Is there some law protecting the insurers from class action claims?
Pharmacist was shocked.
...To briefly reiterate one example, a local Chicago-area university-health-center-based orthognathic surgeon who personally examined a subject determined the medical necessity of a procedure. UHC had an ENT in Baton Rouge look at no scans, but just the request, and "determine" that it was just an overbite (or an underbite, as it was then called in the next sentence) and did not require the procedure.
If I'd been a meanie, I'd have filed a complaint against this goofy ENT's medical license. It's evident that there are medical professionals out there who are just rejection machines who are paid a piece rate.
An appeal letter telling them we’re hiring a lawyer
ends up with them paying.
I feel bad for those who are afraid to “ fight city hall”
and just pay it out of pocket to avoid conflict.
If I had a choice I’d dump these fuckers in a minute.
It used to be that if you wanted to appeal/do a peer to peer, you called up the number and would be transferred to a physician reviewer immediately. It was annoying, but at least you could get a thumbs up or thumbs down for your patient right away.
Now, if you call, you get put on hold and once you finally talk to a person you have to set up a future appointment to talk to a physician reviewer. That’s usually at least several days afterwards and you have to make sure you have time set aside and have the chart up and ready to go.
They also now send a letter to the patient placing the blame on the physician for not supplying enough information for them to approve the procedure or test. This leads to the patient becoming irate not at their insurance company who denied the claim but the physician’s office. In my case at least, it’s almost always nonsense as while I have many faults, detailed note taking isnt one of them.
If you had told me 15 years ago that I would be in favor of a single payer health system, I would have figured I must have lost my marbles. But the whole current system is so screwed up, I’d take it over what we have now. If all the people in the current health insurance system lost their jobs tomorrow, I wouldn’t miss a minute of sleep.
They also fail to call at the appointed time. We are getting denials from many insurers, UHC included, for doing multiple procedures in a visit which is annoying for both us and the pts.
The insurance companies at this point are corrupt and beholden to profits. From a state legislative level, just when you think things they are telling the legislators and policies they are enacting could not get more comical, they do.
That being said, the health insurance companies are so ridiculously powerful at this point that I don't see any possible exit strategy. They own the legislators, they own state and federal regulatory agencies, and physicians are stuck holding the bag
We have an issue going on right now with CMS over Medicaid Managed Care reimbursements. In the past, when this particular policy was enacted in other states, within 12 months CMS shot it down (while the insurance companies pocketed the difference in the meantime). In Virginia, CMS approved it, despite federal law actually clarifying even more than before that it is illegal. Shortly after, that person left CMS for a lucrative job with Anthem. Her replacement...delayed review for a year, then took a lucrative job with the health plans. So for 2 year the health insurance companies are pocketing (through decreased reimbursements...this is above an beyond their normal profits) between $25 and $75 on nearly every patient that comes to an ER.
Eventually a single payer could deny claims to meet budget, and insured patients have no recourse or alternatives. At least now, other companies ostensibly exist to provide an alternative to UHC and Cigna’s denial of claims and therefore a more desirable option.
However right now healthcare is controlled primarily by insurance companies, and to a lesser degree hospitals, and patients/doctors are caught in the middle.
Also, even the majority of government payor contracts are administered by managed care organizations that are paid to administer the Medicare/Medicaid plan. So the private company still benefits from not paying, even when the government is the original payor.
The government is inefficient, but at this point I'll take inefficient over evil.
for most people. Few people get to choose their health insurance company. It is done for them by their company’s HR exec and CFO. Those are Cigna’s true customers.
The cost to the employees is paramount in our decision process. It’s not quite as comfy a relationship as you insinuate.
and the nuances of service will rarely be apparent in that process
By not approving claims. It's all a big vicious circle.
A large portion of most outpatient docs day is fighting these denials. That takes up time that could be used seeing other patients.
Then there's the fact that some percent of patients will switch insurance or die in the window you're denying them. As long as that outweighs the likelihood they end up in the hospital and cost you more than they otherwise would. You win.
Then you get large systems over billing in response because of their incentives, and a lot of money gets tied up in an arms race to fight the claims process better.
Every actor is doing things that are in themselves rational, but it creates a highly irrational system.
I am saying the individual does not have much or any say in choosing the insurer. Or has the ability to switch to another if they find the service provided unacceptable. It is a fundamental problem in our employer based system.
It is good that you strive to get the lowest cost for your employees. I suspect that for most of them that is the prime concern. For me it was secondary. However at no time in my career did I have any choice in insurance companies. That decision was always made for me.
The fact remains that the employer is the primary customer, not the individual insured.
Providers can go out of network. Employers can select a different plan. It’s not happening, but it’s at least possible in a way that isn’t with a single payer employing the same predatory strategy.
We’ve got one plan to choose from, only option is the level of deductible.
When I lived in Cali, we could opt for Kaiser HMO or HDHP, but even the Kaiser option was eventually scrapped by my company.
Do most companies give multiple options?
It is only employers and providers who have any leverage when the insurance companies behave badly. But optionality for those constituents theoretically keeps worse behavior in check. My point was to refute the claim that “single payer is the only answer”. I think the lack of optionality means that is not the case. In fact, one of the cases for single payer is that it will reduce cost specifically from the leverage the singular payer will have over providers.
Germany, France, or Switzerland than the UK. They've shown what happens when the government has the option of slowly gutting the system to balance the budget.
JAMA put out a policy editorial proposing we create a regulated exchange that rationalizes/places rules about how insurance companies and hospitals interact (basically take away the incentive to overbill on one end and blanket deny on the other).
I'm not sure if the public realizes that medical funding is close to 50% government funded. We haven't had a "free market" system in a long time.
I was contrasting the Bismsrk model with that. I think that
A) it's more likely to get to through gradual reform/evolution and
B) Harder to screw up in the long run (more actors to stop you from arbitrarily freezing benefits) and
C) easier to incorporate supplementary insurance/split off things that are able to be priced in a more free market manner.
I think proposing single payer gives insurance companies something to run against (big gov taking your docs away) vs attacking insurance companies for distorting the market and regulating them.
Granted, the new way to attack reform seems to be calling anything that reduces spending cutting Medicare, so this probably won't get resolved until we're staring at the edge of the fiscal cliff.
Prompt: Write an appeal letter to an insurance company from a physician regarding denial of a chest CT to detect metastatic disease. Make the tone aggressive.
Dear [Insurance Company],
I am writing this letter to appeal the denial of coverage for a chest CT to detect metastatic disease in my patient [Patient Name]. As the treating physician, I am deeply concerned about the decision to deny coverage for this essential diagnostic tool, and I urge you to reconsider your decision immediately.
As you are aware, early detection of metastatic disease is critical for the successful treatment of cancer. The chest CT is an essential diagnostic tool in detecting metastatic disease, and its denial will significantly impact the ability to detect cancer early and treat it effectively.
The decision to deny coverage for the chest CT is not only concerning, but it is also unacceptable. This denial places my patient's health and life at risk and disregards the medical necessity of this diagnostic test. The denial of coverage for such a vital test sends a message that your company prioritizes cost-saving over the well-being of your policyholders, which is utterly reprehensible.
I cannot overstate the urgency and importance of this diagnostic test in the care of my patient. The denial of this test places my patient at risk for delayed detection and treatment of metastatic disease, which could result in a poorer prognosis or worse yet, death. As a physician, I cannot and will not accept that my patient's health is being compromised by a decision made by an insurance company that lacks medical expertise.
I strongly urge you to reconsider your decision and provide coverage for the chest CT for my patient, [Patient Name]. I implore you to put the well-being of your policyholders first and foremost and to provide the necessary diagnostic tools to detect and treat cancer early.
If your company remains unwilling to cover the chest CT, I will be forced to escalate this matter through all available channels, including but not limited to legal action. My patient's health is my top priority, and I will not allow your decision to jeopardize their well-being.
I expect a prompt and satisfactory resolution to this appeal. Thank you for your attention to this matter.
Will be fun to watch