I’ll bite. And this is rich coming from me (who doesn’t bill ins). My pts who use the state regulated private plans seem to love them. I think fundamentally, when the relationship is between doc and pt and separately between pt and ins, that solves the problem.
I wonder if that has to do with the high percentage of large companies that self-insure. I worked at large tech companies for 17 years and never had a claim denied. It's the almost 2 years at smaller companies where we've had denials.
Kaiser has a lot of issues — their mental health care is a true embarrassment, and they failed to diagnose my sometimes life-threatening genetic condition — but my research on this subject has led me to the firm conclusion that Kaiser is the least bad private insurer.
My experience with Kaiser has been so much better than any other insurance company. They’re not perfect of course, but for my run-of-the-mill healthcare, they’ve been great. I dread the thought of going back to a regular PPO.
I have complex medical issues, and in 2020 incurred over $1.2 million in brain surgery and rehab costs with Kaiser. I never once had to fight for a single authorization, never had a claim denied, never had to fight a single bill. Under a traditional insurer, I'd still be dealing with billing/claims.
Not to mention that I have ongoing annual care needs, and went through a series of brain radiation treatments this year. Again, I never had to worry about authorization or fight for billing. Is Kaiser perfect? No, but compared to the traditional system, it's freaking paradise.
It is so stressful having to fight insurance companies, especially when you should be focused on your own recovery! It’s obscene what people have to go through to get care, what’s been normalized in this country.
As someone who has to routinely transport patients with immediately-life-threatening "hospitals" to a real hospital, my experience is a little different.
(Also, putting their "hospital" near a real one and not having an ER to avoid having to provide care to anyone who walks in without coverage is kinda a d*ck move. Just saying.)
( Can they deal with significant trauma? No. Can they deal with major medical? No. Do they have facilities for ambulances, for when those questions become highly relevant? Also no. Every call, we get told to come to a back door, but a different one every time. )
Kaiser has brand new hospitals in the SF Bay Area. I was with them briefly. It was very efficient with a large emphasis on preventative medicine in my experience.
Kaiser is weird in the healthcare side of things imo: they want you to attempt once with a Kaiser facility/doctor before going to an external practice (more expensive), so it's already a pain to submit a Kaiser claim if you don't have a referral from a Kaiser doc saying "I can't do this"
Yup. They don't have certain specialists and made a friend wait days to get his broken jaw fixed with an outside specialist. 🤦🏼♀️ They had to rebreak it in surgery, as it already began to heal. Ouch!
used to work in patient admin, at a non Kaiser facility. Patients with Kaiser coverage would ask if we could cover them and I felt bad giving them the spiel. Better that it came from me than the insurance 1-800-# but it was depressing as fuck each time.
I don't like their setup. I tried Kaiser once. They refused my surgey and wanted me to live on pain medication indefinitely. F that. Switched to another health insurance and fought them to get surgery covered for my rare condition. I have them as a big No to try again. Their coverage is weird.
Interesting. I thought they kept this data locked down. But they say its from claims data. Still worry it’s unclear provenance. Even for UHC 32% seems insane.
Health insurance companies are in the business of generating profit. The fewer claims they pay, the more they profit. So good business for them is denying anything they can legally get away with. Which is why profit seeking has no place in public healthcare.
Anthem denied my son's open heart surgery after they pre-approved it. I had to appeal it. Because it was in CA, the law prevents them from doing that. Didn't stop them from trying anyway.
I'm just thankful they ended up covering it and the dedicated healthcare team he has. He's hit the old lifetime caps a few times over. Million dollar baby! I just don't know what we will do if the ACA is repealed. If ppl think its bad now, just wait till we go back to the bad old days.
Why even ask? Unless you are a physician, you wouldn’t even know what treatments are necessary or unnecessary. And yet Americans tolerate a system in which the least qualified decide what the most qualified should do.
I analyze this data (along with the healthcare metrics) and it’s a more complex issue than just a straight denial rate however i totally buy this, especially if you account for the denial coding properly. If you do it the way the insurance companies like, it’s less but it misses the bigger picture.
I read a post on Facebook this year from someone who said that their insurance, via AI, denied payt for their annual physical. The rep on the phone said they could not reverse any decision that AI made, even one that was obviously incorrect. That not even a supervisor could override the AI.
Also, as a Canadian who has had extensive medical needs, I have considered writing the pod regarding what we call extended medical, how it works, and how in 2019, even w only govt insurance I paid $0 in fees, deductibles copays (which don’t exist outside America), not one dollar …
for an extended chole w liver resection, 2 ambo rides, at least 5 scans, 4 er visits, meds, 8 days post op, an OT consult, pathology, etc. Ttl expenses were 1 pk Steri Strips, Tylenol/Advil, & a cab ride to get my path results (no cancer, woot). I’m also an American & lived with US health care so I
see the difference. Also, when we found my 4.3 cm mass, there was never any discussion about networks, they just immediately called the head of hepatobiliary surgery for our area. The difference is stark.
I'm in northern California and have Kaiser. When my brain tumor was diagnosed, my doc called the neurosurgeon directly the same morning, and started the referral process before even calling me, because she wanted to get the ball rolling. With Kaiser, as long as you're at a Kaiser facility, you're
covered, so I didn't have to worry about "in-network" or not - I just showed up for the neurosurgery consult on the day/time that had been booked for me. I really appreciated not having to navigate an unfamiliar system - who the fuck wants to comparison shop for BRAIN SURGERY?!?!
Extended health care is offered by employers here. It’s a top up plan for extra medication coverage, more home support, orthotics, massage therapy, chiropractic, etc. In 2009 my now ex and I used about $12k in additional medical expenses over what the government covers.
In 2018 it was about 58 billion a year US wasted on private insurance. Paying that much for a system to keep us from healthcare we need. There is a clear path forward that only greed prevents us from achieving.
Millionaires and billionaires who gleefully watch children suffer and dies so they can earn an extra half a percent, and get a smaller yacht for their bigger yacht, getting assassinated in the streets is crazy. It’s like people are starting to realize the real solution to our problems.
As someone who has worked with denial data, there are some caveats. For example, not all denials harm the patient - sometimes the provider fills info out incorrectly and the insurer denies the claim, sending it back to the provider to fix it. It might be approved and the patient never knows of delay
Wouldn't that result in a relatively consistent percentage of denials across all companies? United is still 2x the industry average, so even if that is contributing United is still denying significantly more claims
It’s a good question. I sat in a meeting with a bunch of insurers and regulators on this topic… the insurers were comparing notes and it turned out that what one company might call a denial, another company doesn’t. We still use this data because it’s the only info, but it’s not perfect.
Some of my cancer surgery /chemotherapy was originally denied hy UHC. My doctors had to spend hours convincing them why I needed it (thankful for my doctors).
Fuck UnitedHealth care for sure, and the whole US private health insurance industrial complex as a whole, but how can the industry average be 16% if more insurers are higher than that and UHC is the largest insurer in the nation and at 32%?
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All of the insurance companies suck. 😫
https://www.valuepenguin.com/health-insurance-claim-denials-and-appeals
This was after fighting tooth and nail to get it approved in the first place.
It was eventually fixed with a "Oops, our bad." email.
They should all be in prison or worse.