands of miles away thought it might be.
If you think you hate insurance companies, find an honest doctor and ask them what they think of the US Healthcare system and health insurance. I’ve never seen a doctor so worked up and angry than when discussing the current medical system.
Edit: this guy is fun to watch on this topic: https://youtu.be/s33AVskz3T8?si=Qqx2nAJjguMOxnNL
It’s like calling your ISP and you can see the fucking wire dangling down from the pole but they won’t continue unless you turn the modem off and on first.
I worked in Pharmacy claims remediation for a while. Fun times. Never again. Why the fuck is my barely-above-minimum-wage-ass the one that has to tell medicaid that little Timmy is gonna die if he doesn’t get his chemo?
Because it’s more profitable if Timmy dies. Why would they want effective, highly paid workers doing the job of trying to cut into their bottom line?
It’s a modern war for a modern economy.
Instead of pitting the poor and destitute soldiers of opposing countries against each other in bloody combat, we have opposing corporations (in my case, the pharmacy and the insurance company) pitting their minimum-wage phone-jockeys against each other in a battle of wits when death is on the line.
Fortunately for our patients, I’m part Sicilian.
Fortunately for our patients, I’m part Sicilian.
Thank you for your service o7
No, unironically though, helpful folks in the healthcare industry despite the system’s labyrinthine and hellish construction have kept me from several major breakdowns. You going to bat for the patients has likely saved at least one person from a psych ward visit.
No way ? insurances have a say against the word of doctors ? I must be hallucinating, I thought I knew all about it
Last time my doctor had to bill my insurance he said he would just run it immediately, because apparently “routine denial” is a thing where they just automatically deny it because if you really need it the doctor will then have his office try again with more justifications. He hated this a lot, because it basically meant he had to just assume first denial for no real reason and then his staff had to take the time to almost always go back and resubmit. He said sometimes he would submit it with the info, it would be denied, and then he would resubmit it two more times and suddenly it would be approved.
Like seriously, what the fuck. But only does that hold up necessary care, it also makes doctors do more bureaucratic work and hire more staff, which, of course, makes medicine more expensive. Brilliant.
Shared risk pools are a good idea. Making them for profit is not.
I really believe a lot of this comes down to poorly automated systems and people not allowed to go off script … and insurers have no reason to change this.
When there’s a claim it gets entered into the insurer system by procedure code. It’s only decided based on what procedure code is recognized by the system. The peon deciding to reject it likely has no power to say otherwise nor incentive to. Even when they do ask for a doctors opinion, do you really think he reads all the case notes, or even has access to them, or has time to read them, or incentive? Nope, just whatever codes were entered into the system. You read a lot about issues where procedures have to be recoded for insurance, but I’ll bet many more of the rejects are as simple as the code not supporting the treatment and no one at the insurer looking farther. This is more a form of institutional incompetence but insurers have a profit motive in maintaining this incompetence
I did pharmacy billing for a while and this is a kind of innocent take that people are just being lazy. The training was terrible (I was taught the basics of the software and then given a photocopy of various employees hand written notes for common rejection solutions over the years …most of which didn’t still apply and those employees had long left; when I left in sure my notes were copied to the pile). There were metrics that kept being increased meaning spending more than 30 seconds on a claim was going to put you behind (I did night shift and my boss was talked to about me once or twice because I sometimes had an hour or two where I’d cleared everything I could and had nothing to do because the rest of the world was asleep). And, finally:
The software was designed to actively fight us. My most common reject was insurance won’t pay for anything $X or more with X being stupidly low. For many insurances you could not put in a recurring override for monthly maintenance meds. Your options were either give the patient a 2/3/whatever day supply to get the cost down and they’d just have to visit the pharmacy for pickup so much they might as well work there. Or do a one time special override every. Single. Time. Which involved me doing a special code on my end (which wasn’t the same for every insurer and sometimes they’d just randomly change it for shits and giggles with no communication, I had a list of codes that were often used I’d try guessing with). Calling their help desk whose employee retention and training were also in the toilet. If the insurance end person knew the process for a one time special override, great. If not I started specifically keeping notes by insurer to teach new people because otherwise I’d be subjected to an hour of phone hockey while they tried to find someone who both knew how to do it and could cram my call into their metrics. Then we’d have to go through generating specific rejects just because we needed it in our logs we tried shit we knew wasn’t going to work. Doctor note saying md knows med is expensive and that pt needs it to live regardless attached? Okay run it through as cost doctor approved to get the “fuck the doctor we don’t want to pay” reject. Insurance doctor/nurse team reviewed that yes the doctor is correct the patient needs this med to live code put in? Okay run it again to get the fuck our own doctors we still won’t pay reject. Now insurance help desk has to message their next level support to get authorization for a one time override for medical necessity. Okay now it’ll go through on the insurer end (as long as they didn’t fatfinger anything because the override only works for one single attempt). Great, we did it one try team! Now my turn to do it on my end which involves me removing all my codes because the software no longer recognizes the reject so will reject me for needless codes which will make us have to get the One Single Try Authorization again…
You don’t have to die to visit hell just work in medical billing.
Also, there’s this common “feature”:
Dr: “You need this procedure.”
Me: “How much will it cost me?”
Office Manager: “I won’t know until I bill your insurance and find out if it is covered.”
Me: “What is the cash price I would pay you if it isn’t covered by insurance.”
Office Manager: “I have no idea.”
I’m actually ok with this system, but only because I throw the bills away after
Actually, since January 2022, you have the right to request a good faith estimate for services from healthcare providers if you’re not billing insurance.
I’d like to see a law that says you get a complete and correct bill in 3 months or less as well. I avoid getting healthcare because even though I have insurance, every single time I’ve gone, the billing gets fucked up and I don’t find out about it until 6 months, or even up to 2 years later, and I’m on the hook for that. It ought to be law, that if your office is so fucked up that you can’t produce a correct bill for services in 3 months and deliver it to your customer, then you should have to nullify it.
This shit really needs to end.
