A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

If you&#x27;re a tech entrepreneur, it&#x27;s the first story in here that should alarm you the most. It&#x27;s about denying coverage altogether, not about denying individual claims. Outside of the &quot;guaranteed issue&quot; ACA market, there is virtually no due process for coverage denial. You can be denied on a whim, with little recourse.<p>The list of conditions for which insurance outside the ACA will be denied is long and opaque. The story makes it sound as if they&#x27;re looking for reliably diagnosed conditions like diabetes. No. They&#x27;re looking for <i>indicators</i> of a long list of <i>potential</i> conditions. If you or your spouse has a functioning female reproductive system, the chance of your family being denied is high, even without a diagnosed or treated condition. We were denied for something like that, and also because my daughter had an unexplained seizure when she was 4 (she&#x27;s now 16 and just fine). To get insurance for the first couple years of Matasano, my wife had to take a crappy full-time job with group coverage.<p>Without insurance, a typical working family is one major medical incident away from zeroing themselves out. My daughter has never met a pickleball net that didn&#x27;t break her ankle (she has met one pickleball net). Even with insurance, the cost of that injury was high single-digit thousands of dollars. Without it? The cost of a pretty decent car. Find a friend who&#x27;s had an appendectomy some time and try to find out how much the insurance company was (nominally) billed for it. A down payment on a house.<p>If you work in this industry, intend ever to start your own business and potentially have a family at the same time, you should be extremely alarmed at the prospect of guaranteed issue regulated health insurance (the ACA) being replaced.

This is a good article, but it only shows a few parts of a much more complex whole, and extrapolating from these anecdotes to a broader system is not really accurate<p>Many hospitals lose money on every Medicare and Medicaid patient. The only reason they survive is because they can charge private insurance companies more. So hospitals and health systems have been consolidating to strengthen their negotiating position against insurers<p>This article paints Medicare as the good guy, private insurance as evil, and hospitals as mixed. The reality is more complicated, and more regional, but overall healthcare is a zero sum game today between payers and providers fighting for dollars, and power comes largely from scale. In geographies where payers are bigger and stronger, they push hospitals and force many to consolidate or die. In areas where hospitals are stronger, they basically dictate price and rates can skyrocket<p>There&#x27;s a lot of bad stuff happening on all sides, and it isn&#x27;t clear that private insurance is always evil. If we become a single payer society, small providers that are struggling to survive will probably be the first to die, and providers will probably consolidate much more aggressively into massive national chains, like the Walmart of healthcare<p>The cause of a lot of healthcare issues is not one particular party (insurance, Medicare, hospitals) but a system that encourages monopoly seeking behavior without any good mechanism for regulating this

This story is couched in terms of how bad things were <i>before</i> Obamacare, but I’d like to point out that things aren’t great now either. To prevent Obamacare from bankrupting them, insurance companies are resorting to legally dubious mass-denials, one of which affected me personally.<p>A few months ago, I woke up the next morning after eating some fast food and began vomiting. I couldn’t stop throwing up, and I couldn’t eat anything, for 2 straight days. I had a 101 degree fever at the worst point. At the beginning of day 3, when I vomited so hard that I passed out for a few seconds and fell on the floor, I went to the ER. They gave me IV fluids and anti-nausea medication, which worked.<p>About 2 months later, I received a letter from my insurance company (Anthem). They had determined that my situation didn’t qualify as an “emergency,” and therefore they were denying the entire bill for this ER visit. I have appealed, and so far it has not been overturned. I am now on the hook for thousands of dollars, even though I had already covered my entire deductible for the year.<p>I thought that this had to simply be a mistake, but then I learned this is actually a new policy that insurance companies are implementing in the era of Obamacare [1]. Patients are expected to self-diagnose whether or not their situation meets their insurance company&#x27;s definition of an “emergency,” and are rolling the dice as to whether or not an ER visit will be covered.<p>[1] <a href="https:&#x2F;&#x2F;www.vox.com&#x2F;policy-and-politics&#x2F;2018&#x2F;1&#x2F;29&#x2F;16906558&#x2F;anthem-emergency-room-coverage-denials-inappropriate" rel="nofollow">https:&#x2F;&#x2F;www.vox.com&#x2F;policy-and-politics&#x2F;2018&#x2F;1&#x2F;29&#x2F;16906558&#x2F;a...</a>

It&#x27;s hard to believe that the country is putting up with a system that can bankrupt you any time you get sick and there is pretty much nothing you can do other than being lucky or having a lot of money already. The actual medical care is fine but the billing practices are just ridiculous. I would call them fraudulent in a lot of cases.

Every health care system rations care since no current system has enough resources to care for everyone without some form of waiting. The U.S. health care system rations care in the most immoral way of the advanced nations. A person should not profit by denying care to someone else.<p>As a nation we should try optimizing for a more moral, just system. As I see it that would be something like Medicare for all but I&#x27;m open to suggestions&#x2F;solutions.

I&#x27;m old and deal with the health &quot;care&quot; system more than anyone else here. What I&#x27;ve learned: 1) You are responsible for your own health. Eat less, eat better, and exercise more. Get enough sleep. Don&#x27;t over worry. Don&#x27;t drink too much. Don&#x27;t touch recreational drugs. Your own health must be your number one priority. Teach your children this, too. 2) ACA, for whatever problems it caused, will save many of us from bankruptcy. &quot;Us&quot; being everyone who is or wants to be a founder. 3) The biggest problem with health cost is lack of transparency. If I could shop around, even a little, I could save tens of thousands of dollars a year. But it&#x27;s hard to negotiate for price when nobody knows what anything really costs, or what you actually get for that cost; even the people selling it. 5) Every day you are in good health is a good day. Thank God, nature, or other deity(s) of your choice for your lack of health problems.

I&#x27;ve begun to suspect is that &quot;universal healthcare&quot; means &quot;you weren&#x27;t denied, you&#x27;re just on a waiting list, and every physician is an interchangeable cog&quot;.<p>I often wonder why health insurance companies don&#x27;t use a similar tactic.<p>Edit: Try finding a pediatrician in Berlin. (Seriously, I would love to hear recommendations)

That&#x27;s a very interesting insight into the world of American healthcare and privatized healthcare in general. Previously I thought that all these statements about the US healthcare system were seriously exaggerated, but I guess I was wrong. It&#x27;s kind of terrifying that being sick excludes you from access to healthcare. In my experince, public healthcare has many problems, but you get what you need.

This is why I prefer Europe over US: we have realised healthcare is a human right, not a business.

Healthcare is a basic infrastructure problem, not that it is considered this. As a basic infrastructure problem, there are many who see a profit to be made in supplying services. Each country views healthcare from a specific point of view and that dictates how they will, as a country, provide the general healthcare service.<p>A country like the USA see this in the light of healthcare as a business, make as big a profit as you can, irrespective of the actual services that you provide. In other countries where the relevant governments provide universal service they allow private businesses to dictate the price that the government pays for the supplies required.<p>So, we have general commodities when supplied into the healthcare system being charged at 10x or greater for on item which, if not used in a healthcare environment, is charged a much lower price. This applied to things like computers, phones, chairs, tissues, matches, paper, toilet paper, gloves, etc,<p>The suppliers get away with this because of the perception that these goods are of a higher quality. These goods often come off the same production lines as those sold in a normal commercial market.<p>I have seen up to date medical equipment that cost a large fortune that looked pretty, but if you actually looked at the basic equipment was technology that was anything up to 10 years old and was superseded by stuff your could get commercially.<p>The amount of money charged for drugs is based on the amount of money spent of research, which if you actually looked at the figures thrown about were spent by the public purse not the private.<p>It is a captive market and those supplying into it want it that way to maximises their profits. Morality questions are not considered to be important unless it has regulatory considerations that will significant reduce your profit margins if you fail to live up to them.<p>The problems within the healthcare system (insurance included) will not be solved any time soon. Even if there was a revolution that changed the entire basis of how and when healthcare was supplied, it will soon return to what we see today as greed is the basic motivator for society as a whole.<p>To bring about real change requires people really changing and this will not happen because we are basically looking out for ourselves and our own. This occurs on the local level, on the regional level, on the state level and on the national world levels.<p>The healthcare system is an area that needs a complete overhaul worldwide. It is not going to happen since most people do not have the ability to see past their local situation.

This is a sickening and inhumane system

This is sickening