Health Insurers Deny 850M Claims a Year. The Few Who Appeal Often Win

Their strategy is more nefarious. They deny knowing most people won't appeal and they know those that do appeal likely have a limited time to receive the treatment they need. They deny and defend until the patient runs out of time.

This has happened to me personally. My daughter was diagnosed with a fast growing tumor that was not removable. We thought we were in luck, the FDA recently approved a new medication that had much better success rates in treatment.

Insurance denied it. Their reason was because the FDA didn't approve it in children although there are many studies and cases where it has been used in children to great success. Not to mention, FDA approval for children takes many years.

We appealed and were denied again. We appealed a second time and were denied again. Then, out of no where I got a call from a third party pharmacy to schedule the delivery of the medication (apparently it was approved in some internal review).

All in all, the treatment was delayed four weeks and the tumor more than doubled in size. Ultimately, the medication didn't even work and we had to stop and proceed with chemo which seems to not be very effective either.

Gift link: https://www.wsj.com/health/healthcare/health-insurance-denia...

It would be interesting to explore what would happen if they approved all 850M claims, and what the denominator is.

Presumably, these are mostly services rendered and billed to patients. Most peoples premium would go up, and some people would have less out of pocket.

The bigger uncertainty is what the total claims would like the each subsequent year.

Related:

UnitedHealth Is Sick of Everyone Complaining About Its Claim Denials

https://news.ycombinator.com/item?id=42992121

The ones who appeal presumably would have the strongest cases.

If you're part of a self funded plan, at least is some states, there is no external oversight over what they do or don't approve. There is an appeals process, but after exhausting it (where in our case it was the same reviewer in all three stages of the appeal - actually four, because they applied the wrong standard of care one of the times so we got to do it over) there is no legal recourse if they choose not to pay, whatever their rationale. My advice here, is if they tell you they can only authorize treatment once you've begun, that is not true, and if the plan is self-funded, they have very little incentive to do so, and ultimately you have no recourse if they don't.

Denial is a way of avoiding paying out claims by making the appeals process as painful and time consuming as possible. Anyone who has dealt with it knows exactly how it is. And it is by design. This is a part of the economy where we need more regulations. But unfortunately the companies involved have donated and lobbied a lot.

This appears to be a good opportunity for an AI health appeal tool.

"Deny" is one leg of the stool: https://www.delaydenydefend.com/

This could be straightforwardly fixed basically overnight by prohibiting providers from billing patients directly, when the patient has an in-network health management plan ("insurance"). Claims being denied is a contractual matter between the provider and the management organization, and it should be made to stay that way rather than being hostilely foisted onto patients.

Its interesting , a whole industry the rest of the world agreed on shouldn't exist, trying to spread via lobbying, while the citizens in majority are for it to be busted and dissolved .

It displays the anti democratic nature of any given market in perfection. Hypothetical, if the masses rebelled and shot a CEO in a starting-gun-event, this industry would be the first to defect democracy and dash for a open oligarchy.