I recently had a skin biopsy come back as a melanoma, and discovered this morning (one day before I go under the knife to have it removed) that one of the tests my dermatologist ordered was denied...
I recently had a skin biopsy come back as a melanoma, and discovered this morning (one day before I go under the knife to have it removed) that one of the tests my dermatologist ordered was denied by my insurance company--to the tune of $8500, which (assuming none of the appeal paths I plan on pursuing go anywhere) I have to pay out of pocket and won't even count towards my deductibles. It stemmed from the phone conversation where I was given my diagnosis, during which my dermatologist suggested "I think we should run XYZ test to help determine how concerned we should be about metastasis and recurrence, is that OK?" and me, having just learned I have cancer, saying "yeah, that sounds like a good idea."
That bill is going to sting a lot, but I'm privileged enough that it shouldn't hurt my day-to-day quality of life too much (just erase a pretty significant percentage of my savings). I can't say for certain I would have said no if I understood the cost of the test and that there was a chance I'd have to foot it myself, but I definitely would have put more thought and research into it before just shrugging and nodding. I think it's absurd that:
a) private insurance companies with a strong financial incentive to deny coverage get to second-guess decisions that the actual medical providers make in the best interest of their patients; and
b) patients who are potentially already feeling overwhelmed by whatever medical issue they're facing also have to parse every treatment and testing decision that they or their doctor makes through the lens of "what is the likelihood my insurance will cover this and how f***ed am I if not?"
I don't know what the solution is, but it needs to address those problems at least. Anyway, I just wanted to vent a bit. I truly loathe the state of the American health care system.
For starters, there's likely no good reason that test costs $8500. That's not what the insurance will pay if they have to cover, and that's not what anyone else in the world likely pays for these...
For starters, there's likely no good reason that test costs $8500. That's not what the insurance will pay if they have to cover, and that's not what anyone else in the world likely pays for these things.
The whole system is supremely fucked up because of this exact point, and it's why I found the ACA to be mostly toothless. Until we can actually start charging companies, doctors, etc for what this is (out and out fraud), the system will never be fixed.
And yes equally as important is that insurance should NEVER be able to second guess a doctor. Ever. End of discussion. It's horrific it's even allowed.
Correct, it is not what the insurance would pay, it's just what the provider billed them for. @Rudism, IF all, and I mean every single possible avenue of appeal including sending a letter to the...
For starters, there's likely no good reason that test costs $8500. That's not what the insurance will pay if they have to cover, and that's not what anyone else in the world likely pays for these things.
Correct, it is not what the insurance would pay, it's just what the provider billed them for. @Rudism, IF all, and I mean every single possible avenue of appeal including sending a letter to the insurance stating you're also sending a copy to your state board of insurance regarding the medical necessity of the procedure, fail and you end up having to pay for it, you'll want to request the "self pay rate" for the procedure. It will be the cash price as if you never had insurance, will be much lower, and either the same or less than what insurance would pay. It's also entirely possible that the biller at your provider's office simply billed it wrong. Medical billing, largely because of what is discussed further below, is a threading the needle game of cat and mouse.
[Of the very long list of occupations I've had in my many years it includes: medical billing, running physician offices, writing medical billing software, and more in this shit of a healthcare industry we have in the US[
And yes equally as important is that insurance should NEVER be able to second guess a doctor. Ever. End of discussion. It's horrific it's even allowed.
Not to defend insurance companies at all, I utterly despise them from both an intelligent human and having spent far too much time in the industry standpoint, but rampant fraud exists at the provider level as well which leads to requiring second guessing the medical necessity of what is billed. Even Medicare and Medicaid do so with thousands of policies dictating what can and cannot be billed for various reasons. When fraudsters stop billing every single test under the sun for a stubbed toe or head cold the payors will stop second guessing providers.
I have complicated feelings about this, but I think it comes down to this: I get the emotional impetus that drives you to cry 'fraud' here. But I don't think it's accurate or really fair to assert...
Until we can actually start charging companies, doctors, etc for what this is (out and out fraud),
I have complicated feelings about this, but I think it comes down to this: I get the emotional impetus that drives you to cry 'fraud' here. But I don't think it's accurate or really fair to assert that companies, doctors, etc, are all committing fraud. I also don't think it's all that effective. Much better to instead point out that the complex system we've created is leading to unexpected negative outcomes, and we need to fix it.
It's more than just quibbling over language. Empirically, we know that when people feel accused, they tend to dig in their heels ("I'm not committing fraud!"). If we say instead "this is nobody's fault, but it needs to be fixed," we're much more likely to get broad buy in and support.
Except it absolutely is just that. This is not normal market economics. NO ONE is paying that price except the consumer, and even then, if you actually call your doctor/hospital they will almost...
Except it absolutely is just that.
This is not normal market economics. NO ONE is paying that price except the consumer, and even then, if you actually call your doctor/hospital they will almost certainly give you a discount. When a hospital is charging $25 for a single aspirin in the US, and no other country does that, what are they funding?
They're funding the risk of being sued, and care in all cases they're required to give care even if people can't pay. I have relatives that practice medicine. Around a third of their annual income...
They're funding the risk of being sued, and care in all cases they're required to give care even if people can't pay.
I have relatives that practice medicine. Around a third of their annual income goes to paying malpractice insurance.
And then hospitals are for-profit because healthcare isn't universal or government-run, but still in part government funded. The whole system is bonkers. This means that even more of the money goes to profits of the 'medical insurance and litigation business', and 'owning-healthcare providers' business. These are very lucrative businesses.
The threat of non-payment or calling out overpricing isn't worth not lowering the price to see what you can get away with. It's also a system where you for some reason have to barter, and the same procedures can cost hugely different sums depending on which hospital was closest when one neede emergency care.
Healthcare cannot be market economics, because as we approach death or serious permanent harm, the willingness to pay approaches infinity, going somewhere else often isn't practically possible and financial ruin is viewed as an acceptable outcome.
Simplified, the problems with the US healthcare system aren't about the US healthcare system, but the US insurance system and regulations regarding financial responsibility. I think that's why...
Simplified, the problems with the US healthcare system aren't about the US healthcare system, but the US insurance system and regulations regarding financial responsibility.
I think that's why cries against hospitals/health care workers ring so hollow for me: That's not what any of this is about, which means fixing the healthcare system isn't about fixing the healthcare system at all. The care is world class, but it's just inaccessible to many of those who should have access due to the stupid financial organization.
On the contrary, that's not their job nor should they know it. A patient shouldn't be concerned with what a medically necessary procedure costs, nor should a provider; their concern is the health...
The doctors themselves often don’t know what the procedure they’re recommending costs. I think that’s pretty messed up.
On the contrary, that's not their job nor should they know it. A patient shouldn't be concerned with what a medically necessary procedure costs, nor should a provider; their concern is the health of their patient. Should every conversation with your provider go something along the lines of:
Provider: You need ABC done to stop your XYZ condition.
Patient: Great, let's get that done.
Provider: How much money do you have?
Patient: Huh?
Provider: Well, your insurance might not cover it, and it'll be $25k if they don't.
Patient: I don't have that kind of money.
Provider: Sucks to be you, champ. How much is relief from that XYZ condition worth to you?
---or---
Provider: [thinking internally] Patient needs ABC to stop XYZ, but they look like they can't afford it, so I might as well not even suggest it to get their hopes up.
Provider: [speaking to patient] How about some pain meds?
Yes, healthcare shouldn't work this way, but it does in this fucking country.
Okay, let me rephrase that. Given that the patient might actually have to pay for it, it’s fucked up that they aren’t told what it would cost in advance, and doctors, who are running or work for a...
Okay, let me rephrase that. Given that the patient might actually have to pay for it, it’s fucked up that they aren’t told what it would cost in advance, and doctors, who are running or work for a business and are the ones actually talking to the customers, don’t know what they charge and don’t talk about it. What other business works that way? Dentists, opticians, and hearing aid providers don’t work that way.
On the other hand, for emergency services, it does make sense that they should simply be provided and paid for by the government. When a house is on fire, nobody asks how much the firefighters charge to put it out, nor should they.
Some healthcare things are more like emergencies and some are things you could shop for if given a chance. Unfortunately there often isn’t a clear distinction between them.
Handling costs are what the provider's supporting staff are for, when I ran physician offices we provided estimates for all procedures performed and what they'd cost at the self pay rate if...
Handling costs are what the provider's supporting staff are for, when I ran physician offices we provided estimates for all procedures performed and what they'd cost at the self pay rate if insurance denied coverage. The physicians that owned the practices didn't keep track of prices for procedures, what insurance paid, or anything financial as there was and should be a separation between the medical and financial side of things. A provider's only concern should be the wellbeing and best course of care for their patient, period.
Outside of very small practices, providers don't generally keep up with the costs of procedure. Dentists, opticians, and audiologists are usually in that category; largely because their practices are very rigid. They're the fast food of healthcare where it's a numbers game. They know it's X number of cleanings/eye exams/hearing aids needed to pay the bills. An oncologist isn't going into practice with the thought "if I can get 40 poor souls per month with cancer I can get that new Ferrari F80 by spring."
Providers typically don't want to keep up with the costs either, it's not what they went to school for, and is one of the many "selling points" that private equity/hospital groups has latched onto and caused the mass consolidation of healthcare.
On the other hand, for emergency services, it does make sense that they should simply be provided and paid for by the government. When a house is on fire, nobody asks how much the firefighters charge to put it out, nor should they.
I’m not sure I agree. It’s not always clear what medically necessary means, there isn’t an unlimited supply of care, and there are diminishing returns from testing unlikely conditions. Somebody in...
I’m not sure I agree. It’s not always clear what medically necessary means, there isn’t an unlimited supply of care, and there are diminishing returns from testing unlikely conditions. Somebody in the process needs to be able to do a cost benefit analysis for a proposed procedure.
I’m not sure I agree. It’s not always clear what medically necessary means, there isn’t an unlimited supply of care, and there are diminishing returns from testing unlikely conditions. Somebody in the process needs to be able to do a cost benefit analysis for a proposed procedure.
Yeah, they deal with the medicine side. They just know you need it or it may help. Hospital administrators, however, will try to figure out what they can charge for it. Hospitals are a bit crazy...
Yeah, they deal with the medicine side. They just know you need it or it may help. Hospital administrators, however, will try to figure out what they can charge for it. Hospitals are a bit crazy in how they often move money around to pay for different departments and cover different expenses
In case you're unaware, people have started using LLMs to fight healthcare appeals. One such service can be found at https://fighthealthinsurance.com/. Your doctors are probably fairly familiar...
assuming none of the appeal paths I plan on pursuing go anywhere
In case you're unaware, people have started using LLMs to fight healthcare appeals. One such service can be found at https://fighthealthinsurance.com/. Your doctors are probably fairly familiar with what needs to be done for your basic appeals, but it never hurts to submit your own testimony as well.
I recently had a skin biopsy come back as a melanoma, and discovered this morning (one day before I go under the knife to have it removed) that one of the tests my dermatologist ordered was denied by my insurance company--to the tune of $8500, which (assuming none of the appeal paths I plan on pursuing go anywhere) I have to pay out of pocket and won't even count towards my deductibles. It stemmed from the phone conversation where I was given my diagnosis, during which my dermatologist suggested "I think we should run XYZ test to help determine how concerned we should be about metastasis and recurrence, is that OK?" and me, having just learned I have cancer, saying "yeah, that sounds like a good idea."
That bill is going to sting a lot, but I'm privileged enough that it shouldn't hurt my day-to-day quality of life too much (just erase a pretty significant percentage of my savings). I can't say for certain I would have said no if I understood the cost of the test and that there was a chance I'd have to foot it myself, but I definitely would have put more thought and research into it before just shrugging and nodding. I think it's absurd that:
a) private insurance companies with a strong financial incentive to deny coverage get to second-guess decisions that the actual medical providers make in the best interest of their patients; and
b) patients who are potentially already feeling overwhelmed by whatever medical issue they're facing also have to parse every treatment and testing decision that they or their doctor makes through the lens of "what is the likelihood my insurance will cover this and how f***ed am I if not?"
I don't know what the solution is, but it needs to address those problems at least. Anyway, I just wanted to vent a bit. I truly loathe the state of the American health care system.
For starters, there's likely no good reason that test costs $8500. That's not what the insurance will pay if they have to cover, and that's not what anyone else in the world likely pays for these things.
The whole system is supremely fucked up because of this exact point, and it's why I found the ACA to be mostly toothless. Until we can actually start charging companies, doctors, etc for what this is (out and out fraud), the system will never be fixed.
And yes equally as important is that insurance should NEVER be able to second guess a doctor. Ever. End of discussion. It's horrific it's even allowed.
Correct, it is not what the insurance would pay, it's just what the provider billed them for.
@Rudism, IF all, and I mean every single possible avenue of appeal including sending a letter to the insurance stating you're also sending a copy to your state board of insurance regarding the medical necessity of the procedure, fail and you end up having to pay for it, you'll want to request the "self pay rate" for the procedure. It will be the cash price as if you never had insurance, will be much lower, and either the same or less than what insurance would pay. It's also entirely possible that the biller at your provider's office simply billed it wrong. Medical billing, largely because of what is discussed further below, is a threading the needle game of cat and mouse.
[Of the very long list of occupations I've had in my many years it includes: medical billing, running physician offices, writing medical billing software, and more in this shit of a healthcare industry we have in the US[
Not to defend insurance companies at all, I utterly despise them from both an intelligent human and having spent far too much time in the industry standpoint, but rampant fraud exists at the provider level as well which leads to requiring second guessing the medical necessity of what is billed. Even Medicare and Medicaid do so with thousands of policies dictating what can and cannot be billed for various reasons. When fraudsters stop billing every single test under the sun for a stubbed toe or head cold the payors will stop second guessing providers.
I have complicated feelings about this, but I think it comes down to this: I get the emotional impetus that drives you to cry 'fraud' here. But I don't think it's accurate or really fair to assert that companies, doctors, etc, are all committing fraud. I also don't think it's all that effective. Much better to instead point out that the complex system we've created is leading to unexpected negative outcomes, and we need to fix it.
It's more than just quibbling over language. Empirically, we know that when people feel accused, they tend to dig in their heels ("I'm not committing fraud!"). If we say instead "this is nobody's fault, but it needs to be fixed," we're much more likely to get broad buy in and support.
Except it absolutely is just that.
This is not normal market economics. NO ONE is paying that price except the consumer, and even then, if you actually call your doctor/hospital they will almost certainly give you a discount. When a hospital is charging $25 for a single aspirin in the US, and no other country does that, what are they funding?
They're funding the risk of being sued, and care in all cases they're required to give care even if people can't pay.
I have relatives that practice medicine. Around a third of their annual income goes to paying malpractice insurance.
And then hospitals are for-profit because healthcare isn't universal or government-run, but still in part government funded. The whole system is bonkers. This means that even more of the money goes to profits of the 'medical insurance and litigation business', and 'owning-healthcare providers' business. These are very lucrative businesses.
The threat of non-payment or calling out overpricing isn't worth not lowering the price to see what you can get away with. It's also a system where you for some reason have to barter, and the same procedures can cost hugely different sums depending on which hospital was closest when one neede emergency care.
Healthcare cannot be market economics, because as we approach death or serious permanent harm, the willingness to pay approaches infinity, going somewhere else often isn't practically possible and financial ruin is viewed as an acceptable outcome.
Simplified, the problems with the US healthcare system aren't about the US healthcare system, but the US insurance system and regulations regarding financial responsibility.
I think that's why cries against hospitals/health care workers ring so hollow for me: That's not what any of this is about, which means fixing the healthcare system isn't about fixing the healthcare system at all. The care is world class, but it's just inaccessible to many of those who should have access due to the stupid financial organization.
The doctors themselves often don’t know what the procedure they’re recommending costs. I think that’s pretty messed up.
On the contrary, that's not their job nor should they know it. A patient shouldn't be concerned with what a medically necessary procedure costs, nor should a provider; their concern is the health of their patient. Should every conversation with your provider go something along the lines of:
Provider: You need ABC done to stop your XYZ condition.
Patient: Great, let's get that done.
Provider: How much money do you have?
Patient: Huh?
Provider: Well, your insurance might not cover it, and it'll be $25k if they don't.
Patient: I don't have that kind of money.
Provider: Sucks to be you, champ. How much is relief from that XYZ condition worth to you?
---or---
Provider: [thinking internally] Patient needs ABC to stop XYZ, but they look like they can't afford it, so I might as well not even suggest it to get their hopes up.
Provider: [speaking to patient] How about some pain meds?
Yes, healthcare shouldn't work this way, but it does in this fucking country.
Okay, let me rephrase that. Given that the patient might actually have to pay for it, it’s fucked up that they aren’t told what it would cost in advance, and doctors, who are running or work for a business and are the ones actually talking to the customers, don’t know what they charge and don’t talk about it. What other business works that way? Dentists, opticians, and hearing aid providers don’t work that way.
On the other hand, for emergency services, it does make sense that they should simply be provided and paid for by the government. When a house is on fire, nobody asks how much the firefighters charge to put it out, nor should they.
Some healthcare things are more like emergencies and some are things you could shop for if given a chance. Unfortunately there often isn’t a clear distinction between them.
Handling costs are what the provider's supporting staff are for, when I ran physician offices we provided estimates for all procedures performed and what they'd cost at the self pay rate if insurance denied coverage. The physicians that owned the practices didn't keep track of prices for procedures, what insurance paid, or anything financial as there was and should be a separation between the medical and financial side of things. A provider's only concern should be the wellbeing and best course of care for their patient, period.
Outside of very small practices, providers don't generally keep up with the costs of procedure. Dentists, opticians, and audiologists are usually in that category; largely because their practices are very rigid. They're the fast food of healthcare where it's a numbers game. They know it's X number of cleanings/eye exams/hearing aids needed to pay the bills. An oncologist isn't going into practice with the thought "if I can get 40 poor souls per month with cancer I can get that new Ferrari F80 by spring."
Providers typically don't want to keep up with the costs either, it's not what they went to school for, and is one of the many "selling points" that private equity/hospital groups has latched onto and caused the mass consolidation of healthcare.
On the contrary...
I’m not sure I agree. It’s not always clear what medically necessary means, there isn’t an unlimited supply of care, and there are diminishing returns from testing unlikely conditions. Somebody in the process needs to be able to do a cost benefit analysis for a proposed procedure.
Which is what the insurance company does.
Yeah, they deal with the medicine side. They just know you need it or it may help. Hospital administrators, however, will try to figure out what they can charge for it. Hospitals are a bit crazy in how they often move money around to pay for different departments and cover different expenses
In case you're unaware, people have started using LLMs to fight healthcare appeals. One such service can be found at https://fighthealthinsurance.com/. Your doctors are probably fairly familiar with what needs to be done for your basic appeals, but it never hurts to submit your own testimony as well.