Some insurance irregularities I've noticed over the years of working in health care, working with specialized populations, and spending time in various marginalized communities and listening to...
Exemplary
Some insurance irregularities I've noticed over the years of working in health care, working with specialized populations, and spending time in various marginalized communities and listening to their struggles with insurance and health care as a whole:
Systemic Denials
Automatic denials of this sort are systemic. As others have stated, this is not a new thing, nor is it specific to Cigna. This kind of behavior has been pretty standard for quite some time, for all the capitalistic reasons you can imagine. This article is helping to draw attention to some of these practices which are frankly not good for the consumer and only instituted because they are good for profits.
Formalized health care
Extremely formalized health care is change resistant. I mentioned this in another reply in this thread, but I want to highlight this as an issue not just with this kind of automatic denial system, but in the very way that for profit health insurance works. Let's imagine a graph where along the x-axis we have a historical timeline representing how long a particular kind of care has existed in humanity. On the far left would be extremely old techniques such as bandaging wounds and on the far right we would have extremely new techniques such as a MRNA based HIV vaccine. Along the y-axis we have known effectiveness, or how much scientific evidence we have for this being an effective treatment. If we label the top left quadrant (old, lots of evidence) as quadrant I, the top right II, bottom left III, and bottom right IV, insurance companies tend to formalize towards prioritizing quadrant I. From a practical perspective, and from a distant perspective, this makes sense. The way this is typically accomplished, is by simply ascribing the various medical care that exists in quadrant I as 'approved' treatments for conditions for which they treat.
The issue with this, however, is that the way that new treatments are designed is that by nature they must exist within quadrant IV or II before moving to quadrant I or III. Furthermore, we've actually added a third axis to our graph, one for which applicability to medical condition spans from not applicable on one side to perfectly applicable on the other. Insurance companies aren't thinking along this modality, and ascribe applicability as a simple 0/1 function. Either the treatment is approved for a condition, or it is not. Medical care is particularly complicated. An approved treatment for a blood pressure issue might be a medication which is contraindicated in the patient for different reasons - said drug might tax the kidneys and the patient has poor kidney function, said drug might interact with other conditions the patient has, said drug might interact with other drugs the patient is on, or simply said drug may not be tolerated by the patient because they experience negative side effects which may outweigh the clinical benefit of said drug. All of this is lost when we simplify down to <condition> maps to <treatment>. This is what the review process is supposed to be for, to ensure that patients still get care even when they don't neatly fit into the automatic denial systems. In fact, what we should be doing is viewing these systems as automatic approval systems, not denial systems, but that's been corrupted by the capitalistic incentive of running a for-profit company.
Coding specificity
The specificity of coding adds another layer of issues. Medical coding is a process in which very specific codes are attributed to patients in order to quantify attributes about them. Coding systems exist across a variety of medical needs, but for the purposes of simplicity I'll talk about only one relevant coding system: the international classification of diseases (ICD). The ICD system was originally purely a system of diagnoses - meant to classify patients in a standardized fashion. The disease state of asthma, for example, would classify to a single code representing the kind of asthmatic state the patient is experiencing. Over time this has expanded to also include procedures (sometimes referred to as ICD-PCS) and other useful medical taxonomy. As you can imagine, the number of applicable codes expands each released version. Over time this system has expanded from just numeric classifications to alphanumeric classifications, and codes are sometimes moved from one tree into another or expanded to create additional codes.
Asthma (J45 in ICD-10) for example is a tree consisting of mild intermittent asthma, mild persistent asthma, moderate persistent asthma, severe persistent asthma, and other and unspecified asthma. Of note among these codes is that some of them didn't used to exist (asthma was simply code 493 in ICD-8 and did not have separate codes for chronicity and severity) and the final code listed here is for "other and unspecified". For many disease states and for many procedures, there is what is colloquially known as a "9" or "99" code (depending on terminology) which exists as a catch-all for future expansion. If it doesn't neatly fit into the list of diagnoses or procedures, it'll be coded in the 9 code. 9 and 99 codes are almost universally rejected by insurance, because they necessarily fall into quadrant II and IV as described in 2. These represent the expansion of medicine as a field, and we don't have a history to really understand how to treat these conditions or whether they should be their own separate condition in the first place. 9 and 99 codes also exist a LOT when you deal with extremely specialized medicine. If you have a very rare kind of cancer, for example, you might not even make the ICD system because they are unaware that your condition exists, or what doctors even do to treat this condition. In fact, you may be fighting for it to be recognized AS a condition, or with other taxonomies to split your condition out of existing conditions as it is improperly grouped. For example, being gay used to be a classified disorder in the DSM as was being transgender… gender dysphoria still exists in the DSM-V but as you can imagine grouping the two together makes getting healthcare complicated and transgender healthcare does not represent the needs or concerns of cisgender non-heterosexual healthcare.
In-network, out-of-network
A further layer of complication comes when determining which providers are in-network versus out of network. The services that a provider performs are at a higher level than coding. A maxillofacial surgeon, for example, does surgeries on the head, neck, mouth, jaw and face. As you can imagine, there's a variety of surgeons that would fall into this broad category. One maxillofacial surgeon may specify in cleft lip repair, for example, and never perform rhinoplasties. Someone who needs a rhinoplasty because of trauma caused by an accident may be told that the maxillofacial surgeon which only does cleft lip repair is in network, and therefore they cannot go out of network to another provider which specializes in rhinoplasty.
This gets even further complicated when you're talking about conditions which overlap with procedures which are commonly not covered, such as breast augmentation following breast removal (common for individuals with breast cancer in only one breast who wish to even things out by augmenting one, rather than removing both breasts). There may be an automatic rejection of the codes combined with surgeons in network who don't perform this specialized kind of surgery. In other cases there may be specialized versions of surgeries which broadly overlap with existing surgeries. Using the previous example, a plastic surgeon may be in network who does breast augmentations but typically does it for gender affirmation reasons and so is used to and has been trained on how to make breasts larger using particular methods. A reconstructive surgeon whose goal is to restore a breast has a different outlook on surgery and may use a different set of tools to understand how best to reconstruct said breast. They may, for example, take measurements of the existing breast to ensure that the reconstructed breast is symmetrical to the existing breast and may use special techniques to ensure that the augmented tissue sits in the body in a similar way to the other breast - the techniques they employ to accomplish the same procedure (augmentation of breast) differs greatly from the gender affirming surgeon and yet these differences are not visible when using simple procedure and diagnoses codes to determine whether a provider is in or out of network.
What these add up to is frankly a shitty experience for people suffering from rare and expensive disease states, the very people which often need the most help because their conditions make their lives more difficult to navigate. What I have learned from direct experience with my own health care and those of other minorities and rare disease groups is that you have to learn how to fight the system to get the care that you need. Ask someone with chronic pain how they've experienced the healthcare system, let alone the repeated governmental attempts to "control" an opioid epidemic of their own making. Ask someone with an expensive medication, such as antiretrovirals used to treat HIV whether they've had to fight for access to their drugs. There's sadly a systemic problem caused by capitalism which puts the burden on the people which need the burden alleviated the most.
Very enlightening and interesting. @JCPhoenix's story about their coworker also greatly moved me. I'm not yet fully convinced that capitalism is the biggest culprit. I think it has a large role...
Very enlightening and interesting.
@JCPhoenix's story about their coworker also greatly moved me.
I'm not yet fully convinced that capitalism is the biggest culprit. I think it has a large role because incentives in capitalism pervert many aspects of healthcare. Simultaneously, some aspects of healthcare would improve in purer market conditions, like showing prices so patients can shop around for non-emergency procedures.
An aside: I'm looking to get an eye exam soon in California but don't have vision insurance.
Back when I lived in the Netherlands, I would find eye exam prices online. They're often between €35 and €60. I'd book an optometrist who is both on the lower price end and well-rated. Easy.
Here in the Bay Area, I have to call to ask for prices. I'm finding that prices can range between $80 to $150, and I've heard that some places can even charge up to $250. Every place will let me book an eye exam appointment without telling me the price before or after booking; I'm supposed to accept whatever amount they present to me at the end of the exam. I can't know the cheapest eye exam in the area unless I bother to call every single optometrist.
But I get the sense that the Modern Healthcare Problem is the result of massive uber complex system engineering. It's a web of systems bolted together with little attention paid to the end consumer experience. It is badly in need of rearchitecting that is very difficult to achieve at meaningful scale due to economic incentives, entrenched or conflicting interests, and the very ambiguous and non-discrete nature of healthcare itself.
An interesting case is that of the Nevada Culinary Union Local 226. They represent 60,000+ hospitality workers in Nevada's hotels and casinos. They opposed Bernie Sanders on the basis of his Medicare for All plan because the union had negotiated good healthcare for its members, a selling point of the union. The introduction of universal healthcare untied to employment would take away the union's big selling point and thereby threaten the union, so the union was moved by its own interests to secure its power.
Zooming out, 1 in 9 Americans is employed in healthcare, and more are employed in related sectors, and it only keeps growing. And for every doctor there are 16 FTEs, 9 of which are admins, according to this 2016 Politico article. So the figures are probably worse now. Much of the greed that people experience on the patient end goes onto to employ tens of millions of Americans — not that I think this is a good thing; if anything, it's terrible, and terribly inefficient and wasteful. If profit were the primary motive, I'm sure healthcare providers and insurance companies would much prefer to not keep adding on costly, nonproductive personnel at such pace. So I sense that other forces and interactions are at play.
Are there any good resources to learn about the various subsystems at play in the US healthcare system?
Only when we're operating outside of the insurance paradigm. We don't really shop around to find a primary care provider that's cheapest, we shop for one in-network and reasonably close by. Only...
some aspects of healthcare would improve in purer market conditions, like showing prices so patients can shop around for non-emergency procedures
Only when we're operating outside of the insurance paradigm. We don't really shop around to find a primary care provider that's cheapest, we shop for one in-network and reasonably close by. Only when we get to expensive procedures which aren't covered does this really apply. And guess what, this often is because these things are automatically denied. Want an MRI? Well, its gonna cost you if you have a high deductible plan or don't happen to have one of very few conditions for which it's not automatically denied or which you put in time appealing/working the system to get it covered. At that point, it's up to the insurance to tell you where to go. But here's the thing... the insurance company already did that shopping around. That's why there are in-network places to get an MRI. So exposing the cost won't really help these people either. All it helps is for cases where insurance simply isn't footing the bill for whatever reason.
It's a web of systems bolted together with little attention paid to the end consumer experience
Absolutely! Many healthcare providers have noticed this and have changed how they provide medicine. At the organization where I work, there was a significant amount of effort put into this and we even use Gallup and other polling to ensure we're monitoring and attempting to improve the experience of patients. But that's only one system among many that need to work together to make this behemoth work and many aren't savvy enough to realize this will win them patients and therefore dollars.
Much of the greed that people experience on the patient end goes onto to employ tens of millions of Americans
There is some truth behind what you're saying, but I want to address some of the costs out there before jumping into the why, because ultimately it's all supported and pushed into absurdity by capitalism.
There are some salient points about healthcare spend on this page highlighting some ways in which the US leads and lacks as compared to other countries with socialized medicine. We actually visit doctors a lot less in the US than other countries with wildly less expensive healthcare systems. Is some of this inflated spend from additional personnel? Perhaps, but looking at where the spend actually goes paints another story. Looking at a high level at slices of spend you'll note that the US likes its hospitals and the hospitals are very expensive, despite people spending less time in hospitals in the US than most other countries. Hospitals need to compete with one another, and so we have more services than we really need. We perform around double the MRIs as other countries (with the exception of Japan) which shows just one small slice of this competition between hospitals. We have more redundant medical machines than other places in the world because of this competition - you need to offer what the hospital nearby offers in order to remain competitive.
Importantly, there are a number of extremely talented people who've looked at this in a lot more detail than I ever could have. A fantastic journal article originally titled "It's the prices, stupid" published back in 2003 was revisited and published in 2019 with an updated title, "It's still the prices, stupid" which highlights how prices are inflated in the US. UC Berkeley has a much more digestible breakdown article on the original paper that I found which I think does a good job at explaining some of the major factors behind these prices and tracking their growth. Of particular note, raising prescription drug costs (thanks capitalism) moving in tandem with a decrease in their usage (I wonder why people would shy away from more expensive drugs?) and the administrative overhead that comes with the complicated coding and billing that we have to deal with in the US in order to actually get paid for anything. It's no surprise that we need 9 administrative staff per doctor when they have to submit codes to bill to insurance and deal with the same problems that I mentioned above.
To add an anecdote which I think highlights this, the health care system that employs me offers its employees a healthcare plan that we run. This healthcare plan requires you to go to our healthcare system for care, if it can offer it. If it can't offer the care, doctors are sourced from another plan (Aetna) for in-network rates to keep things reasonably affordable. I have a chronic pain issue involving my shoulder. I went to my primary care doctor at this healthcare system, who referred me to a pain doctor who referred me to a different pain specialist who ordered an MRI to confirm the issue and then ordered a corrective surgery. This corrective surgery was denied by the insurance that we run the day before the surgery (in the afternoon, none the less) because it was billed with a 99 code. Ignoring the fact that a bunch of resources had to be reserved in order to perform this surgery which they couldn't exactly mobilize in the few hours left of daylight before the next day to move up another surgery (let alone if someone else would be willing, given the additional support needed such as someone to drive you there/back) but it then had to be appealed three times only for the final decision to be that the insurance would not cover it. The physician group had to get the director of the facility to sign off on providing the procedure without reimbursement in order for it to happen. How much less efficient can you truly get?
What you're saying about hospitals competing with eachother really rings a bell for me; as far as I know we're the only country in the world where hospitals actively advertise their services on...
What you're saying about hospitals competing with eachother really rings a bell for me; as far as I know we're the only country in the world where hospitals actively advertise their services on TVs and billboards. One particular thing that has always mystified me was the ads that focused on their pregnancy and birthing services. There are many ways to deliver a child - many of which do not involve hospitals at all - but of all the factors one should consider, a f-ing advertisement should not sway your decision!
On a personal note, I have had my first real run-in with out-of-network medical expenses and I'm almost impressed at how much of a shitshow it was even though I know I had it much easier than most. I've mentioned before that I have some pretty fantastic healthcare due to being a member of a very vertically integrated healthcare system, but the one thing they don't do is supply you with medical equipment. They have a specific supplier to go through and they put in the order for me. The problem is that as a seperate company they have terrible communication; it took me literally a month of calling the two organizations daily to get them to move and get me the equipment that I needed - in spite of the fact that not using it was supposedly shortening my lifespan.
Beyond that, the machine is so incredibly overpriced that the insurance arm won't actually cover purchasing it; they will only rent it! And because it's a medical device, there is no advertised MSRP; from my research it would appear that they can go for up to $5000. For a simple device roughly the size of a large thermos. Though, granted, if it were to malfunction it could kill me, so I'm fine with paying somewhat of a premium for one that's well designed with plenty of failsafes.
(for an extra bit of frustration, I found out that the difference between the most basic version of this machine and the versions that sell for 2-5x the price is a simple setting in the service menu; you don't even need to change the firmware.)
Can you imagine spending years in medical school, learning how to help people, only to turn around and use that knowledge (or really that M.D. at the end of your name since they aren't even using...
The letter was signed by one of Cigna’s medical directors, a doctor employed by the company to review insurance claims.
Can you imagine spending years in medical school, learning how to help people, only to turn around and use that knowledge (or really that M.D. at the end of your name since they aren't even using their medical skills) to deny people care? That seems like it would just attract the bottom of the barrel doctors who can't find a job elsewhere. And those are the people supposedly charged with deciding who should get care.
Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method, spending an average of 1.2 seconds on each case, the documents show.
[...]
Medical directors do not see any patient records or put their medical judgment to use, said former company employees familiar with the system. Instead, a computer does the work. A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments. Company doctors then sign off on the denials in batches, according to interviews with former employees who spoke on condition of anonymity.
Is there no medical insurance oversight board that can look at those numbers and say, "this is literally impossible, what's going on here? How are they deciding this in literally two seconds without looking at medical records?"
Cigna emphasized that its system does not prevent a patient from receiving care — it only decides when the insurer won’t pay. “Reviews occur after the service has been provided to the patient and does not result in any denials of care,” the statement said.
In the United States, insurance declining to cover something is denying care. Our health system is so tied into insurance that most people can't even afford routine tests or doctor's visits.
I had a procedure my doctor wanted to do denied by my insurance once and I asked what the cost would be if I paid for the procedure myself and she didn't even know. She had to have her insurance liaison (yes that is a real position in most doctor's offices) look it up. That person didn't know because they always just billed insurance. Luckily, I have a family member who worked in a doctor's office for years and she helped me file an appeal. It took months and countless hours but it was finally approved and they covered the procedure.
Most people don't have the knowledge or time to fight those rejections though. So for every appeal, I'm sure there are hundreds of people who just accept the rejection and go without the care they need.
"Our company is committed to improving health outcomes, driving value for our clients and customers, and supporting our team of highly-skilled Medical Directors,” the company said.
I know you're frustrated, and certainly the US medical system is very frustrating. But this seems unsympathetic. Being a doctor sucks in many ways nowadays. If they can't do it and need to get...
Can you imagine spending years in medical school, learning how to help people, only to turn around and use that knowledge (or really that M.D. at the end of your name since they aren't even using their medical skills) to deny people care? That seems like it would just attract the bottom of the barrel doctors who can't find a job elsewhere. And those are the people supposedly charged with deciding who should get care.
I know you're frustrated, and certainly the US medical system is very frustrating. But this seems unsympathetic. Being a doctor sucks in many ways nowadays. If they can't do it and need to get out, what do they do instead? They likely still have student loans to pay off.
Also, you seem to be arguing that the whole job is unnecessary. Auto-approving everything will result in medical fraud that will make insurance even more expensive. There are certainly reasons to disagree with how it's done, but someone has to do it. Guarding against fraud is also necessary for government-run systems like Medicare.
[Edit: withdrawn. I had not read the article and didn't fully appreciate how bad it's gotten.]
Sometimes the harm produced by a person participating in a broken system is less than the harm that would be done to them if they abstained. Let's look at the harm caused by this. Any doctor who...
I know you're frustrated, and certainly the US medical system is very frustrating. But this seems unsympathetic. Being a doctor sucks in many ways nowadays. If they can't do it and need to get out, what do they do instead? They likely still have student loans to pay off.
Sometimes the harm produced by a person participating in a broken system is less than the harm that would be done to them if they abstained. Let's look at the harm caused by this.
Any doctor who does this is personally, actively, best case scenario, causing huge amounts of distress and financial hardship to hundreds or thousands of people. Virtually every single person affected by this is guaranteed to be having a bad time. You can tell because they have medical bills, and unexpectedly in defiance of their supposed coverage suddenly have a lot more. Even if they can resolve it, it's a massive amount of purposeful, deliberate frustration dealing with the insurance companies while simultaneously dealing with serious medical issues.
That's the best case scenario. Medical debt ruins lives. Lack of treatment ends them. The effects of this make people avoid seeking medical care as long as possible, turning treatable issues into terminal ones. Anyone who does this job for a significant amount of time has almost certainly killed people, whether directly through denying life-saving coverage or through indirectly causing someone to wait until it's too late.
So, while it might be theoretically possible for more harm to be done to someone by not participating in this than would be done by doing it, you're getting into the realm of absurd hypotheticals. It's an absolutely fucking despicable practice.
Literally happened to a co-worker. Like three times. When I first met her, she had just been diagnosed with Breast Cancer, which destroyed her finances. She had to declare bankruptcy due to the...
Medical debt ruins lives. Lack of treatment ends them. The effects of this make people avoid seeking medical care as long as possible, turning treatable issues into terminal ones.
Literally happened to a co-worker. Like three times.
When I first met her, she had just been diagnosed with Breast Cancer, which destroyed her finances. She had to declare bankruptcy due to the debt.
She survived cancer and bankruptcy and was trying to get her finances back together. One day, however, she went to a nail salon to get her nails done like she normally did. Afterwards, one of her fingers started to hurt but she didn't see any sores or cuts or anything. But instead of going to the doctor even though several of us told her she should after like a week of it hurting, she waited. Because seeing a doctor and potentially having a procedure of some sort could be expensive even with insurance. She continued to wait. And wait. And wait even though her finger hurt more. Until she slipped into a coma one morning and her finger was horribly infected and turned gangrenous. They had to cut off half of that finger. Turns out that was a diabetic coma she was in. And the infection was likely exacerbated by the diabetes.
After several years, she somehow managed to pay off most if not all the debt. And she even started taking better care of herself! Insulin was too expensive, even with insurance, so she made it a point to vastly improve her diet and lose A LOT of weight, so she wouldn't have to buy/use as much insulin. Moneywise, she was doing much better, especially since she was free of the medical debt.
And all was good until right before COVID where she was struck by another ailment. She collapsed in the parking lot one day after work. She survived, but was hospitalized again for quite a while. She also had to have a large chunk of her thigh/buttocks removed. And have some homecare, which isn't cheap. I don't know exactly what she got, but it almost killed her. I almost wonder if it was related to her diabetes again. She can walk, but just barely and usually needs a cane or a walker. Even sitting can be painful for her. The only "plus" from that one is that she was the first to go full, permanent remote, which she enjoys. But her quality of life is certainly harmed. And of course she's back under a mountain of medical debt.
She's 63 and she thinks she'll never be able to retire. She rents; has never owned a home. And there's no way she could afford one being single. Not after three bouts of major medical crises.
Medical debt destroyed her life three times. And maybe had she gone to seek medical advice/help sooner, she might have avoided these ailments (aside from the cancer diagnosis). But it's hard to fault people for being scared of seeing a doctor when it can lead to some expensive outcomes. Soon after my coworker lost her finger, I got a toothache. I quickly ran to my dentist to have her check it out, not wanting to end up like my coworker, even though I was young, healthy person. A week or two later, I was getting my wisdom teeth removed. That was like $1600, even with insurance, more or less out of the blue.
Unfortunately, like you said, waiting just means it's typically more expensive, if it doesn't kill you. So pay a lot now, or pay even more later, or pay with your life. Great options.
Why does someone who is allowing this kind of system to exist deserve sympathy? They're spending an average of 1.2 seconds on each case. They are rejecting without even reviewing. They are being...
This seems unsympathetic
Why does someone who is allowing this kind of system to exist deserve sympathy? They're spending an average of 1.2 seconds on each case. They are rejecting without even reviewing. They are being unsympathetic to the patients. In fact, I'd argue they're also being negligent.
Auto-approving everything
Who's suggesting this? Why the jump to the opposite extreme? I think it's reasonable to vent at a clearly capitalistic system that is practically auto-denying in order to save money, especially when this means that some people are not able to receive the care they're paying to get access to and the vast majority of them need.
Fraud prevention is absolutely necessary for government (and private) health payers, but this system does not seem to be focused on fraud prevention but rather on reducing costs to the insurer at...
Fraud prevention is absolutely necessary for government (and private) health payers, but this system does not seem to be focused on fraud prevention but rather on reducing costs to the insurer at the expense of the patient.
It's a difficult problem, because most fraud in government healthcare is committed by providers, and involves things like upcoding, unbundling, overprescription, and billing for services that have not been rendered. Government payers absolutely have to be diligent in detecting this type of fraud and waste, but I don't think that systematically denying all claims for a service outside a narrow list of Px/Dx combinations is the right way to do that. I don't think any process that is determining medical necessity that doesn't involve an actual review of medical records is operating in good faith.
I work in this field, although I'm not directly involved in FWA (fraud, waste, and abuse) prevention, and I know that healthcare providers (or at least, their billers) frequently submit fraudulent or at least incorrectly coded claims that need to be denied or reviewed. Providers will also bill claims in a way that maximizes their payment as much as they legally can (and sometimes beyond). I think that a lot of this has as much to do with how overly opaque and complex medical billing is in the US as it does with greed. It requires an army of coders/billers and insurance liaisons to navigate the healthcare system, and that gets expensive.
It's worth remembering, though, that most of the time when a claim is submitted to an insurer and denied, the provider is just going to shrug and then pass that bill on to the patient, who is then faced with paying those unexpected and usually high costs, or going through a process that is almost always opaque and frustrating to get their insurance to pay for a procedure. It's maddening to have a physician tell you that you need a test or a procedure, and for you to have to think "Is my insurance going to pay for this? Are they going to agree with my doctor's clinical decision?" The incentives for private insurers are generally not to place the health of the patient first.
I don't know what the solution to all of this is, although I have lots of thoughts. There are people that know way more than I do about healthcare policy that struggle with all of these factors. I do know that the system that we have now is not working for most people, though.
I'm not arguing that the job is unnecessary, I'm saying that it will, by its very nature, attract bottom of the barrel talent. Somebody has to be the worst doctor out there...do we really want...
I'm not arguing that the job is unnecessary, I'm saying that it will, by its very nature, attract bottom of the barrel talent. Somebody has to be the worst doctor out there...do we really want them to be the one making medical decisions for hundreds of thousands of people each year?
Auto-approving everything will result in medical fraud that will make insurance even more expensive.
They shouldn't be auto-approving everything, but they also shouldn't be spending 1.2 seconds on each patient before approving or denying a claim. (Side note regarding cost: That should be a non-issue. We shouldn't have health insurance in the first place...we desperately need a single payer system)
If this unethical crap is the only job said doctor can find that works for them (not a convincing argument, tbh) then we're still better off them not taking the job. I have more sympathy for the...
If this unethical crap is the only job said doctor can find that works for them (not a convincing argument, tbh) then we're still better off them not taking the job. I have more sympathy for the hundreds/thousands of patients involved than a single doctor's employment opportunities. Many of these patients will be in far more dire financial situations than anyone that's had the opportunity to become a doctor.
If your job involves this kind of direct affect on others' health and financial situations, you don't get sympathy from me for doing immoral/unethical work just because you need a job (and only in very particular situations would this ever make sense). Come on...
To me, if these doctors knowingly denied these claims without looking at the patient files, they should be prosecuted. This is criminal behavior. Of course, whoever setup this system, and the...
To me, if these doctors knowingly denied these claims without looking at the patient files, they should be prosecuted. This is criminal behavior.
Of course, whoever setup this system, and the company itself, are also guilty.
I would really like to believe that this was done benignly. Given that health insurance itself is just a completely useless middleman, an automated system that can automatically approve a claim is...
I would really like to believe that this was done benignly. Given that health insurance itself is just a completely useless middleman, an automated system that can automatically approve a claim is a good thing as it reduces expenses (and hopefully that means it becomes less expensive for the patient as well).
But having human doctors rubber stamping the rejections is a huge problem that I don't really see anyone implementing without seeing a problem. Those denials really should be reviewed automatically - medicine is complicated - and not left denied waiting for people to appeal the decision. I would hope that it was just a matter of a few people not doing their jobs correctly, but from the way they describe the problem that doesn't seem to be the case.
Yes, from all information given, from multiple prior employees, internal documents, and including the words of people involved in this system's implementation- it seems rather obvious that the...
Yes, from all information given, from multiple prior employees, internal documents, and including the words of people involved in this system's implementation- it seems rather obvious that the entire overall intent of the system in the first place was to deny claims en masse to save money, knowing that many people will not go through the pain of an appeal. This is an admission that they know how terrible the appeal process is, that they are knowingly rejecting valid claims, and are using a purposely obtuse system as a way to essentially dark-pattern people into paying.
Their doctors were essentially able to do a "select all" on a batch of Y number of claims about procedure X and deny them all in one sweep, abandoning any sort of actual review process entirely but trying to use the fact that a doctor was the one pressing the button as a loophole to say the claims were "reviewed" when they were not. That is wholly unethical and should be considered criminal and a doctor involved does not just get to say they were "following orders".
Denying claims without review, at a mass scale, is on-its-face morally bankrupt and those involved do not get to claim innocence.
Maybe the individual reviewers didn't do it maliciously, although I would argue that spending less than 2 seconds per claim and denying without reviewing the medical records is at the very least...
Maybe the individual reviewers didn't do it maliciously, although I would argue that spending less than 2 seconds per claim and denying without reviewing the medical records is at the very least negligent, the incentives in private health insurance do not favor the patient. The incentive is for insurance providers to deny as many claims as possible, with as little human review as possible. There is very little reason for health insurance providers to ever pay claims if they can help it when it is not required by federal law or a state insurance regulator. Obviously they have to pay enough to attract customers, but given that most Americans get their health insurance through their providers, and there is very little competition in many markets, why would they bend over backwards to pay for care that they don't have to?
Sometimes you work in an industry long enough that you forget that the public are largely unaware of how it works. I, thankfully, no longer work in healthcare, but what the article covers is...
Sometimes you work in an industry long enough that you forget that the public are largely unaware of how it works. I, thankfully,no longer work in healthcare, but what the article covers is denial due to not being "medically necessary", they just have some MDs on staff push the deny button to appease some zero-oversight law in some places.
During my latest healthcare tenure I was the medical necessity resource due to my experience on both the provider and payor sides of the equation and I authored software that was specifically designed to get around this cat-and-mouse game. We're not allowed to tell a provider how to code a procedure, but the software gave a pretty heavy handed hint that the way they coded it didn't meet the insurance's medical necessity requirements and a "Here's some alternative diagnosis codes that just happen to be really close to the one(s) you're using" message along with a link to view the medical necessity documentation.
Every insurer publishes, you just have to know where to look, their medical necessity documentation and it often includes citations/studies as to why they only accept certain diagnoses for those procedures. We just took it, parsed it, made it digestible to the provider, and automatically check for it when they coded it.
I haven't quite gotten around to writing a thorough comment for this thread yet, but literally my first thought when this article broke was "yeah, that's how it works". In fact, it's quite a bit...
I haven't quite gotten around to writing a thorough comment for this thread yet, but literally my first thought when this article broke was "yeah, that's how it works". In fact, it's quite a bit more insidious than the article implies, it's actively resistant to change and developing medicine no matter how much better the developing medicine is (new procedures have to be billed as 'misc' codes until they are formalized into a newer edition of CPT or ICD) and there's an amount of specialized medical care out there where the person that reviews the appeal is actually the only truly relevant factor as it will be denied regardless as it is not considered medically relevant in any context. There's also a decent amount of stuff that falls through the cracks based on the specificity of coding. Two surgeries that accomplish the same thing but use different tissues to do so are billed the same way, because of this you can end up with situations where one is medically impossible (tissue does not exist or cannot be harvested) and yet a person is repeatedly denied their claims because an in-network provider is shown as performing the same procedure as the out of network provider who can do that procedure with a different relevant tissue.
One solution might be to legally require health insurers to pay for the procedure for free after wrongful denials have been appealed, coupled with some total compensation minimum in order to deter...
One solution might be to legally require health insurers to pay for the procedure for free after wrongful denials have been appealed, coupled with some total compensation minimum in order to deter denial of cheap procedures.
Some insurance irregularities I've noticed over the years of working in health care, working with specialized populations, and spending time in various marginalized communities and listening to their struggles with insurance and health care as a whole:
Systemic Denials
Automatic denials of this sort are systemic. As others have stated, this is not a new thing, nor is it specific to Cigna. This kind of behavior has been pretty standard for quite some time, for all the capitalistic reasons you can imagine. This article is helping to draw attention to some of these practices which are frankly not good for the consumer and only instituted because they are good for profits.
Formalized health care
Extremely formalized health care is change resistant. I mentioned this in another reply in this thread, but I want to highlight this as an issue not just with this kind of automatic denial system, but in the very way that for profit health insurance works. Let's imagine a graph where along the x-axis we have a historical timeline representing how long a particular kind of care has existed in humanity. On the far left would be extremely old techniques such as bandaging wounds and on the far right we would have extremely new techniques such as a MRNA based HIV vaccine. Along the y-axis we have known effectiveness, or how much scientific evidence we have for this being an effective treatment. If we label the top left quadrant (old, lots of evidence) as quadrant I, the top right II, bottom left III, and bottom right IV, insurance companies tend to formalize towards prioritizing quadrant I. From a practical perspective, and from a distant perspective, this makes sense. The way this is typically accomplished, is by simply ascribing the various medical care that exists in quadrant I as 'approved' treatments for conditions for which they treat.
The issue with this, however, is that the way that new treatments are designed is that by nature they must exist within quadrant IV or II before moving to quadrant I or III. Furthermore, we've actually added a third axis to our graph, one for which applicability to medical condition spans from not applicable on one side to perfectly applicable on the other. Insurance companies aren't thinking along this modality, and ascribe applicability as a simple 0/1 function. Either the treatment is approved for a condition, or it is not. Medical care is particularly complicated. An approved treatment for a blood pressure issue might be a medication which is contraindicated in the patient for different reasons - said drug might tax the kidneys and the patient has poor kidney function, said drug might interact with other conditions the patient has, said drug might interact with other drugs the patient is on, or simply said drug may not be tolerated by the patient because they experience negative side effects which may outweigh the clinical benefit of said drug. All of this is lost when we simplify down to <condition> maps to <treatment>. This is what the review process is supposed to be for, to ensure that patients still get care even when they don't neatly fit into the automatic denial systems. In fact, what we should be doing is viewing these systems as automatic approval systems, not denial systems, but that's been corrupted by the capitalistic incentive of running a for-profit company.
Coding specificity
The specificity of coding adds another layer of issues. Medical coding is a process in which very specific codes are attributed to patients in order to quantify attributes about them. Coding systems exist across a variety of medical needs, but for the purposes of simplicity I'll talk about only one relevant coding system: the international classification of diseases (ICD). The ICD system was originally purely a system of diagnoses - meant to classify patients in a standardized fashion. The disease state of asthma, for example, would classify to a single code representing the kind of asthmatic state the patient is experiencing. Over time this has expanded to also include procedures (sometimes referred to as ICD-PCS) and other useful medical taxonomy. As you can imagine, the number of applicable codes expands each released version. Over time this system has expanded from just numeric classifications to alphanumeric classifications, and codes are sometimes moved from one tree into another or expanded to create additional codes.
Asthma (J45 in ICD-10) for example is a tree consisting of mild intermittent asthma, mild persistent asthma, moderate persistent asthma, severe persistent asthma, and other and unspecified asthma. Of note among these codes is that some of them didn't used to exist (asthma was simply code 493 in ICD-8 and did not have separate codes for chronicity and severity) and the final code listed here is for "other and unspecified". For many disease states and for many procedures, there is what is colloquially known as a "9" or "99" code (depending on terminology) which exists as a catch-all for future expansion. If it doesn't neatly fit into the list of diagnoses or procedures, it'll be coded in the 9 code. 9 and 99 codes are almost universally rejected by insurance, because they necessarily fall into quadrant II and IV as described in 2. These represent the expansion of medicine as a field, and we don't have a history to really understand how to treat these conditions or whether they should be their own separate condition in the first place. 9 and 99 codes also exist a LOT when you deal with extremely specialized medicine. If you have a very rare kind of cancer, for example, you might not even make the ICD system because they are unaware that your condition exists, or what doctors even do to treat this condition. In fact, you may be fighting for it to be recognized AS a condition, or with other taxonomies to split your condition out of existing conditions as it is improperly grouped. For example, being gay used to be a classified disorder in the DSM as was being transgender… gender dysphoria still exists in the DSM-V but as you can imagine grouping the two together makes getting healthcare complicated and transgender healthcare does not represent the needs or concerns of cisgender non-heterosexual healthcare.
In-network, out-of-network
A further layer of complication comes when determining which providers are in-network versus out of network. The services that a provider performs are at a higher level than coding. A maxillofacial surgeon, for example, does surgeries on the head, neck, mouth, jaw and face. As you can imagine, there's a variety of surgeons that would fall into this broad category. One maxillofacial surgeon may specify in cleft lip repair, for example, and never perform rhinoplasties. Someone who needs a rhinoplasty because of trauma caused by an accident may be told that the maxillofacial surgeon which only does cleft lip repair is in network, and therefore they cannot go out of network to another provider which specializes in rhinoplasty.
This gets even further complicated when you're talking about conditions which overlap with procedures which are commonly not covered, such as breast augmentation following breast removal (common for individuals with breast cancer in only one breast who wish to even things out by augmenting one, rather than removing both breasts). There may be an automatic rejection of the codes combined with surgeons in network who don't perform this specialized kind of surgery. In other cases there may be specialized versions of surgeries which broadly overlap with existing surgeries. Using the previous example, a plastic surgeon may be in network who does breast augmentations but typically does it for gender affirmation reasons and so is used to and has been trained on how to make breasts larger using particular methods. A reconstructive surgeon whose goal is to restore a breast has a different outlook on surgery and may use a different set of tools to understand how best to reconstruct said breast. They may, for example, take measurements of the existing breast to ensure that the reconstructed breast is symmetrical to the existing breast and may use special techniques to ensure that the augmented tissue sits in the body in a similar way to the other breast - the techniques they employ to accomplish the same procedure (augmentation of breast) differs greatly from the gender affirming surgeon and yet these differences are not visible when using simple procedure and diagnoses codes to determine whether a provider is in or out of network.
What these add up to is frankly a shitty experience for people suffering from rare and expensive disease states, the very people which often need the most help because their conditions make their lives more difficult to navigate. What I have learned from direct experience with my own health care and those of other minorities and rare disease groups is that you have to learn how to fight the system to get the care that you need. Ask someone with chronic pain how they've experienced the healthcare system, let alone the repeated governmental attempts to "control" an opioid epidemic of their own making. Ask someone with an expensive medication, such as antiretrovirals used to treat HIV whether they've had to fight for access to their drugs. There's sadly a systemic problem caused by capitalism which puts the burden on the people which need the burden alleviated the most.
Very enlightening and interesting.
@JCPhoenix's story about their coworker also greatly moved me.
I'm not yet fully convinced that capitalism is the biggest culprit. I think it has a large role because incentives in capitalism pervert many aspects of healthcare. Simultaneously, some aspects of healthcare would improve in purer market conditions, like showing prices so patients can shop around for non-emergency procedures.
But I get the sense that the Modern Healthcare Problem is the result of massive uber complex system engineering. It's a web of systems bolted together with little attention paid to the end consumer experience. It is badly in need of rearchitecting that is very difficult to achieve at meaningful scale due to economic incentives, entrenched or conflicting interests, and the very ambiguous and non-discrete nature of healthcare itself.
An interesting case is that of the Nevada Culinary Union Local 226. They represent 60,000+ hospitality workers in Nevada's hotels and casinos. They opposed Bernie Sanders on the basis of his Medicare for All plan because the union had negotiated good healthcare for its members, a selling point of the union. The introduction of universal healthcare untied to employment would take away the union's big selling point and thereby threaten the union, so the union was moved by its own interests to secure its power.
Zooming out, 1 in 9 Americans is employed in healthcare, and more are employed in related sectors, and it only keeps growing. And for every doctor there are 16 FTEs, 9 of which are admins, according to this 2016 Politico article. So the figures are probably worse now. Much of the greed that people experience on the patient end goes onto to employ tens of millions of Americans — not that I think this is a good thing; if anything, it's terrible, and terribly inefficient and wasteful. If profit were the primary motive, I'm sure healthcare providers and insurance companies would much prefer to not keep adding on costly, nonproductive personnel at such pace. So I sense that other forces and interactions are at play.
Are there any good resources to learn about the various subsystems at play in the US healthcare system?
Only when we're operating outside of the insurance paradigm. We don't really shop around to find a primary care provider that's cheapest, we shop for one in-network and reasonably close by. Only when we get to expensive procedures which aren't covered does this really apply. And guess what, this often is because these things are automatically denied. Want an MRI? Well, its gonna cost you if you have a high deductible plan or don't happen to have one of very few conditions for which it's not automatically denied or which you put in time appealing/working the system to get it covered. At that point, it's up to the insurance to tell you where to go. But here's the thing... the insurance company already did that shopping around. That's why there are in-network places to get an MRI. So exposing the cost won't really help these people either. All it helps is for cases where insurance simply isn't footing the bill for whatever reason.
Absolutely! Many healthcare providers have noticed this and have changed how they provide medicine. At the organization where I work, there was a significant amount of effort put into this and we even use Gallup and other polling to ensure we're monitoring and attempting to improve the experience of patients. But that's only one system among many that need to work together to make this behemoth work and many aren't savvy enough to realize this will win them patients and therefore dollars.
There is some truth behind what you're saying, but I want to address some of the costs out there before jumping into the why, because ultimately it's all supported and pushed into absurdity by capitalism.
There are some salient points about healthcare spend on this page highlighting some ways in which the US leads and lacks as compared to other countries with socialized medicine. We actually visit doctors a lot less in the US than other countries with wildly less expensive healthcare systems. Is some of this inflated spend from additional personnel? Perhaps, but looking at where the spend actually goes paints another story. Looking at a high level at slices of spend you'll note that the US likes its hospitals and the hospitals are very expensive, despite people spending less time in hospitals in the US than most other countries. Hospitals need to compete with one another, and so we have more services than we really need. We perform around double the MRIs as other countries (with the exception of Japan) which shows just one small slice of this competition between hospitals. We have more redundant medical machines than other places in the world because of this competition - you need to offer what the hospital nearby offers in order to remain competitive.
Importantly, there are a number of extremely talented people who've looked at this in a lot more detail than I ever could have. A fantastic journal article originally titled "It's the prices, stupid" published back in 2003 was revisited and published in 2019 with an updated title, "It's still the prices, stupid" which highlights how prices are inflated in the US. UC Berkeley has a much more digestible breakdown article on the original paper that I found which I think does a good job at explaining some of the major factors behind these prices and tracking their growth. Of particular note, raising prescription drug costs (thanks capitalism) moving in tandem with a decrease in their usage (I wonder why people would shy away from more expensive drugs?) and the administrative overhead that comes with the complicated coding and billing that we have to deal with in the US in order to actually get paid for anything. It's no surprise that we need 9 administrative staff per doctor when they have to submit codes to bill to insurance and deal with the same problems that I mentioned above.
To add an anecdote which I think highlights this, the health care system that employs me offers its employees a healthcare plan that we run. This healthcare plan requires you to go to our healthcare system for care, if it can offer it. If it can't offer the care, doctors are sourced from another plan (Aetna) for in-network rates to keep things reasonably affordable. I have a chronic pain issue involving my shoulder. I went to my primary care doctor at this healthcare system, who referred me to a pain doctor who referred me to a different pain specialist who ordered an MRI to confirm the issue and then ordered a corrective surgery. This corrective surgery was denied by the insurance that we run the day before the surgery (in the afternoon, none the less) because it was billed with a 99 code. Ignoring the fact that a bunch of resources had to be reserved in order to perform this surgery which they couldn't exactly mobilize in the few hours left of daylight before the next day to move up another surgery (let alone if someone else would be willing, given the additional support needed such as someone to drive you there/back) but it then had to be appealed three times only for the final decision to be that the insurance would not cover it. The physician group had to get the director of the facility to sign off on providing the procedure without reimbursement in order for it to happen. How much less efficient can you truly get?
What you're saying about hospitals competing with eachother really rings a bell for me; as far as I know we're the only country in the world where hospitals actively advertise their services on TVs and billboards. One particular thing that has always mystified me was the ads that focused on their pregnancy and birthing services. There are many ways to deliver a child - many of which do not involve hospitals at all - but of all the factors one should consider, a f-ing advertisement should not sway your decision!
On a personal note, I have had my first real run-in with out-of-network medical expenses and I'm almost impressed at how much of a shitshow it was even though I know I had it much easier than most. I've mentioned before that I have some pretty fantastic healthcare due to being a member of a very vertically integrated healthcare system, but the one thing they don't do is supply you with medical equipment. They have a specific supplier to go through and they put in the order for me. The problem is that as a seperate company they have terrible communication; it took me literally a month of calling the two organizations daily to get them to move and get me the equipment that I needed - in spite of the fact that not using it was supposedly shortening my lifespan.
Beyond that, the machine is so incredibly overpriced that the insurance arm won't actually cover purchasing it; they will only rent it! And because it's a medical device, there is no advertised MSRP; from my research it would appear that they can go for up to $5000. For a simple device roughly the size of a large thermos. Though, granted, if it were to malfunction it could kill me, so I'm fine with paying somewhat of a premium for one that's well designed with plenty of failsafes.
(for an extra bit of frustration, I found out that the difference between the most basic version of this machine and the versions that sell for 2-5x the price is a simple setting in the service menu; you don't even need to change the firmware.)
Can you imagine spending years in medical school, learning how to help people, only to turn around and use that knowledge (or really that M.D. at the end of your name since they aren't even using their medical skills) to deny people care? That seems like it would just attract the bottom of the barrel doctors who can't find a job elsewhere. And those are the people supposedly charged with deciding who should get care.
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Is there no medical insurance oversight board that can look at those numbers and say, "this is literally impossible, what's going on here? How are they deciding this in literally two seconds without looking at medical records?"
In the United States, insurance declining to cover something is denying care. Our health system is so tied into insurance that most people can't even afford routine tests or doctor's visits.
I had a procedure my doctor wanted to do denied by my insurance once and I asked what the cost would be if I paid for the procedure myself and she didn't even know. She had to have her insurance liaison (yes that is a real position in most doctor's offices) look it up. That person didn't know because they always just billed insurance. Luckily, I have a family member who worked in a doctor's office for years and she helped me file an appeal. It took months and countless hours but it was finally approved and they covered the procedure.
Most people don't have the knowledge or time to fight those rejections though. So for every appeal, I'm sure there are hundreds of people who just accept the rejection and go without the care they need.
Go fuck yourselves, Cigna.
I know you're frustrated, and certainly the US medical system is very frustrating. But this seems unsympathetic. Being a doctor sucks in many ways nowadays. If they can't do it and need to get out, what do they do instead? They likely still have student loans to pay off.
Also, you seem to be arguing that the whole job is unnecessary. Auto-approving everything will result in medical fraud that will make insurance even more expensive. There are certainly reasons to disagree with how it's done, but someone has to do it. Guarding against fraud is also necessary for government-run systems like Medicare.
[Edit: withdrawn. I had not read the article and didn't fully appreciate how bad it's gotten.]
Sometimes the harm produced by a person participating in a broken system is less than the harm that would be done to them if they abstained. Let's look at the harm caused by this.
Any doctor who does this is personally, actively, best case scenario, causing huge amounts of distress and financial hardship to hundreds or thousands of people. Virtually every single person affected by this is guaranteed to be having a bad time. You can tell because they have medical bills, and unexpectedly in defiance of their supposed coverage suddenly have a lot more. Even if they can resolve it, it's a massive amount of purposeful, deliberate frustration dealing with the insurance companies while simultaneously dealing with serious medical issues.
That's the best case scenario. Medical debt ruins lives. Lack of treatment ends them. The effects of this make people avoid seeking medical care as long as possible, turning treatable issues into terminal ones. Anyone who does this job for a significant amount of time has almost certainly killed people, whether directly through denying life-saving coverage or through indirectly causing someone to wait until it's too late.
So, while it might be theoretically possible for more harm to be done to someone by not participating in this than would be done by doing it, you're getting into the realm of absurd hypotheticals. It's an absolutely fucking despicable practice.
Literally happened to a co-worker. Like three times.
When I first met her, she had just been diagnosed with Breast Cancer, which destroyed her finances. She had to declare bankruptcy due to the debt.
She survived cancer and bankruptcy and was trying to get her finances back together. One day, however, she went to a nail salon to get her nails done like she normally did. Afterwards, one of her fingers started to hurt but she didn't see any sores or cuts or anything. But instead of going to the doctor even though several of us told her she should after like a week of it hurting, she waited. Because seeing a doctor and potentially having a procedure of some sort could be expensive even with insurance. She continued to wait. And wait. And wait even though her finger hurt more. Until she slipped into a coma one morning and her finger was horribly infected and turned gangrenous. They had to cut off half of that finger. Turns out that was a diabetic coma she was in. And the infection was likely exacerbated by the diabetes.
After several years, she somehow managed to pay off most if not all the debt. And she even started taking better care of herself! Insulin was too expensive, even with insurance, so she made it a point to vastly improve her diet and lose A LOT of weight, so she wouldn't have to buy/use as much insulin. Moneywise, she was doing much better, especially since she was free of the medical debt.
And all was good until right before COVID where she was struck by another ailment. She collapsed in the parking lot one day after work. She survived, but was hospitalized again for quite a while. She also had to have a large chunk of her thigh/buttocks removed. And have some homecare, which isn't cheap. I don't know exactly what she got, but it almost killed her. I almost wonder if it was related to her diabetes again. She can walk, but just barely and usually needs a cane or a walker. Even sitting can be painful for her. The only "plus" from that one is that she was the first to go full, permanent remote, which she enjoys. But her quality of life is certainly harmed. And of course she's back under a mountain of medical debt.
She's 63 and she thinks she'll never be able to retire. She rents; has never owned a home. And there's no way she could afford one being single. Not after three bouts of major medical crises.
Medical debt destroyed her life three times. And maybe had she gone to seek medical advice/help sooner, she might have avoided these ailments (aside from the cancer diagnosis). But it's hard to fault people for being scared of seeing a doctor when it can lead to some expensive outcomes. Soon after my coworker lost her finger, I got a toothache. I quickly ran to my dentist to have her check it out, not wanting to end up like my coworker, even though I was young, healthy person. A week or two later, I was getting my wisdom teeth removed. That was like $1600, even with insurance, more or less out of the blue.
Unfortunately, like you said, waiting just means it's typically more expensive, if it doesn't kill you. So pay a lot now, or pay even more later, or pay with your life. Great options.
Why does someone who is allowing this kind of system to exist deserve sympathy? They're spending an average of 1.2 seconds on each case. They are rejecting without even reviewing. They are being unsympathetic to the patients. In fact, I'd argue they're also being negligent.
Who's suggesting this? Why the jump to the opposite extreme? I think it's reasonable to vent at a clearly capitalistic system that is practically auto-denying in order to save money, especially when this means that some people are not able to receive the care they're paying to get access to and the vast majority of them need.
Fraud prevention is absolutely necessary for government (and private) health payers, but this system does not seem to be focused on fraud prevention but rather on reducing costs to the insurer at the expense of the patient.
It's a difficult problem, because most fraud in government healthcare is committed by providers, and involves things like upcoding, unbundling, overprescription, and billing for services that have not been rendered. Government payers absolutely have to be diligent in detecting this type of fraud and waste, but I don't think that systematically denying all claims for a service outside a narrow list of Px/Dx combinations is the right way to do that. I don't think any process that is determining medical necessity that doesn't involve an actual review of medical records is operating in good faith.
I work in this field, although I'm not directly involved in FWA (fraud, waste, and abuse) prevention, and I know that healthcare providers (or at least, their billers) frequently submit fraudulent or at least incorrectly coded claims that need to be denied or reviewed. Providers will also bill claims in a way that maximizes their payment as much as they legally can (and sometimes beyond). I think that a lot of this has as much to do with how overly opaque and complex medical billing is in the US as it does with greed. It requires an army of coders/billers and insurance liaisons to navigate the healthcare system, and that gets expensive.
It's worth remembering, though, that most of the time when a claim is submitted to an insurer and denied, the provider is just going to shrug and then pass that bill on to the patient, who is then faced with paying those unexpected and usually high costs, or going through a process that is almost always opaque and frustrating to get their insurance to pay for a procedure. It's maddening to have a physician tell you that you need a test or a procedure, and for you to have to think "Is my insurance going to pay for this? Are they going to agree with my doctor's clinical decision?" The incentives for private insurers are generally not to place the health of the patient first.
I don't know what the solution to all of this is, although I have lots of thoughts. There are people that know way more than I do about healthcare policy that struggle with all of these factors. I do know that the system that we have now is not working for most people, though.
I'm not arguing that the job is unnecessary, I'm saying that it will, by its very nature, attract bottom of the barrel talent. Somebody has to be the worst doctor out there...do we really want them to be the one making medical decisions for hundreds of thousands of people each year?
They shouldn't be auto-approving everything, but they also shouldn't be spending 1.2 seconds on each patient before approving or denying a claim. (Side note regarding cost: That should be a non-issue. We shouldn't have health insurance in the first place...we desperately need a single payer system)
If this unethical crap is the only job said doctor can find that works for them (not a convincing argument, tbh) then we're still better off them not taking the job. I have more sympathy for the hundreds/thousands of patients involved than a single doctor's employment opportunities. Many of these patients will be in far more dire financial situations than anyone that's had the opportunity to become a doctor.
If your job involves this kind of direct affect on others' health and financial situations, you don't get sympathy from me for doing immoral/unethical work just because you need a job (and only in very particular situations would this ever make sense). Come on...
To me, if these doctors knowingly denied these claims without looking at the patient files, they should be prosecuted. This is criminal behavior.
Of course, whoever setup this system, and the company itself, are also guilty.
I would really like to believe that this was done benignly. Given that health insurance itself is just a completely useless middleman, an automated system that can automatically approve a claim is a good thing as it reduces expenses (and hopefully that means it becomes less expensive for the patient as well).
But having human doctors rubber stamping the rejections is a huge problem that I don't really see anyone implementing without seeing a problem. Those denials really should be reviewed automatically - medicine is complicated - and not left denied waiting for people to appeal the decision. I would hope that it was just a matter of a few people not doing their jobs correctly, but from the way they describe the problem that doesn't seem to be the case.
Yes, from all information given, from multiple prior employees, internal documents, and including the words of people involved in this system's implementation- it seems rather obvious that the entire overall intent of the system in the first place was to deny claims en masse to save money, knowing that many people will not go through the pain of an appeal. This is an admission that they know how terrible the appeal process is, that they are knowingly rejecting valid claims, and are using a purposely obtuse system as a way to essentially dark-pattern people into paying.
Their doctors were essentially able to do a "select all" on a batch of Y number of claims about procedure X and deny them all in one sweep, abandoning any sort of actual review process entirely but trying to use the fact that a doctor was the one pressing the button as a loophole to say the claims were "reviewed" when they were not. That is wholly unethical and should be considered criminal and a doctor involved does not just get to say they were "following orders".
Denying claims without review, at a mass scale, is on-its-face morally bankrupt and those involved do not get to claim innocence.
Maybe the individual reviewers didn't do it maliciously, although I would argue that spending less than 2 seconds per claim and denying without reviewing the medical records is at the very least negligent, the incentives in private health insurance do not favor the patient. The incentive is for insurance providers to deny as many claims as possible, with as little human review as possible. There is very little reason for health insurance providers to ever pay claims if they can help it when it is not required by federal law or a state insurance regulator. Obviously they have to pay enough to attract customers, but given that most Americans get their health insurance through their providers, and there is very little competition in many markets, why would they bend over backwards to pay for care that they don't have to?
Sometimes you work in an industry long enough that you forget that the public are largely unaware of how it works. I, thankfully, no longer work in healthcare, but what the article covers is denial due to not being "medically necessary", they just have some MDs on staff push the deny button to appease some zero-oversight law in some places.
During my latest healthcare tenure I was the medical necessity resource due to my experience on both the provider and payor sides of the equation and I authored software that was specifically designed to get around this cat-and-mouse game. We're not allowed to tell a provider how to code a procedure, but the software gave a pretty heavy handed hint that the way they coded it didn't meet the insurance's medical necessity requirements and a "Here's some alternative diagnosis codes that just happen to be really close to the one(s) you're using" message along with a link to view the medical necessity documentation.
Every insurer publishes, you just have to know where to look, their medical necessity documentation and it often includes citations/studies as to why they only accept certain diagnoses for those procedures. We just took it, parsed it, made it digestible to the provider, and automatically check for it when they coded it.
I haven't quite gotten around to writing a thorough comment for this thread yet, but literally my first thought when this article broke was "yeah, that's how it works". In fact, it's quite a bit more insidious than the article implies, it's actively resistant to change and developing medicine no matter how much better the developing medicine is (new procedures have to be billed as 'misc' codes until they are formalized into a newer edition of CPT or ICD) and there's an amount of specialized medical care out there where the person that reviews the appeal is actually the only truly relevant factor as it will be denied regardless as it is not considered medically relevant in any context. There's also a decent amount of stuff that falls through the cracks based on the specificity of coding. Two surgeries that accomplish the same thing but use different tissues to do so are billed the same way, because of this you can end up with situations where one is medically impossible (tissue does not exist or cannot be harvested) and yet a person is repeatedly denied their claims because an in-network provider is shown as performing the same procedure as the out of network provider who can do that procedure with a different relevant tissue.
One solution might be to legally require health insurers to pay for the procedure for free after wrongful denials have been appealed, coupled with some total compensation minimum in order to deter denial of cheap procedures.