And when the patient turned out to be fine after the scan, the insurance company will try to blame that the doctors are lying so that the insurance company has to pay the hospital more It’s like they thought that the doctors must be able to see through the patients’ body as if they forgot that the reason for these equipments to exist in the first place is that because the doctors can’t really be 100% sure about what’s actual situation inside human body
There’s two sides to this coin. On the one end, you have insurance companies refusing to pay for anything because the modern industry is just six scams in a trench coat.
But on the other, you have doctor’s offices where the physician literally leases an MRI machine to the tune of several million dollars and then has to run a certain number of patients through the scanner every year or lose money. That’s because the MRI patent is held by GE and they can charge 10-100x markups on hardware that is fundamental to modern medicine.
Its the same with diabetes treatments. Insurance companies will try and refuse service or kick people off their policies if they are at risk. But then pharmacy companies will sell $3 of insulin for $75, then kickback a chunk of the balance to judicial/congressional bribes in order to guarantee the cash flow.
At some level, the only insurance companies that can survive in such a market are the ones that say “No!” to everything. The even-remotely-ethical firms just get fleeced by the for-profit industry until they get bought out or go bankrupt. That, or you’re Medicare/Medicaid and you have an infinite wallet backstopped by the US Treasury. You don’t care if you’re paying multiples of whatever any other clinic anywhere else in the world would charge on an enormous population of poor and elderly patients, because you have an unlimited money cannon to mow it all down with.
Six scams in a trench coat
Fucking poetry lol. I’m gonna use this.
*cough* single payer fixes all this *cough*
Sorry, cough has been acting up. I should go see a doctor with a MRI about that…
cough single payer fixes all this cough
I’d go one further and say a National Health System fixes all this. Rather than paying a guy to pay a guy, you just have publicly financed clinics and hospitals. This is the traditional way of building up medical infrastructure, btw. City hospitals used to be the norm. We only entered the era of corporate consolidation when we sold off our public infrastructure for a song during the neoliberal turn of the 70s and 80s.
IThey can’t even be sure after the MRI. Which again, proves your point. It took one MRI battery and one alert and skilled MRI tech to catch my brain cyst, THEN another whole set, I straight up spend a whole 8hr shift in an MRI machine, Then a TEAM of neurologists studied my custom hand made brain for MONTHS. THEN they had a really good set of educated guesses. Then they did the surgery, and only after they opened up my brain case did the actually see what in the hell was going on. Even after all that, my neurologists was like ‘‘This is what we think is happening’’, I asked what it would take to really know factually, he said an autopsy. He didn’t recommend it. The point is, Doctors save lives with these scans, and nothing is certain. That’s not a barrier to treatment, but no scans Is a barrier to treatment.
Sure we could save lives by listening to doctors! But who will save our dollars, huh? The REAL value!
Fuckingcapitalists
tl;dr: It doesn’t.
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.
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
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.”
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.
This is great information, thanks! In several cases it wouldn’t have helped us because of the 3 day advance request requirement, but at least its an improvement. Still not as good as what auto mechanics are required to provide, but its a step in the right direction.
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.
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.
I work for a neurologist practice, and the amount I have to argue with insurance (and inevitably have to get the neurologist on the phone to directly request something for many) is insane. A good chunk of my job isn’t providing care, but arguing with insurance that the care is necessary. These companies are actively delaying patient care, and try to blame the physician whenever possible.
Wildly infuriating, especially when the denials are worded along the lines of “we reviewed this, and don’t consider it medically necessary”. Motherfucker, a doctor said it was necessary and listed the clinical reasons why this test or procedure would be beneficial. Nothing has radicalized me for universal healthcare more than working in healthcare.
How is that even legal? How is someone who hasn’t examined the patient and isn’t their physician allowed to make treatment decisions? If they even have the necessary qualifications.
Because of money!
Every time you see something that feels illegal but isn’t, or that makes no sense in general, look for the money trail. There’s always one, and it always leads to the explanation.
In this case, insurance companies have made such an absolute ass ton of money by killing off their customers that they have become a political entity. They now use their deep pockets to lobby politicians to keep their scam legal.
This is 100% the answer
They’re technically not making treatment decisions, they’re making payment decisions about treatment decisions. Effectively it’s a distinction without a difference though. And it’s usually a “doctor” working for the healthcare company rubber stamping the denials. It’s a thoroughly shitty system.
Specifically, it’s the doctors who technically passed med school, but only just. They’re not going to practice medicine anywhere else, but they can make good money writing up legally protected reports that say “in my professional opinion, this patient’s lack of arms does not prevent him from going back to his roofing job”.
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People love to shit on the VA, because they’re the largest American healthcare provider in the country so there’s a lot of bad stories
But my last MRI went like this:
Doctor: you need an MRI, let me check if it’s open. (Less than a minute on laptop). Ok, go down to room ____ and they can get you in now.
There’s a huge up front cost for that machine, so for profit hospitals went everyone to use it to make the money back, and insurance wants no one to use it so they don’t have to pay.
Take insurance out of the picture, take the hospital trying to make money out of the picture. And it’s really that easy. No one pushes for unnecessary tests, no one tries to prevent necessary tests. And there’s a huge push towards preventive medicine, because it’s cheaper to catch shit early.
We already pay more than what it would cost, it’s just the healthcare industry donates to both parties, so as long as both standards are “at least they’re not the other team” shits never going to get fixed.
If we hold higher standards than that, it won’t take many election cycles to get change to actually happen
It’s cheaper to catch shit early.
This is a huge takeaway. Insurance doesn’t care about your longevity, health, quality of life or even long term costs.
People hop insurance providers all the time so the companies are literally focused on profits quarter by quarter.
On the flip side, I can’t imagine being the person arguing for the insurance companies makes them a better or happy person in the long term. Being a devil’s henchman, over time it must destroy important parts of them like empathy, trust in people, and their basic human decency. Virtues that are needed now more than ever in society.
I expect it’s like any call center - the computer spits out a result and they have a script to follow, and are not allowed to stray from the script
Well yeah that’s why they keep doing it
And some doctors themselves will be hesitant to give care that might not be provably required beyond all doubt but is objectively prudent.
I feel like we’re getting to the point that this needs to be an election deciding issue. It won’t be this upcoming election, but probably the one after where the presidency isn’t on the line. We need to ignore republican/democrat talking points and elect based on a will to completely revamp the system. Obama tried but it didn’t go far enough. Once its bad enough that people are willing to cross party lines to fix it, then you’ll see change, and I (probably too optimistically) think we’re almost there.
Hospitals should unionize and sue the the ever-loving shit out of insurance companies for lost time. Not like our neoliberal politicians are going to do anything about it.
Universal health care? I don’t want government making my health care decisions! We have for-profit companies for that.
Death panels?
Believe it or not, that’s also Frank.
Fun fact, he was named after the health insurance industry’s inspiration, 1789 France.
Frank is a busy man. Denying medical treatments, sitting on death panels. Is there nothing Frank can do?
Oh yeah, Frank can’t approve medical treatment.
i have a friend who’s a transplant patient and has been taking the same meds for over 10 years post transplant-- every year it’s a furious battle with insurance who, every year, decides the meds are no longer “medically necessary” and drops coverage for it. fucking helloooo these are anti-rejection pills, the textbook definition of “medically necessary.”
it’s not that insurance companies are stupid, it’s that they’re saving money on people dying when those people don’t get what they needed to live.
insurance is the biggest fucking scam of all time
I don’t get it why americans still put up with this if I suffered from that in France I would just leave my country.
The insurance system does not work in the medical field, it would never work because insurance is for managing risks that are unknown, like a house flooding or your car getting hit in an intersection.
In medical “insurance” it is often dealing with known issues, and the insurance system is just not set up to deal with preventative care, annual check ups, mammograms, blood tests, or pre-existing conditions. It would be like trying to use car insurance to pay for an oil change, which is just as ridiculous as it sounds in your head.
That’s exactly why the term “insurance” should be used when discussing a single payer system, it’s not really insurance, it should be a collective action group that works together with the medical community to find a middle ground where hospitals can still exist and pay wages to their staff, the people can get the medical care they need without getting thrown into poverty for daring to get sick, and the government benefits from having a healthier population as a whole.
Too bad theres way too much money in the short term in keeping this all private, and having a sicker population, so we have decades of insurance company propaganda to work against, and a huge population of people that don’t understand that by doing single payer health care your taxes would go up, but you also wouldn’t be paying out the nose for medical insurance & medical care (because they don’t cover anything). Also think of a world where your health care isn’t beholden to your employment, all the different choices you’d make in your life.
But insurance companies said that if everyone paid for insurance, especially the people who don’t need it, that costs would go down
I have a chronic condition that requires expensive medication. Every. Single. Year. I have to fight insurance to renew the prescription. I went without for months the first time and ended up needing a far more expensive surgery to fix the damage it caused. I was already pretty left-leaning before my diagnosis, but now I don’t believe there is any justification for private anything in healthcare. It’s a completely morally bankrupt business to be making money off of people’s unavoidable suffering.
The cruelty of the US American for-profit health system is what should be uniting all US Americans in protest, riot, and violent overthrow of the current system.
Frank didn’t even look at it. He just fed your claim into their computer and it spat out a rejection.
Bold to assume he bothered to feed it to a computer when you can just reject without having to do that. Feeding something to a computer takes time, and time is money y’know.
Frank bought a self-inking stamp that says “REJECTED” and saw a 70% productivity increase.
Frank has management written all over him!
Nonsense. Frank was replaced with an AI years ago. It only took a half hour to train on a Raspberry Pi.
Everything is filed electronically, having a person step in will always be more work and money dude…
And leaves a nasty paper trail!
If check: accept
Else: reject
Had my buddy over who brought over his incredibly questionable 30yo brother who shared some real incel levels of talk. He used my bathroom and asked if I wore tampons since a pack was visible. Like bro, I have a wife and a daughter.
Anyways, that guy works in health insurance!
I don’t know how much decisions he can actually make. But that dude has a middle-school level education about sex ed and struggled to explain what a period is. And he is one of the barriers to approving/rejecting your health care.
“You want me to whip out my dick and slap you with it since that was the stupidest question I’ve heard?”
You should see what @pancakes@sh.itjust.works wrote in this very thread. You basically just answered their question about what this industry must do to a person’s ability to empathize and be a decent person to others. Or in this case, maybe lack thereof is a job requirement?
There’s different teams doing different types of work.
Like the claim system might have it setup so X codes in Y situations can’t be automated. Then someone looks at the claim, determines based on their written guidelines that this one needs to be reviewed so they look to see if there are notes attached. If there aren’t they request the notes, maybe by sending a letter. If there are, they send it to the team that reviews notes and makes these decisions. Those people probably also have written guidelines on what is allowed or not and if it’s more complicated they (should) have someone qualified that can review it. Then the claim is probably sent back to the other team saying “Hey, deny that code and allow this code”, where they then just do whatever that says.
They probably also have situations where X code in Y situation is “never” allowed and the first people reviewing it just always deny it. Then, as mentioned elsewhere here, the provider has to resubmit it and then it’s allowed on “appeal” by another team. This brother you mentioned is probably doing very little decision making beyond applying already decided guidelines to each claim, if he even processes them.
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.
Right, but it might still have to be you paying, insurance or no.
