ions were initially denied fully or partially, and the vast majority were approved when doctor or other provider sends additional info.

Usually this is because the doctor's office did a poor job of requesting authorizations. For example, a doctor requests 3 additional hospital days for a patient that just finished an uncomplicated hernia operation. Insurer says pending additional info, we believe the 3 days aren't necessary for an uncomplicated hernia op. Then doc's office goes, oh chit we forgot to mention the patient developed pneumonia. Lets send in additional info. Almost always, that would be approved.

"In 2022, insurers fully or partially denied 3.4 million (7.4%) prior authorization requests. Though insurers approved most prior authorization requests, the share of requests that were denied jumped between 2021 and 2022. The share of all prior authorization requests that were denied increased from 5.7% in 2019, 5.6% in 2020 and 5.8% in 2021 to 7.4% in 2022."

https://www.kff.org/medicare/issue-brief/use-of-prior-authorization-in-medicare-advantage-exceeded-46-million-requests-in-2022/

Other examples would be a provider asks for approval for 14 encounters of physical therapy, but plan says 10 are sufficient -- usually based upon standards of care -- and we will reevaluate that if patient needs additional care as therapy approaches end.

In any event, the idea this justices killing someone is, well, trumpian. Call up your Congressman and tell them to enact legislation for a better healthcare system. I bet money they'll say -- if honest -- there is no way to enact health care reform that doesn't include private insurers.

Gallop Poll 2023

WASHINGTON, D.C. -- A 57% majority of U.S. adults believe that the federal government should ensure all Americans have healthcare coverage. Yet nearly as many, 53%, prefer that the U.S. healthcare system be based on private insurance rather than run by the government. These findings are in line with recent attitudes about the government’s involvement in the healthcare system, which have been relatively steady since 2015.

https://news.gallup.com/poll/468401/majority-say-gov-ensure-healthcare.aspx

And if you don't think doctors and hospitals cheat, spend a little time on this CMS/Medicare site:

https://oig.hhs.gov/fraud/enforcement/

is just for Medicare and Medicaid. The order services that aren't need, especially if they profit from it. I've seen doctors order say one MRI per hundred patients from a freestanding facility when they couldn't profit from it. Then, when they get an MRI in their own office --where they can make money of the technical component and professional component -- utilization shoots up to 400%. So, it wasn't needed when they couldn't profit from it, but suddenly is needed when they can bill $1000. Don't think so.

I've seen doctors order knee replacement when the don't even meet original Medicare coverage requirements.

So, yes, at a minimum you are misunderstanding.

2015
But when it comes taking on big and well-connected insurance companies that have been ripping off the Medicare program for years, the administration has been far less aggressive in catching, much less punishing, the abusers.

As the Center for Public Integrity reported last week, officials in the Obama administration were advised as long ago as 2009 that a formula the government uses to pay private insurers that participate in the Medicare Advantage program “triggered widespread billing errors and overcharges” that waste billions of tax dollars every year.

There was no press release issued by the administration about that 2009 report; in fact, the administration buried it. The report probably never would have surfaced at all had the Center for Public Integrity not filed a Freedom of Information request seeking records going back several years regarding payments to Medicare Advantage plans.
https://www.middletownpress.com/opinion/article/Wendell-Potter-Fed-war-on-health-care-spending-11797618.php

"There is no way to enact health care reform that doesn't include private insurers."

Why in the world would that be?

Give people the option. I am not aware of any proposal that would outlaw private health insurance.

Polls heavily influenced by industry fear mongering tell us exactly nothing. Those signs people carry that say "government keep your hands off my Medicare" tell us all we need to know regarding "attitudes about the government’s involvement in the healthcare system."

In any case, the politicians don't care about public opinion, they are worried about campaign donations.

private insurers, it would not have passed then and definitely not now.

I will say, you need to read up on how many people don't trust "gubmint" insurance.

Obama compromised and backed down from the beginning.

That excuse always works. "Well it ever would have passed anyway because..." and "we would have done the right thing if only..."

There is no doubt that universal heath care advocates were completely left out of the discussion and industry lobbyists were brought to write the bill. Maybe the public option - which was itself a fall back compromise position - ever would have passed even if Obama had fought for it. But for sure nothing will happen if you don't fight for it.

We are lucky they even let us live at all, I guess. We will just have to settle for whatever crumbs fall off the table.

What's your take on the whole thing?

have granted us healthcare coverage. And how long should we wait and hope for “one day in the future”? What rot.

waiting for the munificence of our leaders or the billionaire class.

It is not even logical. It is certainly reactionary and anti-democratic. We are talking abiut pressuring the leaders to address the desperate needs of the people. You say that we are stuck with the leaders who oppose that and we can't do anything about it.

"I must confess that over the past few years I have been gravely disappointed with the white moderate. I have almost reached the regrettable conclusion that the Negro's great stumbling block in his stride toward freedom is not the White Citizen's Counciler or the Ku Klux Klanner, but the white moderate, who is more devoted to 'order' than to justice; who prefers a negative peace which is the absence of tension to a positive peace which is the presence of justice."

- Dr. Martin Luther King, Jr.

Better get some GOPers too. And get rid of trump.

Sadly, Biden didn’t go after universal healthcare and Harris totally ignored it during campaign except to support ACA which uses private insurers.

Yes, it has become more and more difficult. Your point? Give up?

We have an infinitely better chance of enacting universal healthcare by not automatically excluding private healthcare because of voter sentiment discussed before.

I’d like to see a Public Option too. If it’s as good as we think/hope, people will gravitate to it quickly.

But remain a purist, and I’d wonder if you really want universal healthcare or just want to scream at the clouds.

But, I know it’s quaint, naive and old fashioned to think so, they’re supposed to work for and represent us!

The opportunity has been there and there is broad public support. Of course the industry has run a well financed campaign to mislead the public, but we look to Democrats - the leadership especially, but all of us, including you - to fight back ffs.

are rejected by you.

Hope you succeed, but not gonna wait 50 years.

I’d get enthusiastic if you honestly think you can even get a bill signed by 90% of Democrats in say next 4 years. Of course, we’ll need some GOPers, assuming no Democrats refuse because their constituents aren’t on board.

So, the beatings will continue until morale improves.

Why the hell should we hold what fucking ignorant people say in a poll? You think doctors that don’t take Medicare or Medicaid don’t cheat? The American public has been brainwashed to believe that the private sector can do a better job managing healthcare. It’s bullshit.

There was a time when government was generally not reviled.

Of course, that time was when women had to be in the kitchen keeping their mouths shut, gays had to be so far back in the closet that they couldn’t see the light when the door opened and Blacks had to be happy with whatever crumbs they got. Disapproval of government started with FDR, imo, and accelerated with Brown v Bd. Of Ed. When people started seeing social change reactionary forces generally backed by wealth started fighting back albeit quietly. The election of the piece of human garbage named Ronald Reagan gave those forces the courage to show themselves. The agitprop has been going full bore for over 60 years.

This country will not survive the oligarchy. But most of us will not be around to try and pick up any pieces.

it actually rips off the US Taxpayer and Medicare.

support-the-private-alternative-to-medicare/

Last edited Fri Dec 6, 2024, 04:20 PM - Edit history (1)

try to take away what 32 Million (51% of Medicare eligble beneficiaries) believe is best for them.

If Congress does that, then sure get rid of MA.

When do you think that might happen?

Just saying . I have Medicare and its back up by my former employers insurance coverage. They pay for my Medicare that come out of SS. I just had an 800k medical issue in Florida not my home state . Minimum co-pays not even 500.
all the drugs via CVS 54 day hospital stay and rehab. Plus another month in home rehab. No expense was spared or questioned.

https://www.medicare.gov/basics/get-started-with-medicare/get-more-coverage/your-coverage-options/compare-original-medicare-medicare-advantage]

way for poorer people to save a little money on premiums and get a little bit of extra benefits.

Original Medicare works well for you and me (except I’ll probably have to go on MA at some point).

My point is why should wealthier Medicare beneficiaries try to take a few bucks away from poorer people.

If Congress got off its ass and bumped up original Medicare, I’d be fine with removing MA. But that’s not going to happen anytime soon.

Enjoy your benefits, but let the 31 million who choose MA because it’s better for them keep what they want.

I worked at a movement disorders clinic (Parkinson's, Tourette's, etc.) at a hospital in Boston. If an expensive drug is prescribed (often levodopa where I was), the insurance companies require the doctor to fax paperwork giving a detailed explanation of why the patient needs it.

Then, the approval is only for 6 months and they will discontinue coverage if they don't get faxed an explanation all over again. These were high level doctors who were very busy - seeing patients one day a week, running research labs, lecturing overseas.

The burden of the paperwork fell entirely on clerical staff, who were already busy and things fell through the cracks. That's what the insurance companies count on, that if they make people repeatedly jump through hurdles, that some of them won't follow up and the company won't have to pay.

if you are a high user. Ever go on prepayment review or been audited for alleged billing abuse?

And I bet you taught your doc how to document those cases where all you had to do was send in their documentation without having to beef it up. Bet you had traditional Medicare claims denied too.

It was a busy office and I was doing scheduling 20 hours a week for a few doctors; someone else did the billing. I attended the meetings of the editors of a research journal and heard conversations about how Medicare pays the hospital much less than private insurance does. They count on making more money from the private insurance patients to compensate for the Medicare ones.

The Editor in Chief of the journal wrote an Editorial about how "Medicare for All" wouldn't work (when Bernie was talking about it during the 2020 primaries) because of that. He meant that a single payer plan couldn't use the same formula to pay the hospitals that Medicare does, not that they were opposed to some kind of single payer.

In terms of the scheduling that I did, there were way more hurdles with private insurance.

Do you have some professional expertise in this area?

insurance companies. I really liked working for the state Medicaid agency because people were getting help that was previously out of reach. But the bureaucratic BS got too me.

I even wrote a paper recommending universal Medicare/caid coverage for all in 1981 for a government committee exploring options in a rube red state. You can imagine how little they wanted to hear a recommendation for "socialized medicine." So, I gave up on that aspect.

It is much more complicated than it should be for a lot of reasons.

Hurt and kill people to make a buck, deal with the concequences

They should all be deported back to their coder of origin.

With regulations and heavy taxation of the filthy-rich or it will control you. I think we are at the stage where it has conplete control.

However, I will name my next bowel movement in his honor as a gesture of goodwill.

No tears were shed for Brian Thompson.

Sayonara sucker.

... careening into a FAFO moment.

Some of us have been dealing with the impact of this shit for years. But we're sure as hell not going to get it under a fascist dictatorship of unqualified kakistocrats.

And fuck insurance, especially "health insurance."

People? Pshaw! What matteeds is shareholder value..... and his bonus!

It introduced requirements that any for profit insurance company had to spend 80 cents on the dollar on medical expenses and the remaining 20 cents for costs. Doesn't really serve as inducement to keep premiums down, but it means denying claims only means you have to refund members.

You can bet they did their best to make sure they stayed as close to the required numbers as possible.

Maybe CEOs will think twice about their policies.

Maybe CEOs will request sensible gun control?

That's my hope, anyway...

Last edited Thu Dec 5, 2024, 06:18 PM - Edit history (1)

...that particular shitshow might be preferable to the one we're about to get. History will be the judge there. Personally, I doubt it will be kind.

Blue Cross Blue Shield posted a few days ago that if an operation went too long they would not cover extra anesthesia. People posted a photo on social media of their top executive - today they said they would not go thru with that policy.

“
“Anthem Blue Cross Blue Shield halts anesthesia payment policy after backlash
The health insurer planned to cap the length of time anesthesia can be covered during medical procedures in three states, prompting outrage.“

https://www.nbcnews.com/health/health-care/anthem-blue-cross-blue-shield-time-limits-anesthesia-surgery-rcna183035

What the CEO‘s will do is get beefed up personally security (paid for by the company!) and stop being the public face of companies.

Park 'em on 5th Avenue and get to work! See if you lose any supporters.

With the amount of guns in hands(legally and illegaly) in the US, this won't end well.

asking for a friend

I haven't seen anybody think of that!

Goddamn squeezed and shit on with no relief that it comes a matter of blind revenge against the system.

similar to the industry phrase "delay, deny, defend" of how to avoid paying claims:

https://people.com/bullet-casings-words-echo-scathing-phrase-insurance-industry-delay-deny-defend-8756658

Are you kidding me? Next we'll have for profit prisons. Oh this s*** country already has those? I'm sure the prisoners are housed fed and cared for really well. I don't know how to make that little sarcasm thing show up but no I'm being extremely sarcastic. Too bad there's no help for pieces of s*** like that

You can easily imagine what happened. As if foster care wasn‘t already fucked up.

Wow, that is a new level of dehumanizing medical care.

Off the top of my head I can only remember "Sorry, my thoughts and prayers are out of network." But there are a lot.

OK, you owe me a new keyboard.


AND.......the adult beverage that ruined it.............

You know, you can actually wash keyboards in the top rack of a dishwasher. You just have to be careful - remove batteries if they're cordless, and be sure they are fully dry before putting them in contact with electricity. I live in a very dry climate - if yours is humid you might want to have a spare while waiting for it to fully dry.

But if one of them are doing it you can bet most... If not all... Are doing it. Something to think about.

Link to tweet

Up thread were two interesting posts.

1) Insurance companies don't make more money by denying claims because the ACA mandates that they have to spend 80cents on the dollar for medical care. I can't say I understand how this works, but it gave me pause.

2) Initial denials don't usually result in permanent denials. What is this chart measuring?

According to a lawsuit filed Tuesday, Humana's use of the AI model constitutes a "fraudulent scheme" that leaves elderly beneficiaries with either overwhelming medical debt or without needed care that is covered by their plans. Meanwhile, the insurance behemoth reaps a "financial windfall."

Until further notice, I will lay the blame of this killing on Trump as he has made America an unsafe place. IMHO.

For example an AI probably has a better chance than a human at spotting an unforseen complication with a new drugs interactions when paired with a combination of other medications than a human.
Further an AI probably has a better chance at spotting an actual improved drug combination than a human might.

And AI is another one of the unheralded reasons why Donnie's about to be Emperor for Life

Nor the fact that once a person is convicted but has filed an appeal bites the dust, the conviction is vacated. Nor the fact that the CEO's wife might have figured out her comfy lifestyle (kids or no kids) might cease if he got convicted. Reports of her telling of threats that afternoon turned into LE have found no threats against the CEO on the nightly news. I'm not a conspiracy person but too many moving parts at this juncture for me.

It seemed suspicious to me that he was said to have received threats, but no details about such threats were revealed. As I understand your comment, LE is now stating that it knows of no such threats having been made.

Sorry to be crass but he did.

I'm a casualty of his work.

They tried to deny my wife's urgent care during a double transplant lifesaving experience. Said she was too healthy for rehab while recovering. Fortunately we prevailed and she is fine now. It was harrowing though. Cold-blooded. Period.

The CEO was a scum bag. I feel sorry for his children, but that's about it. Karma.