How medical insurance works

Death panels?

Believe it or not, that's also Frank.

Don't be so sure it would be different. I collapsed, nearly drove off the road 3 times in one week and decided that it was enough and went to the doctor. He sent me home, wrote me in as extreme burnout (completely true, I had to sleep at work for every coffee break to make it through the day and 30 mins before driving home to actually make it). So I thought Great, I will rest for a few months and go back to work after that! Nope. The state heath insurance office said Our specialists decided, that you are perfectly fine. No sick pay. Get back to operating the industrial concrete blender. The health center doctors signed a letter, but no, I was fucked. So on top of this I got extreme financial stress. We got out of this crap by renting our cabin and starting going full into an outdoor adventure business. What a great time. Where was this? In Sweden in January 2019.

Do people believe that there? I can assure you the government has no roll in our health care decisions, and what the doctor wants the patient can always get.

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.

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.

But insurance companies said that if everyone paid for insurance, especially the people who don't need it, that costs would go down

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.

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.

If check: accept

Else: reject

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.

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

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.

And some doctors themselves will be hesitant to give care that might not be provably required beyond all doubt but is objectively prudent.

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.

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.

“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.

Question: how the fuck did any of this ever become legal?

I would guess lobbying.

You do need some checks and balances because what's to stop a hospital from profiting off the insurance companies by asking for a CT scan/whatever of every single patient just because they can.

I suppose we could have the government run the hospitals too. But noooooo, that's never going to work out because communism or something.

Maybe we should try effective altruism and accelerationism instead? Let's just hand over all our money to a few tech bros and then we can go beg them to pay for the scans. And if they don't pay for it, surely someone will come up with a cheaper technology to do the same. Yes, that'll definitely work.

It became legal when we decided medicine was too important to be handled by a free market, and we created a labyrinth of laws governing how medicine must be administered.

I fucking wish. At least then I wouldn't have to be put on hold for 30 min just to have to eventually explain to a person who was hired 3 weeks ago how to do their job.

Private insurance always has you speak to an actual adjuster for authorization, mainly because they know any sort of automated system would be more accurate and faster than having you talk to their undertrained and understaffed employees.

Private insurance's goal is to erect as many barriers between the provider and the patients as possible, and then blame the provider for all the barriers. It works every time.

"I have the best insurance, they told me it would be covered". Nope, Medicare is the best insurance and you traded that away for a privatized Medicare supplemental that lies to you about your coverage.

Sometimes the Frank is an AI that is wrong 90% of the time. That's fine, because reasons $$$.

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.

source

I’m actually ok with this system, but only because I throw the bills away after

Shared risk pools are a good idea. Making them for profit is not.

The sad thing is they do hire some licensed healthcare professionals to fall back on when appealed. They just look for the least compassionate MDs to rubber stamp denials.

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.

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.

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.

So like did he complete his residency then head straight for insurance field?

Yes, I think that's exactly what my doctor was trying to describe. He said if they're at that point, they basically have to guess what information they're looking for other than "I'm a qualified physician that has run diagnostic tests and determined this is the best course of treatment. Here are those tests and why it indicates X and therefore requires Y."

I've had to do unnecessary labs to prove an ailment wasn't something else that some person hundreds or thousands of miles away thought it might be.

If you think you hate insurance companies, find an honest doctor and ask them what they think of the US Healthcare system and health insurance. I've never seen a doctor so worked up and angry than when discussing the current medical system.

Edit: this guy is fun to watch on this topic: https://youtu.be/s33AVskz3T8?si=Qqx2nAJjguMOxnNL

I file a complaint with the department of insurance instantly when they deny anything. I don't negotiate with them for 3 months first, I jump straight to sicking the Feds on them and my doctors have always provided me every bit of data I need and cheered me on.

And I've won every time. It annoys me that I have to do it, but I enjoy that it costs the insurance extra every time.

I recently went in because I had a thunderclap headache, thought it was about to die from a brain aneurysm. No insurance. They did 1 CT scan and billed me for a Head CT, Neck CT and a Cervical Spine CT, each costing over $3K. After months of calling their billing department I ended up having to setup a payment plan before they sent it to collections. Not a single person in the billing department, up to and including the head of billing, could tell me the difference between a neck CT and a cervical spine CT. Still on the hook for over $11K. Probably going to have to file for bankruptcy soon. My life is effectively over.

"Because I said so."

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?)

Capitalism is based on free markets.

Deviations from free market status in this scenario include:

• The MRI machine is extremely expensive because it’s from a government-enforced patent monopoly
• The insurance is expensive because it’s mandated by government
• The MRI requires a doctor’s prescription because that’s the law

If we had capitalism in medicine, OP would be paying $150 out of pocket to buy an MRI scan from a private company, and that would be that.

Well. No. They have a say about whether they'll pay for what the doctor has decided is best for the patient.

I did pharmacy billing for a while and this is a kind of innocent take that people are just being lazy. The training was terrible (I was taught the basics of the software and then given a photocopy of various employees hand written notes for common rejection solutions over the years ....most of which didn't still apply and those employees had long left; when I left in sure my notes were copied to the pile). There were metrics that kept being increased meaning spending more than 30 seconds on a claim was going to put you behind (I did night shift and my boss was talked to about me once or twice because I sometimes had an hour or two where I'd cleared everything I could and had nothing to do because the rest of the world was asleep). And, finally:

The software was designed to actively fight us. My most common reject was insurance won't pay for anything $X or more with X being stupidly low. For many insurances you could not put in a recurring override for monthly maintenance meds. Your options were either give the patient a 2/3/whatever day supply to get the cost down and they'd just have to visit the pharmacy for pickup so much they might as well work there. Or do a one time special override every. Single. Time. Which involved me doing a special code on my end (which wasn't the same for every insurer and sometimes they'd just randomly change it for shits and giggles with no communication, I had a list of codes that were often used I'd try guessing with). Calling their help desk whose employee retention and training were also in the toilet. If the insurance end person knew the process for a one time special override, great. If not I started specifically keeping notes by insurer to teach new people because otherwise I'd be subjected to an hour of phone hockey while they tried to find someone who both knew how to do it and could cram my call into their metrics. Then we'd have to go through generating specific rejects just because we needed it in our logs we tried shit we knew wasn't going to work. Doctor note saying md knows med is expensive and that pt needs it to live regardless attached? Okay run it through as cost doctor approved to get the "fuck the doctor we don't want to pay" reject. Insurance doctor/nurse team reviewed that yes the doctor is correct the patient needs this med to live code put in? Okay run it again to get the fuck our own doctors we still won't pay reject. Now insurance help desk has to message their next level support to get authorization for a one time override for medical necessity. Okay now it'll go through on the insurer end (as long as they didn't fatfinger anything because the override only works for one single attempt). Great, we did it one try team! Now my turn to do it on my end which involves me removing all my codes because the software no longer recognizes the reject so will reject me for needless codes which will make us have to get the One Single Try Authorization again......

You don't have to die to visit hell just work in medical billing.

don't joke about that, you might cut into their profits if it happened. /s

There wouldn't be an insurance company to tell you no in a single payer system

There wouldn't be a for-profit middleman taking billions out of the system for themselves yearly.

Critics point out that government-run healthcare would be less efficient and would also have to draw the line in approving/denying care somewhere too, but I can only imagine that it would pale in comparison to the insurance companies who have a profit-motive to screw you over.

Supporting this assumption is the fact that Americans already spend way more on healthcare than other countries, even those that already have universal:

So, basically we're all overspending solely to make insurance companies rich.

How things work in BC:

When a practitioner changes for a service, they can't bill any more than what the Payment Schedule says that procedure costs. So if the Medical Services Plan isn't being billed (eg the doctor or patient opted out of MSP, the patient is a non-resident, the service is in the Payment Schedule but the Payment Schedule requirements consider it unnecessary) or MSP isn't covering the full cost (some stuff like a second or third biopsy will only be covered 50 %), then the doctor can't bill the patient any more than they would've billed MSP. This means practitioners have no incentive to not bill MSP.

The Payment Schedule (and thus allocation of the MSP budget) is set out by the Medical Services Commission which is composed of three representatives from the government, three from the Doctors of BC (the professional association which promotes the interests of member doctors) and three members of the public. So even if the government pushes for more stringent coverage requirements and budget surplus, the doctors are there to push for higher fees and less billing paperwork (besides exceptional circumstances like out-of-country care, patients can't submit claims directly; everything is on the practitioner's end), and the public is there to push for more coverage.

In practice this means that for the vast vast majority of services, the only justification that the practitioner needs to give MSP for coverage is the International Classification of Diseases diagnostic code for the condition being treated.

Brit here. Not saying the NHS has no problems, long waiting lists being the most obvious, and on a practical/personal note shared wards, but at least in principle if the doc says you need X then you get X. There's no beancounter to persuade that you really need this thing who then says no anyway. There might be another step: GP -> specialist -> diagnosis -> solution but in principle it's pretty straightforward. It's funded by a 9% tax so you pay according to your ability, and it's free at the point of delivery to all British citizens.

If the solution is a pill or potion from the chemist then you get it free if you're on a low income, but at a capped price on prescription.

Because it's free to use, you (can) go to the doc as soon as you have a problem, unlike in the USA where you dread massive bills so you hope it goes away on its own, meanwhile it gets worse so you go when you have to and when the bills are at their highest. And because the NHS is tied into the government who regulate the pharmaceutical industry they (should but don't always) get best prices on everything, along with bulk discounts because it's just one buyer for the whole country.

I'm probably oversimplifying a lot here; I don't work in the NHS so this is just my view as an outsider. I think there are some regional variations; every so often "NHS postcode lottery" comes up in the news, but I don't know how they work.

That study is idiotic. It's literally an embodiment of the joke: "You could have found it faster if you looked in the last place first".

Standardized triage testing has been shown over and over to save many more lives than doctor intuition alone. Just because a test rules out a diagnosis doesn't make it "unnecessary".

Oof man. Reread the entire sentence.

Permanently Deleted

There should be a comma after experience.

I'm drunk in the back of the car and I'm crying like: a baby coming home from the bar.