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 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.
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.
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."
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.
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.
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.
The private for profit health insurance industry - because what could make number go up better than a (LEGALLY MANDATED) do nothing middle man who's only purpose is to take your money and ensure as little as possible is spent on healthcare sitting between you and not dying?
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.
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
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.
Maybe if you can't afford to pay premiums that allow you to have an IRM, just
don't indulge in expensive illnessesdie already.tl;dr: It doesn't.
This shit really needs to end.
My $7000/mo medication has a bunch of "cost relief" programs so they can pretend that they give a shit about affordability, then when you actually try to use them they make you do like 20 phone calls over the span of several months until they finally let you enroll and when you do it only lasts for a short amount of time before they kick you off and you have to start the process all over again. I've had to miss multiple doses of the medication which is dangerous for my physical health because I don't have the money to pay for it and this process takes so fucking long.
Recently, they signed me up for some super shady thing where I pay for the medication upfront and then they pay me back after showing me the receipt. What they didn't tell me is that it has a limit for how much it will pay for, so I pay for the medication, and what a surprise, they rejected my claim and now I lost $5000 to the medication, which could have paid for a car or a semester of community college. Our healthcare system does a great job at making dying sound like a decent alternative to healthcare.
Yes I would like to change this, too. Who do I vote for to make this happen? Just kidding I don't have access to $10B of "free speech."
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.)
Sure we could save lives by listening to doctors! But who will save our dollars, huh? The REAL value!
America is one of the richest countries, but life expectancy is so low because of all these inequalities and shootings.
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.
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
Can someone explain how universal healthcare would solve this issue? It seems like an additional problem beyond the fact that prices are gouged based on insurance that not everyone has. On top of that bullshit, insurance does this stuff. What about universal health care, if implemented tomorrow in the US, would make it different?
(Side note: I love how I get all these downvotes for trying to learn more! What a fucking asshole, right? Yall are too used to trolls, grow up and humble yourselves. Learn to distinguish asking about how barriers work from advocating for those barriers to stay. Jesus fucking christ some of you are so much dumber than you realize you are.)
The health insurance company has little motivation to care about your health, but doctors have little motivation to care about money and money is actually important too. Ultimately you end up paying for all that unnecessary testing and there has to be some mechanism for controlling cost.
With that said, one time I was appealing a rejection of home care for my grandfather and I mentioned that his condition had declined and he was currently in the hospital. The guy from the insurance company said that clearly someone in a hospital doesn't need home care and so my appeal should be rejected and I should file a new claim (which can take months) after my grandfather was home again. The arbitrator didn't agree with that (although she said that she could postpone the hearing until he was discharged if that was what the insurance company wanted) but I was still so angry.
