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Frank didn’t even look at it. He just fed your claim into their computer and it spat out a rejection.
Bold to assume he bothered to feed it to a computer when you can just reject without having to do that. Feeding something to a computer takes time, and time is money y’know.
Everything is filed electronically, having a person step in will always be more work and money dude…
And leaves a nasty paper trail!
If check: accept
Else: reject
I work for a neurologist practice, and the amount I have to argue with insurance (and inevitably have to get the neurologist on the phone to directly request something for many) is insane. A good chunk of my job isn’t providing care, but arguing with insurance that the care is necessary. These companies are actively delaying patient care, and try to blame the physician whenever possible.
Wildly infuriating, especially when the denials are worded along the lines of “we reviewed this, and don’t consider it medically necessary”. Motherfucker, a doctor said it was necessary and listed the clinical reasons why this test or procedure would be beneficial. Nothing has radicalized me for universal healthcare more than working in healthcare.
People love to shit on the VA, because they’re the largest American healthcare provider in the country so there’s a lot of bad stories
But my last MRI went like this:
Doctor: you need an MRI, let me check if it’s open. (Less than a minute on laptop). Ok, go down to room ____ and they can get you in now.
There’s a huge up front cost for that machine, so for profit hospitals went everyone to use it to make the money back, and insurance wants no one to use it so they don’t have to pay.
Take insurance out of the picture, take the hospital trying to make money out of the picture. And it’s really that easy. No one pushes for unnecessary tests, no one tries to prevent necessary tests. And there’s a huge push towards preventive medicine, because it’s cheaper to catch shit early.
We already pay more than what it would cost, it’s just the healthcare industry donates to both parties, so as long as both standards are “at least they’re not the other team” shits never going to get fixed.
If we hold higher standards than that, it won’t take many election cycles to get change to actually happen
It’s cheaper to catch shit early.
This is a huge takeaway. Insurance doesn’t care about your longevity, health, quality of life or even long term costs.
People hop insurance providers all the time so the companies are literally focused on profits quarter by quarter.
On the flip side, I can’t imagine being the person arguing for the insurance companies makes them a better or happy person in the long term. Being a devil’s henchman, over time it must destroy important parts of them like empathy, trust in people, and their basic human decency. Virtues that are needed now more than ever in society.
I expect it’s like any call center - the computer spits out a result and they have a script to follow, and are not allowed to stray from the script
Well yeah that’s why they keep doing it
This part isnt brought up enough. You can take more severe examples, folks working in slaughter houses, military translators marking targets based on vague phrasing, and they have well documented negative effects on people who work those jobs in general.
Theres no reason to think someone working an insurance claims job might not develop the same type of problems if they feel they are helping cause harm, even if to a lesser degree.
And some doctors themselves will be hesitant to give care that might not be provably required beyond all doubt but is objectively prudent.
I feel like we’re getting to the point that this needs to be an election deciding issue. It won’t be this upcoming election, but probably the one after where the presidency isn’t on the line. We need to ignore republican/democrat talking points and elect based on a will to completely revamp the system. Obama tried but it didn’t go far enough. Once its bad enough that people are willing to cross party lines to fix it, then you’ll see change, and I (probably too optimistically) think we’re almost there.
Hospitals should unionize and sue the the ever-loving shit out of insurance companies for lost time. Not like our neoliberal politicians are going to do anything about it.
Had my buddy over who brought over his incredibly questionable 30yo brother who shared some real incel levels of talk. He used my bathroom and asked if I wore tampons since a pack was visible. Like bro, I have a wife and a daughter.
Anyways, that guy works in health insurance!
I don’t know how much decisions he can actually make. But that dude has a middle-school level education about sex ed and struggled to explain what a period is. And he is one of the barriers to approving/rejecting your health care.
“You want me to whip out my dick and slap you with it since that was the stupidest question I’ve heard?”
You should see what @pancakes@sh.itjust.works wrote in this very thread. You basically just answered their question about what this industry must do to a person’s ability to empathize and be a decent person to others. Or in this case, maybe lack thereof is a job requirement?
There’s different teams doing different types of work.
Like the claim system might have it setup so X codes in Y situations can’t be automated. Then someone looks at the claim, determines based on their written guidelines that this one needs to be reviewed so they look to see if there are notes attached. If there aren’t they request the notes, maybe by sending a letter. If there are, they send it to the team that reviews notes and makes these decisions. Those people probably also have written guidelines on what is allowed or not and if it’s more complicated they (should) have someone qualified that can review it. Then the claim is probably sent back to the other team saying “Hey, deny that code and allow this code”, where they then just do whatever that says.
They probably also have situations where X code in Y situation is “never” allowed and the first people reviewing it just always deny it. Then, as mentioned elsewhere here, the provider has to resubmit it and then it’s allowed on “appeal” by another team. This brother you mentioned is probably doing very little decision making beyond applying already decided guidelines to each claim, if he even processes them.
So here is a question:
A medical professional examined the person IN PERSON and has a requirement.
In comes the insurance to tell you your doctor is wrong and that you’re perfectly fine, your doctor is basically lying to you.
Question: how the fuck did any of this ever become legal?
Question: how the fuck did any of this ever become legal?
I would guess lobbying.
Politics are dumb but very important.
You do need some checks and balances because what’s to stop a hospital from profiting off the insurance companies by asking for a CT scan/whatever of every single patient just because they can.
I suppose we could have the government run the hospitals too. But noooooo, that’s never going to work out because communism or something.
Maybe we should try effective altruism and accelerationism instead? Let’s just hand over all our money to a few tech bros and then we can go beg them to pay for the scans. And if they don’t pay for it, surely someone will come up with a cheaper technology to do the same. Yes, that’ll definitely work.
Yes, it’s clear why it’s legal and necessary to some extent. In a for-profit system, a doctor’s office or hospital, every procedure or test the doctor can order (and have the patient pay for) will generate profit. Doctors have an incentive to order as many tests as possible. I assume that most doctors are somewhat honorable and won’t abuse this too much, but they’ll probably still err on the side of ordering as many tests as possible not necessarily because of profits, but because more tests gives them more information.
Meanwhile, in a for-profit system, an insurance company will generate the most profit by agreeing to as few tests and procedures as possible. So, they will have an adversarial relationship with doctors and will try to arrange as few tests and procedures as possible. My guess is that the average insurance company is less ethical than the average doctor, so they’re probably more likely to refuse to allow tests that are actually medically necessary.
In a sane system, there would be a neutral referee, the government, who would resolve disputes and severely punish any actor in the system that was behaving badly. But, AFAIK that only rarely happens in the US, where the idea is that the “invisible hand of the free market” will magically make it all work.
Doctors do not directly profit from ordering tests. They get paid whether they order a test or not.
You want to know who profits from over testing? Quest Diagnostics.
https://bergermontague.com/quest-diagnostics-pay-1-79-million-settle-false-claims
These guys literally defrauded the government, but everyone points their fingers at poor people, doctors, liberals, ethnic minorities, lgtbq people, ect. The problem is corrupt businesses and their CEO’s hoovering up as much money as they can so they can shove it up their ass.
Doctors have an incentive to order as many tests as possible
This would conceivably be true for car repair as well. A mechanic is incentivized to order as many repairs as possible for a car.
So why don’t they?
The answer is many-faceted, but the main ones are (a) professional ethics, (b) reputation, and © second opinions which kinda feed into b.
Any provider whether doctor/mechanic/wedding photographer/whatever is also incentivized to serve their customers well by selling them only things that truly benefit them.
We don’t need insurance companies in all those other industries to prevent providers from using an infinite-billing hack to generate infinite money.
Great example, mechanics are notorious for ripping people off.
This would conceivably be true for car repair as well. A mechanic is incentivized to order as many repairs as possible for a car.
So why don’t they?
They do. Car mechanics have a notorious reputation for doing repairs that aren’t necessary, or for breaking something so that the owner has to come in again soon.
is also incentivized to serve their customers well by selling them only things that truly benefit them.
Yeah, there’s a natural counterbalance that means they don’t want to be seen as dishonest. Similarly, an insurance company is counterbalanced against trying to prevent every test or procedure by also wanting to be seen as honest.
We don’t need insurance companies in all those other industries
You’re aware that car insurance is a thing right? Any industry where the charges are going to be extremely high is going to involve insurance. Cars are fairly expensive devices, and so there’s car insurance, and if you’re in a big accident your car insurance will pay for the repairs. But, the car insurance will keep an eye on you to make sure you’re not committing insurance fraud, and also limit how much the car repair shops are allowed to spend to repair your car.
If a hospital is found to push doctors to prescribe unneeded medicine or tests, the entire top staff should be questioned and jailed for fraud where applicable.
If an individual doctor does this, same treatment
We’re not just talking money here were talking human lives. If you risk health for money, off yo jail you go
what’s to stop a hospital from profiting off the insurance companies by asking for a CT scan/whatever of every single patient just because they can
The patient saying no. Also a system where the patient isn’t forced to use insurance.
We could have markets run the hospitals but heaven forbid people would consent to their economic interactions.
We could have markets run the hospitals but heaven forbid people would consent to their economic interactions.
“Hello! My mother is clutching her chest. She may be having a heart attack. Could you please email me an estimate for the treatment? I’m talking to two other car dealers, and I’ve read all the posts about the 4 square method online, I’m on to your tricks.”
It became legal when we decided medicine was too important to be handled by a free market, and we created a labyrinth of laws governing how medicine must be administered.
Medicine in the US is the closest we have to a free market. (Newly developed pharmaceuticals being a bit of exception due to the nature of our patent system) In a free market you work on principles of supply and demand. An important concept here is that of inelastic demand. For certain goods, up to a certain point demand will remain constant regardless of price as they are essential to life or addictive. Think gasoline, water, cigarettes, etc…
With medicine people will generally spend whatever it takes often even going into debt if necessary because they value continuing to live very highly. As a result, hospitals are able to charge as much as they think people are willing to pay before they decide that dying is a better financial decision.
You could argue that in a free market, hospitals which charge less will see more business pushing costs down. For certain areas like elective plastic surgery the whole free market model actually works out fairly well since people have the option to shop around. However, let’s say you get in a life threatening car crash. In that moment you don’t have the time to shop around for the cheapest ambulance provider and run a cost benefit analysis on which one has the closest ambulance. After that you can’t shop around local hospitals to see which can offer the cheapest solution for your procedure because first off you don’t know exactly what’s wrong until you get to the hospital. Second, you’re currently suffering from serious injuries and need to get to the closest hospital. This is why just about the entire developed world apart from the US has nationalised healthcare. Is it completely free of issues? No. Are there some markets where private healthcare can offer better service? Yes. However, you don’t have people going into financial ruin because they needed emergency medical care.
You literally take the wrong takeaway from all this.
A free market for healthcare is a disaster. A few big companies will form that will squeeze every last cent out of dying people, you get the US system. US healthcare and it’s free market literally is the worst. Be healthy and bankrupt or die
Sometimes the Frank is an AI that is wrong 90% of the time. That’s fine, because reasons.
I fucking wish. At least then I wouldn’t have to be put on hold for 30 min just to have to eventually explain to a person who was hired 3 weeks ago how to do their job.
Private insurance always has you speak to an actual adjuster for authorization, mainly because they know any sort of automated system would be more accurate and faster than having you talk to their undertrained and understaffed employees.
Private insurance’s goal is to erect as many barriers between the provider and the patients as possible, and then blame the provider for all the barriers. It works every time.
“I have the best insurance, they told me it would be covered”. Nope, Medicare is the best insurance and you traded that away for a privatized Medicare supplemental that lies to you about your coverage.
Sometimes the Frank is an AI that is wrong 90% of the time. That’s fine, because
reasons$$$.
Also, there’s this common “feature”:
Dr: “You need this procedure.”
Me: “How much will it cost me?”
Office Manager: “I won’t know until I bill your insurance and find out if it is covered.”
Me: “What is the cash price I would pay you if it isn’t covered by insurance.”
Office Manager: “I have no idea.”
I’m actually ok with this system, but only because I throw the bills away after
Prior authorization should 100% be outlawed. It’s either insurance adjusters practicing medicine without a license, or insurance doctors making diagnoses without examining a patient, both of which are unethical or illegal.
Though I think the real solution is a system where every time a prior authorization denial is overruled by the DOO or a court, the insurance company has to pay punitive damages of at least $200,000 to the patient.
The cruelty of the US American for-profit health system is what should be uniting all US Americans in protest, riot, and violent overthrow of the current system.
Last time my doctor had to bill my insurance he said he would just run it immediately, because apparently “routine denial” is a thing where they just automatically deny it because if you really need it the doctor will then have his office try again with more justifications. He hated this a lot, because it basically meant he had to just assume first denial for no real reason and then his staff had to take the time to almost always go back and resubmit. He said sometimes he would submit it with the info, it would be denied, and then he would resubmit it two more times and suddenly it would be approved.
Like seriously, what the fuck. But only does that hold up necessary care, it also makes doctors do more bureaucratic work and hire more staff, which, of course, makes medicine more expensive. Brilliant.
Shared risk pools are a good idea. Making them for profit is not.
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The sad thing is they do hire some licensed healthcare professionals to fall back on when appealed. They just look for the least compassionate MDs to rubber stamp denials.
Eh, generally a peer to peer won’t get denied but requiring a peer to peer is a good way to waste the doctors time in the hopes they’ll give up on the request. The instance company isn’t paying the doctor extra time to perform the peer to peer after all. Now if that time was billable, you’d see it go away real fast.
American health insurance in a nutshell: https://youtu.be/llx-SaGq4Fs?si=eDIny0fqcGYFkB2a
And before non-Americans ask, yes, that’s actually how it is. The humor in this video isn’t from exaggeration, the comedy derives from the unexpectedly clear way the absurdity of the system is explained.
Yep! The last bit is more of a joke, but the rest is pretty spot on with how the stupid system works. Here’s another example of a video explaining US Healthcare.
The episode of South park where they walk into this 22nd century insurance building and ask to make a claim. They get sent to the “claims office” and it’s like they went back in time to the 1980s with dot matrix printers, rotary dial phones, and fax machines.
Here is the link if anyone is interested: https://www.youtube.com/watch?v=VAfy26xs6e0
I love BDG, everything he makes is fantastic
it seriously blows my mind that the overwhelming majority of my fellow americans tolerate this system, that is if they don’t downright approve of it. The issues mentioned in that video are not isolated incidents. They are common, everyday, business-as-usual practices that almost all of us deal with.
The private for profit health insurance industry - because what could make number go up better than a (LEGALLY MANDATED) do nothing middle man who’s only purpose is to take your money and ensure as little as possible is spent on healthcare sitting between you and not dying?
And when the patient turned out to be fine after the scan, the insurance company will try to blame that the doctors are lying so that the insurance company has to pay the hospital more It’s like they thought that the doctors must be able to see through the patients’ body as if they forgot that the reason for these equipments to exist in the first place is that because the doctors can’t really be 100% sure about what’s actual situation inside human body
IThey can’t even be sure after the MRI. Which again, proves your point. It took one MRI battery and one alert and skilled MRI tech to catch my brain cyst, THEN another whole set, I straight up spend a whole 8hr shift in an MRI machine, Then a TEAM of neurologists studied my custom hand made brain for MONTHS. THEN they had a really good set of educated guesses. Then they did the surgery, and only after they opened up my brain case did the actually see what in the hell was going on. Even after all that, my neurologists was like ‘‘This is what we think is happening’’, I asked what it would take to really know factually, he said an autopsy. He didn’t recommend it. The point is, Doctors save lives with these scans, and nothing is certain. That’s not a barrier to treatment, but no scans Is a barrier to treatment.
This is why we need transporter tech from star trek.
Beam yourself into the copy buffer, kill the copy, and do an autopsy.
There’s two sides to this coin. On the one end, you have insurance companies refusing to pay for anything because the modern industry is just six scams in a trench coat.
But on the other, you have doctor’s offices where the physician literally leases an MRI machine to the tune of several million dollars and then has to run a certain number of patients through the scanner every year or lose money. That’s because the MRI patent is held by GE and they can charge 10-100x markups on hardware that is fundamental to modern medicine.
Its the same with diabetes treatments. Insurance companies will try and refuse service or kick people off their policies if they are at risk. But then pharmacy companies will sell $3 of insulin for $75, then kickback a chunk of the balance to judicial/congressional bribes in order to guarantee the cash flow.
At some level, the only insurance companies that can survive in such a market are the ones that say “No!” to everything. The even-remotely-ethical firms just get fleeced by the for-profit industry until they get bought out or go bankrupt. That, or you’re Medicare/Medicaid and you have an infinite wallet backstopped by the US Treasury. You don’t care if you’re paying multiples of whatever any other clinic anywhere else in the world would charge on an enormous population of poor and elderly patients, because you have an unlimited money cannon to mow it all down with.
Very uninformed take, its almost laughable.
GE isn’t the only one who makes MRIs. The other big players are Siemens, Philips, United, and to some extent Canon, Fujifoto, and Hitachi.
No, that’s really how much it costs. The margin on MRI machines is terrible. I’d like to see you do it cheaper… “Just” build then supercool magnet for superconduction for 3T of homogenius magnetic field, build coils that handle KW of RF/gradients that can fit a human comfortably without artifacts, build the high power and precision circuitry to transmit and receive said RF, then control that equipment accurately and safely.
Super easy, off-the-shelf stuff.
Oh, and you can’t use any ferrous parts, nor can your power supplies generate any noise.
That’s like, senior design level stuff amirite
The other big factor in cost is supply chain. Everything has to be tracable. So the supply chains have to do a lot of paperwork, inspection audits, since a defective part can kill someone.
Six scams in a trench coat
Fucking poetry lol. I’m gonna use this.
*cough* single payer fixes all this *cough*
Sorry, cough has been acting up. I should go see a doctor with a MRI about that…
cough single payer fixes all this cough
I’d go one further and say a National Health System fixes all this. Rather than paying a guy to pay a guy, you just have publicly financed clinics and hospitals. This is the traditional way of building up medical infrastructure, btw. City hospitals used to be the norm. We only entered the era of corporate consolidation when we sold off our public infrastructure for a song during the neoliberal turn of the 70s and 80s.
Shouldn’t that patent have expired by now?
This kind of thing is why it bothers me when people complain about “free market medicine”.
A market where only one entity is allowed to build MRI machines, or license the tech to others to build, is not a free market. That’s a government-enforced monopoly.
Even the fact that a patient can’t just go get their own MRI at Scans-R-Us, but needs to get a doctor’s referral first, is a huge departure from what an actually free market for medicine would look like.
Shouldn’t that patent have expired by now?
It’s an evolving technology. We get new patents with every iteration.
A market where only one entity is allowed to build MRI machines, or license the tech to others to build, is not a free market.
If you spend a few years in Business School getting your MBA, you get an earful about how and why patent law exists. The core argument is that private investment is predicated on returns and we can’t have nice things unless we have men with guns come for the property and freedom of anyone who “steals an idea”.
But more practically, this shit is just a racket. Lots of lobbyist money changes hands to make sure the decks at the casino are properly stacked. Medical treatment is just another opportunity to apply leverage through debt to control other people.
I understand the value of a patent system, but patents should expire.
Is there some reason why previous-generation technology, like the tech being used for MRIs in the 90s, can’t be used to manufacture more competitively-priced machines?
Like, is there a law specifying that the new technology must be used for an MRI to be usable as a diagnostic tool?
patents should expire
They do. It’s just that they can be renewed under various circumstances, typically as an incentive to increase production.
Is there some reason why previous-generation technology, like the tech being used for MRIs in the 90s, can’t be used to manufacture more competitively-priced machines?
You need a certain amount of industrial capital geared towards making these machines and GE is the only one that really does (excepting manufacturers overseas). A big part of the problem is that we don’t have a good mechanism for introducing new small businesses to the market. You really need to know someone that needs a steady number of MRI machines on a regular basis to make a new MRI factory worth it, and unless you have that business connection you have no buyers.
So you’d need to have a single integrated business, just to get all that information in-house.
The same company could build the machines, and sell the MRI scanning service.
Then you’d need a lot of conversations with various doctor’s offices.
But there are probably lots of places who’d rather be able to provide patients with a lower-cost, lower-quality MRI, so it should be possible to collect a number of providers saying “if such a service exists, I’ll use it”.
My guess is there’s gonna be a lot of government money available soon for people who want to build new manufacturing capability in the US
They hire doctors who can’t handle being practicing doctors to prop up their delusions. I’ve only had one on the line in a dispute and he acted quite offended when I asked for his license to prove he was a real doctor. Turns out he was barely a doctor at all. He decided instead of practicing medicine and killing people he would work for a insurance company and kill them that way.
So like did he complete his residency then head straight for insurance field?
From what I remember he was so bad he had trouble being employed. I looked him up and gathered information for my lawyer.
Wild. With how gnarly residency is you’d THINK most of them would be ground out, but guess some folks just see those dollar bills working as a corporate doctor.
My insurance that I pay a ridiculous sum of money for has started doing this neat new thing. When the doctor orders imaging, they mark it as “requested more information but never received any”, and reject the claim. They don’t actually request any additional information, and they ignore me when I contest their decision. So glad that I pay like $400 per month for this coverage.
Yes, I think that’s exactly what my doctor was trying to describe. He said if they’re at that point, they basically have to guess what information they’re looking for other than “I’m a qualified physician that has run diagnostic tests and determined this is the best course of treatment. Here are those tests and why it indicates X and therefore requires Y.”
I’ve had to do unnecessary labs to prove an ailment wasn’t something else that some person hundreds or thousands of miles away thought it might be.
If you think you hate insurance companies, find an honest doctor and ask them what they think of the US Healthcare system and health insurance. I’ve never seen a doctor so worked up and angry than when discussing the current medical system.
Edit: this guy is fun to watch on this topic: https://youtu.be/s33AVskz3T8?si=Qqx2nAJjguMOxnNL
I file a complaint with the department of insurance instantly when they deny anything. I don’t negotiate with them for 3 months first, I jump straight to sicking the Feds on them and my doctors have always provided me every bit of data I need and cheered me on.
And I’ve won every time. It annoys me that I have to do it, but I enjoy that it costs the insurance extra every time.
I didn’t even know that was an option. Thank you! I will do that from now on.
