“We thought it might fall into a legal gray zone,” said the former Cigna official, who helped conceive the program. “We sent the idea to legal, and they sent it back saying it was OK.”
Reading this article is just maddening. I've been dealing with different insurers for the past 7 years or so, and it's my experience they must all do something similar. Anyone with any kind of serious health condition is regularly driven CRAZY dealing with insurance. It's just an insane and broken system.
Wife is a nurse. Required surgery for lifesaving/severe disability (inherited congenital, killed her father). Insurance was Aetna and Hospital Self Insured. Surgery recommended by world class surgeon she worked with.
Finally pre-approved on 3rd appeal after 8 months and 150pages of documentation of every piece of every single communication (who, when, response, expected next contact) only weeks before surgery scheduled >6 months before. First rejection was automatic, second was revealed to be a dermatologist, third was a gynecologist. (They really hated that we figured out who the person was, their specialty, the state they worked in, and pending disciplinary actions).
Standard answer is we can't tell you why you were rejected (code only) because the criteria are from a third party and their review document is proprietary. When you find an online leaked document with the same code it says "unnecessary cosmetic surgery". Wrong contact numbers are provided, people go on vacation and do not respond for weeks, "that person doesn't work here".
If you're not a professional in the field with time on your hands and a detail oriented A-hole, you will be denied anything expensive that isn't considered immediately lifesaving at a trauma ICU recommended by the attending.
After pre-approved surgery with excessive blood loss and an extra 12 hours in recovery... Overcharge/All-claims-denied. Multiple appeals until involving Hospital CFO who agrees to split the extra (self-insured) cost of the insurer and get the final insurance reimbursement check... it is $3k less than promised (hospital paid the correct amount). Surgeon was going to start charging late fees and interest or send it to collection after 4 months.
The sneaky thing to do is have your attorney send a letter to the insurance carrier's liability insurance provider, detailing everything you uncover and that they will be on the hook for the malpractice claim. That will get you an highly aggressive advocate with teeth.
This is excellent advice, and isn't restricted to the medical arena.
Corporate counsel for insurance companies comprise one of the very few spots on the brontosaurus with low-latency innervation from the brain. Poke it, you'll usually get a response that will arrive faster than the usual appeals processes.
Is "not perfect" strong enough criticism if people are being covered by services that do nothing? Today's article is saying that that large insurers might just be rejecting claims without reading them. Without the ACA, presumably money wouldn't be being spent on companies that literally just take the money for compliance reasons then don't provide a service.
This is one of the more annoying failure modes of socialised medicine; when things go wrong the consumer has no control over the waste because they aren't in control of the money being spent.
Absolutely pick a different phrase, but it'll still have applied before the ACA and it'll apply after except for people with preexisting conditions, eliminating lifetime caps, and maximum out of pocket limits.
Like Bernie Sanders? Who was then placed in a debate in an “insurance town” where every audience question was some insurance leech complaint that his plan would destroy their jobs? Yeah dude. That’s the point, your job is bullshit and you shouldn’t be doing it.
The media also loved to bring on people who “adored their current insurance plan and would hate to lose it”. I’ve never met someone like that in real life, but the MSM would have you believing you
were the only one in all of America who had any ill thoughts about their insurance company.
There’s nonviolent revolution, too. But it’s still likely to yield violence in response because these systems are inherently violent and ultimately enforced with violence.
The mainstream media also doesn't mention that Americans already spend, on a per capita basis, the most on socialized medicine on the planet. I wonder if it has anything to do with those drug commercials that they play constantly?
By my understanding, that's the most on health care. This includes private insurance premiums, which is why the "we like private because it's cheaper" argument doesn't hold water.
Interesting. In the summary, it's not clear what qualifies as "compulsory health insurance":
> Health care is financed through a mix of financing arrangements including government spending and compulsory health insurance (“Government/compulsory”)
Digging into the source report[0], we see the following footnote exclusive to the US:
> All spending by private health insurance companies reported under compulsory health insurance. Category “Other” refers to financing by NGOs, employers, non-resident schemes and unknown schemes.
The root is you. The root is people believing they can change things. The far right believed it and has (unforunately) achieved inconceivable successes based only on utter bullshit and madness.
That’s one way of looking at it certainly. However I’ve never in all my life voted in any election where my vote had any capacity to have any bearing whatsoever on the outcome of the election. This is by design: America is about clumping people together into voting blocks so large that first past the post dynamics prohibit any but the most conventional of viewpoints rising to the surface.
What have the “far right” changed? And was it through voting or other means? In a sibling I admit violent revolution as a plausible change causer, and claim it is unique in that regard.
So, no, definitely not perfect. Also, some people are alive today because of it, and many are healthier. I'll take that over a better reform that doesn't get passed, and keep working to elect the people necessary for better reforms in the future. This stuff just doesn't happen overnight, sadly.
I’m a U.S. voter, so yes I’m part of this collective failure to vote well/convince my countrymen to vote well. I’m not sure why you think I’m blaming somebody else?
You talk about a 'system'. The system is in the mirrors, yours and mine. We are it. American tradition is that one person makes a difference, which seems pushed aside now by the fetishization of despair and doom.
Also, it's about far more than voting. Voting is done every once in awhile. Citizenship is every day. Powers-that-be are watching and investing enormous energy in manipulating public opinion - for a reason. It's powerful. Today is the day to act.
I’m not sure that our comments are really all that connected, I used “single payer healthcare system,” as in the term-of-art for a way of distributing funds for healthcare. You seem to have gotten latched onto the word “system” and seem to be using it in a sort of broad “fight the system” way.
There definitely aren’t any healthcare systems inside of my mirror, not even the bathroom one with a cabinet behind it.
I mean, I don't want to say "start shooting them until they get the message that we won't put up with their bullshit", but I honestly can't think of a better plan given that people will find all sorts of excuses to keep voting for the kinds of assholes who prefer it this way.
I'd really like to hear one, cause the violence option isn't really very appealing.
This. So, so, so many flavors of the "abuse of the public to make a few bucks" that is codified in the business models and job duties and KPIs of all sorts of organizations is only viable because people bend over and take it. If there was real risk that came with abusing the public employees would either a) not do that part of their jobs b) demand compensation, likely making the abuse not economically worthwhile c) seek other jobs. Any of these cases would force entities who are abusing the public as part of regular business to change their business or bleed out and die.
To the extent there is anything that can be called "objective" morality, betraying social contract and causing other people to suffer for your own profit is going to be on the "wrong" side of that.
Going all philosophical here is, what, you making excuses for being a monster? Because what you're saying is that ruining other people's lives for your own profit is fine.
And yeah, violence is an extreme and distasteful solution, as I said. But if the only other option is to suck it up and let the exploiters win, then that's on them. You don't get to have a hypocritical morality system where it is ok for you to inflict harm on others for your own profit and not ok for them to inflict harm back in self defense.
Seriously consider a universal healthcare. Accept that it will be imperfect, but more balanced and will offer a chance to everyone. Another way to look at it: everyone pays for a healthcare insurance --> everyone gets covered.
Universal healthcare falls victim to the "I'm an above average driver" brainworm.
"I'm a healthy 22-year old male with no family history to worry about, go ahead and ravage the program to save me a nickel on taxes."
or, from the other side,
"I might need an ingrown toenail treated and how dare that go into a triage list and I have to come back in six months because there are more seriously ill people-- don't they know I'm rich and important?"
Every business has insurance, including insurance companies. This is because they specialize in their own business and outsource non-core business.
An insurance provider for a specific industry has teams of skilled attorneys that are expert in that specific domain. Cigna might self insure if they consider medical malpractice a core part of their business. In that case, your attorney sends the letter to their corporate counsel.
Often times, day to day business people just ignore liability risks because it's not in their core mandate. But the corporate counsel is in charge of managing legal risk, and they will see such a situation as unacceptable. Corporate counsels also hold a lot of sway within a businesses structure.
> Standard answer is we can't tell you why you were rejected (code only) because the criteria are from a third party and their review document is proprietary
So you paid for a service, and you don't get the service you paid for, and you will not be told why?
If I did this in my line of work, I would be in prison for fraud.
Here’s an example of something that happened to my sister that isn’t exactly the same, but is the same sort of philosophy in action.
My sister was the manager of a coffee franchise named after a certain character from classic literature. Her location was doing extremely well, she was a competent type-A who commanded a great deal of respect in her entire district, and was generally assumed to on the fast-track for promotion.
One day, $200 was missing from her daily cash. She was fired the next day. Not for the missing money; they came showed her a list of very minor issue (clerical errors, an unwashed countertop on a random inspection, a couple unhappy customer feedbacks) that had come up in her eight-year career, and said she was fired for general incompetence.
Two weeks later, one of her ex-employees called up, crying; she was doing her laundry, and found $200 in one of her pockets. She had gone to the safe to make change for the register and screwed up.
The point here is: corporations understand that you can't fire someone or deny coverage based on reasons that can be contested. It's not fraud if you fire them for some other reason. It's not fraud if you don't even know why you denied coverage. You're only in trouble if you play fair.
We’re Americans and we love this sht and it's no wonder the CEO of that coffee company thought he deserved to be President.
I don't think you understand. They only have to make case for "their end" to not apply to the specific case, and it's okay. Same as firing someone for incompetence because you suspect them of theft. Realize, an employer has this option always. Why bother "playing the game".
> [...]you can't fire someone or deny coverage based on reasons that can be contested. It's not fraud if you fire them for some other reason. It's not fraud if you don't even know why you denied coverage.
That is a good question. The first appeal was "free" so we didn't have to justify it with anything other than, "no really the surgery is necessary". They only gave us a rejection number on the second and third rejections and we had to request the written forms by mail, which took weeks. The written form didn't have much more, mostly boiler plate, but it did have the number (and maybe a chapter/paragraph number citation?) and on the second one it had a signature by the reviewing doctor along with his typed name, which was luckily relatively uncommon. We had to provide statements from our doctors and surgeon (who also didn't get a reason for the refusal) justifying the surgery's need and effectiveness.
From the doctor's name and the Midwest area code for review center we were able to filter down the doctor's name to a single individual and then do a search in the state medical board system (I'm not sure if this is readily available to non-medical personnel). That popped up his med school, residency, work history (ended more than a year before) and some pending issues with his performance. When we replied by registered mail we made an obvious CC to a local lawyer.
Speaking to the surgeon we were also able to makes some guesses as to the rough name/title of a justification document they would use and that along with the citation number in a google search popped up a downloadable pdf which was 5-6 years old, but seemed about right. And when we looked up the paragraph and rejection it was pretty clearly related to roughly the right kind of surgery. That let us make a more focused/documented appeal to the rejection. When they finally approved we got a bit more documentation about the prior rejections and who reviewed them. I assume ass covering.
In the end the thing that really pissed me off is that they didn't even pay what they promised to and we knew it would another 100hrs of work to get it.
Edit: we paid ~10% out of pocket on a $60k surgery + their shortchange. good news is 15y later totally successful and healthy!
P.s. this is by memory but somewhere we’ve still got that notebook and all the paperwork filed that I’d rather forget.
How on earth can some one read this and think that the American Health System isn’t fucked up?
Can someone explain to me why the model we choose to pay for the health for the populous of this country is through insurance and not straight up taxes??
Because it works well enough for them now, and they seem to have no capacity to either understand or care that others are suffering under the same system. For some, the demand for maintaining the status quo is far more cruel.
> Even on death’s doorstep, Trevor was not angry. In fact, he staunchly supported the stance promoted by his elected officials. “Ain’t no way I would ever support Obamacare or sign up for it,” he told me. “I would rather die.” When I asked him why he felt this way even as he faced severe illness, he explained: “We don’t need any more government in our lives. And in any case, no way I want my tax dollars paying for Mexicans or welfare queens.”
America's health care system is shaped and maintained by those who benefit economically from its configuration. Configuration maintenance tools include lobbying, gerrymandering, targeted tax favors, and wide dissemination of misinformation.
It's a very small fraction of "we" that maintains this status quo.
All it takes is a last name. You dont even need a first name or state I believe, although you may need a lot of patience and some luck to find the right "smith" without a state. Once you have at least a last name, you could look up the doctors specialty even practice address in the public NPES system.
Good for you though! Never though non surgeons would review surgery claims. Seems insane to me and grounds for a professional liability suit
You do need access to the state board if you want to check out complaints. i dont think You will find much though. Doctors rarely get "written up"
Good grief. I'm sorry you had to go through that, the bureaucratic trauma involved in health billing/insurance increasingly seems as bad as or worse than the medical issue itself.
It was definitely a learning experience. If you're in the hospital under a doctor's care it's a lot easier, but if you have major (expensive) preventative care, then the insurers want to discourage or delay that as long as possible.
Instead of paying monthly insurance premiums, the company directly funds the claim payments as they come in. They outsource the work of adjudicating claims, negotiating with providers/facilities, cutting checks, setting approval criteria and first level appeals to another company, called a Third Party Administrator.
Now, who happens to have all the skills and expertise to do the job of a TPA? The big health insurers. These are giant companies with many lines of business. One of those lines is selling insurance to individuals and small businesses, another is selling administrative services to larger ones.
Note that even with a self-insured plan, there’s often insurance involved too: the company will buy a separate “stop-loss” policy that kicks in and starts paying after the employer has paid out a certain amount in total over a year. This protects them from the risk of covering a plan member with a particularly expensive condition.
When someone in my family does not get pre-approved for care, I write a letter and and ask my physician to sign, and ask the other doctors at his practice to sign a letter that goes like this:
"I beleive this procedure _____________ is medically necessary for __________. Time is of the essence, and this procedure should be performed as close to immediately as possible."
In the signature block, I include the degree, specialty and medical school of the doctor. I then fax the letter in, and within 30-40 minutes, I have a phone call apologizing for rejecting and giving me pre-approval for the care. I learned about this when my (at the time) 15 year old was rejected for a cardiac procedure and the billing person pulled out a pre-printed deck of letters that was pre-signed by every department head at the hospital. The one thing the insurance people fear most is risk.
This must have been before insurers adopted the mantra "we aren't denying care, only paying for the care!" With that legal magic wand, there is no risk to the insurer.
I have Crohn's disease, and I'm fairly certain dealing with health insurance's ineptitude directly led to multiple hospitalizations and a major surgery last year.
Had it not been for their constant denials of a drug I had been on for over two years prior, I might still be taking that medication instead of having developed antibodies for the 6 months they denied.
My doctors office gave me free samples as long as they were able, but in 2022 they were wiped out as all patients that were on that drug were being denied coverage.
Worse still, insurance recommended "use drug X, which is similar"... but I couldn't because I was on drug X—until I had anaphylaxis from it!
I also have Crohn's and am going through this right now. Months of delays and denials for a new drug lead to two hospitalizations. I'm currently on TPN (IV nutrition) while I taper my Prednisone dose as low as possible prior to surgery.
The funny/sad thing is: between my hospitalizations, TPN and related home health care, and surgery, this is all going to cost my insurance far more than the drug they were denying would have. One would hope this provides them with motivation to better judge the necessity of treatments, but I'm not holding my breath.
It's simple. Some executive gets a bonus soon if he saves the company money right now. Nobody gets a bonus for saving the company money over a 5-year period, and nobody gets punished for costing the company money over a long period either. The incentives are all about the next quarter.
It still doesn't make sense. This whole ordeal has taken place over about 6 months. If anything, forcing me down the surgery route has pulled their costs forward in time, not pushed them back.
Situations like this are infuriating to me. Our healthcare system needs to have some kind of provision for "this patient needs to be on treatment X probably for life. They are authorized for this treatment and subsequent claims will be approved unless there is a qualifying event (e.g. a recall, condition changes, patient and their doctor switch treatment, etc)."
I have UC that's well-controlled with mesalamine, and I've had a few scares (my insurance rolls out a new prior auth every year, and I have to call my provider to have them sign it for some reason, or the new insurance only covers the name brand (not generics) because of PBM antics). The thought of having to come off of mesalamine for even a week is terrifying. I really feel for you because your condition seems much more severe/hard to control.
Why do I need a new prior auth every year? My medication hasn't changed, and neither has my condition. It's a bureaucratic hoop, and if I don't jump through it I get to spend my whole day on top of a toilet. That's a terrible way to treat a human being.
Even from a purely amoral capitalist perspective, I know the cost of my medication is a small fraction of the dollar value that doesn't get generated if I can't take it. I don't benefit and society doesn't benefit if I'm sick - the only group who benefits is the insurance company who gets to pocket my premiums and avoid paying out. It makes me furious.
Here's a simple solution. Insurance HAS to pay if a doctor recommends it. This is what premiums are for. If insurance cannot pay, they can go out of business.
I don't love insurance companies and I don't love the profit incentive they have.
If a patient breaks a leg and a doctor recommends not experiencing gravity for a while, do we fly them to space?
I am using hyperbole to demonstrate a point: there are meaningful economic limits that must be created by some entity and enforced.
What is the value of a human life? The GDP of a nation is a hard upper limit. The total money a particular person in question has access to is the lower limit.
If you run an insurance company (or you run government run healthcare) you can't avoid answering that question with an actual real dollar amount.
At some point spending money on a person with a particular condition does mean that someone else with a different condition can't have money spent on them.
That's why it's better to have everyone covered under insurance, so that the risk pool is larger, and the cost to the individual is lower.
That's why it's important to spend money on research; to develop new technologies and techniques, and improve existing technologies and techniques; that can make cost of care lower.
That's why it's important to have standards of care and treatment, for all medical providers to follow.
I get your example is hyperbole, but just for fun: the space flight would be recognized as an experimental treatment since it’s known not to be a routine/established procedure. Expenses would be covered if a legitimate clinical trial of space flights were being conducted. Otherwise, costs would be out of pocket unless a special approval were granted. If space flight were being seriously studied for an extremely rare disease, it would likely be paid for by the research institution.
You aren't wrong, per se, but until the incitive for the insurance company stops being "maximize profit", they shouldn't be allowed to make decisions about how health care dollars are allocated.
"For every complex problem there is an answer that is clear, simple, and wrong." - H. L. Mencken
Even a moment's thought about the power disparity between an insurer and an individual facing medical problems leads me to conclude your "simple solution" has little to recommend it.
I have an Aetna PPO and experienced a stroke last year. $100,000+ hospital stay and insurance just… covered it. I paid $1,100 out of pocket.
I had a $100,000+ surgery a few weeks ago to repair a heart issue that may have led to it. They just covered it. No fuss, no hassle. I paid $3,300, which was the remainder of my total annual out-of-pocket, and now I will pay $0 for healthcare for the rest of the year.
For the surgery, I called in advance to double check that it was covered and after five minutes on the phone with a concierge they confirmed that it would be covered.
Obviously I am only a single data point and I can’t speak towards other conditions or procedures. But Aetna has done right by me, at least from within the perspective of our insane for-profit healthcare system.
I'm glad you had such a good experience. Not a counterpoint, though.
Healthcare is like running water, bridges, or banking systems - a high-volume system with extremely high stakes. We need many nines of consistency as protection against preventable harm.
There are around ~35M hospital admissions in the US every year. Even if 9/10 patient experiences are like yours, that means more than 3.5 million people had a sub-par experience that year - that's the entire population of LA. We need to strive for a much higher bar of quality and consistency.
I was simply trying to say that, within the confines of the current system, this particular actor has not gone out of their way to fuck me over in the same way that I hear about so many other actors.
I have no idea if my experience with Aetna is common or an outlier. My hope was that by posting this, it would provide a data point for people forced to choose a private health insurance provider in the future. I also hoped to hear from others who had experiences either mirroring or opposite my own.
If I could, I would dismantle our current system in a heartbeat and replace it with some form of single-payer. I can’t, so I tried to provide information about one player within the incredibly fucked up system Americans are forced to operate within.
My father had a stroke here in Ontario at the beginning of COVID. Total out of pocket costs: $0. This includes 2 ambulance transfers between hospitals because our local hospital didn't have the correct facilities for diagnostic imaging. The only real downside of the system in Canada is that medications aren't covered, but most people get some amount of drug coverage in their employee benefits.
Depends on the demographic. Moving away from the rich (relatively) HN-er data point is the american in an average earning job much richer than the european after salary difference and tax?
I personally don't understand where these numbers come from. When I moved to Europe, my total tax outlay went down, not up. Aggregating costs across a large pool (everyone in the country) means that I paid less than I did in the US.
Right, and also the actual cost of the insurance which is about $20k per family of four per year. That cost will be born by the employer, partly by the employee, or by the taxpayer via aca subsidies.
Yes. I would gladly prefer to live in Europe and benefit from a sane healthcare model.
I don’t and neither do the hundreds of millions of others who remain in the US. So for those people, I wanted to provide a data point that might help them when they, like me, are forced to make decisions about their healthcare in this system.
Also this is anecdotal. I too have an Aetna PPO and can tell you of horrid stories and countless hours on repeated phone calls with them.
Not saying you just did this (you obv did not) but as a whole in this country we need to start dropping the “it didn’t happen to me so something must be wrong with you” mentality. It is pervasive in the healthcare topic and unfortunately in many other facets of American life.
Germans in WWII that enjoyed the fruits of the regime have sang its praises - that didn’t mean the war machine on the whole wasn’t decimating the people and their country. We shouldn’t lose focus of how our country is being decimated by our collective ineptitude.
> Also this is anecdotal. I too have an Aetna PPO and can tell you of horrid stories and countless hours on repeated phone calls with them
Please do!
My point was simply to say that this option is one that has done right by me so far. If there is significant evidence this is an outlier experience, I (and I’m sure others) would benefit from knowing so.
As long as insurance is subsidized by our tax dollars and is regulated to include (forcefully) everything, then theres no way out.
For the record, to comprehend what this means from the doctors side, this means that Doctors (and billers) must be aware of every possible permutation that is "allowed" for billing by every insurer, for every CPT (procedure code).
I did some quick math to measure:
A) There are ~12000 valid CPT codes. (I could not google the exact number but CPT codes go from 0xxxx to 99xxx, plus therr are also S codes (Sxxxx), J codes (Jxxxx) etc.)
B) There are 155,000 ICD-10 diagnosis codes [1].
There are roughly 900 payors in USA. [2]
This means there are 1.67 x 10^12 rules a doctor billing insurance must know.
Even if you consider the narrow view that a doctor of X specialty may bill only top 100 cpt codes, for maybe 50 payors, thats still a huge number (25M!!!) because diagnosis DX (I.e. ICD-10) is not narrow and requires knowledge of related conditions - billing z11 is different result vs billing z11.26 and you must know that.
Its insane to think anyone will memorize 25 million combinations to know what to bill or not bill. And this calc does not consider modifiers OR primary DX....
