‘Make money by denying care’: new US rules aim to curb use of approval by private health insurances

Patients, advocates and researchers welcome regulations but argue rules don’t go nearly far enough to tackle scale of problem

A new set of rules from the Biden administration seeks to rein in private health insurance companies’ use of prior authorization – a byzantine practice that requires people to seek insurance company permission before obtaining medication or having a procedure.

The cost-containment strategy often delays care and forces patients, or their doctors, to navigate opaque and labyrinthine appeals.

The administration’s newly finalized rules will require insurance companies who work in federal programs to speed up the approval process and make decisions within 72 hours for urgent requests. The regulations will also require companies to give a specific reason as to why a request was denied and publicly report denial metrics. The regulations will primarily go into effect in 2026.

Ranvier,

Fun fact, a prior authorization is not a guarantee of payment. They’re just definitely denying payment without. They still could deny even when this process is followed. And for many treatments and situations it’s totally unfeasible anyways.

Sir_Kevin,
@Sir_Kevin@lemmy.dbzer0.com avatar

In what universe is 72 hours considered an acceptable response time for anything considered “urgent”?

spaghettiwestern,

Health Net does this BS all the time. Even care that has been previously approved and paid for is regularly denied if needed again because “It’s not a covered service.” It would literally take hours on the phone to convince Health Net’s customer service that they needed to pay a claim, and even then there was no guarantee that they would actually pay it. Three 60 minute calls to get a bill paid were not unusual.

One time Health Net refused to pay for care they had previously approved in writing. Monthly calls were ignored for 8 months until the medical center sent the bill to collections.

Increasing profits because your company refuses to pay for contracted & covered care should be illegal.

_number8_,

i love how we constantly jerk off about how we’re the best and richest and freeest country in the world but we do this to our citizens

einlander,

The administration’s newly finalized rules will require insurance companies who work in federal programs to speed up the approval process and make decisions within 72 hours for urgent requests.

All I’m seeing is suddenly every request will not be urgent. Your heart transplant isn’t that urgent, see your not dead yet.

deweydecibel,

Going through this right now. Had to change insurance because of new job, this new insurance is fighting tooth and nail to not pay for the medicine I’ve been taking for years that keeps my Crohn’s under control. I’ve been without it for over a hundred days, and things are starting to backslide.

Literally, I’m getting sicker as they waste my time. They’re shit genuinely sickening.

nulluser,

Name and shame

evatronic,

For what it’s worth, contact your employer’s benefits coordinator. They can often slap the insurance company around since they’re the people essentially paying the bill.

Rivalarrival, (edited )

We’re gonna go ahead and adopt universal healthcare now, and offer free guillotinings for anyone who has a problem with that. All this “private health insurance” crap is a scam.

Employer-sponsored healthcare? That’s not a benefit. That’s extortion. It’s pre-emptive retribution for refusing to be exploited. It’s also a scam: as soon as you’re sick enough that you can’t work, and actually need it, you lose your coverage.

Obamacare props up this broken system. It drives people opposed to private insurance and employer-sponsored coverage to earn less, becoming less productive, so as to qualify for the tax credits and remain covered. The only redeeming quality of Obamacare is that in propping up private insurance, the industry becomes reliant on it, and will collapse entirely when we eventually shut it down.

Fuck privatized healthcare coverage.

Lianodel,

My friend just went through this recently.

She had significant sinus problems, one side being blocked entirely. Went to see her doctor, went to see a specialist, tried some things, but what she needed was surgery to get rid of polyps. She schedules it, takes off of work, gets a blood test, goes to the surgical center, and as she is being prepped for surgery, finds out they have to cancel, because her insurance was denying a part of the procedure.

What a huge fucking waste of time and money.

She did get a reason in the rejection letter, but it just pissed me off even more. The insurance company has a “doctor” who said the procedure might not be necessary, so they want to try doing X and Y first. Things she’s already done. Things her PMC doctor and specialist already know, but this one asshole who sold his soul to an insurance company gets paid to skim shit and say “no.” There are plenty of people in the insurance company structure to hate, but some of them are outright scum.

Also, to state the obvious, this is just slowing down the misery machine, when we should be dismantling it. I know it will help people, it’s a small victory, and the Republicans will want to turbo-charge said misery machine, but still.

PunnyName,

US healthcare is extortion.

snooggums,
snooggums avatar

Just ban prior authorization and don't let them deny care. Or even better, switch to single payer and get those parasitic businesses out of healthcare.

TropicalDingdong,

Federalize the health insurance industry.

Kalysta,

The answer to the whole mess is single payer. Where the hell is Biden on that?

HikingVet,

Pretty much the same place any other American president is when they try to change the health care system. Hog tied by the insurance industry.

someguy3,

Time for my link:

Frame Canada

Wendell Potter spent decades scaring Americans. About Canada. He worked for the health insurance industry, and he knew that if Americans understood Canadian-style health care, they might… like it. So he helped deploy an industry playbook for protecting the health insurance agency.

www.npr.org/2020/10/19/925354134/frame-canada

reddig33,

Thanks for that link!🏆

originalucifer,
@originalucifer@moist.catsweat.com avatar

health insurance companies profit can only exist at the cost of human suffering. there is absolutely no way around it.

bluGill,
bluGill avatar

Sure, because there job is to ease the monetary burden of suffering events. That doesn't mean they have to act like they do.

The real problem in the US is most people are not the customer for their health insurance - their employer is. In theory I can buy heath insurance from someplace other than my company, but I'm throwing away $1000/month (more or less - it is hard to find the real number) that I'd have to find if I went elsewhere. That means either insurance I get on my own is worse than what I have, or I have a lot less money for other things.

Which is why I've long said that to solve the US problems we need to remove the tax breaks for company sponsored health insurance. Once that happens I can actually decide which insurance company is the best for me.

admiralteal,

It's the persistent lie of the free market.

Yes, in theory if health insurance were a transparent, understandable product that you could easily switch with another one as an individual based on your needs and costs, market competition would optimize that product rapidly for service and cost.

But every single thing about that theory is wrong.

  1. It's an intensely opaque process. You have no real way to know what the costs are going to be, what your needs will be, what your options will be. You can't even know what a doctor's appointment will cost under healthcare until you get the bill, sometimes a full year later (at least in my experience. Nothing about healthcare costs are understandable even to someone with an advanced medical degree. The layperson has no hope.

  2. You also cannot easily switch it with another product. Open enrollment and contracts severely limit you. There's only fixed, stressful windows where you can change it -- and even then, you're back to point 1. What is the difference between the two plans in actual practice? It's all just gambling.

  3. As you already observed, if your employer offers healthcare, you basically have no choice but to use that product because the subsidies are so intense. You are not an individual. The individual plans suck, are intensely expensive, and usually both across-the-board. The ONLY affordable option for the average person is the employer-offered product, so your choices are severely limited.

And it go this way because the most powerful agents in this system are not individuals.

With home/auto insurance, basically everything gets driven to a commodity product because all costs and risks are pretty uniform and predictable. That's why there is vanishingly little difference in the core products being offered by these kinds of insurance companies, and why the idea that switching your plan is sure to save you gobs of money is... improbable, outside of just periodic renegotiation of rates.

With health, the costs and risks are WILDLY unpredictable. The difference between an "expensive" customer and a cheap one is many, many orders of magnitude.

So naturally, risk must get hedged. The system's need for efficiency is going to try and package people together, just like any other high-risk, low-reward financial product. The need to group people is obvious, so we made it mandatory for employers to provide insurance as a weird workaround to the logical thing of government-run insurance. Now the customers are primarily employers who have TOTALLY different needs and desires from cheap, high-quality healthcare service. The free market will now do its work and optimize based on supply and demand. The efficiency gains will benefit the vendors (insurance companies) and the customers (employers). Individuals are not benefiting from market forces at all.

Free markets are great systems where they apply. They're really good for rapidly assembling efficient systems to get products to customers. But they only work where they work. The persistent lie of the free market is that EVERY problem can be solved with a free market. Nope. Only certain problems can. And where free markets don't work, that typically means you have need of government to step in instead.

Uranium3006,
Uranium3006 avatar

I don't understand why enrollment periods are a thing and I'm just assuming it's just an excuse to screw us

admiralteal,

With group policies, it means that the insurance companies can do their actuarial work on the entire group in aggregate without having to have considerations about prorating based on certain individuals entering or leaving the policy throughout the year.

At least ostensibly. I doubt this actually happens. It's mostly just a way to limit administrative overhead for both the insurance companies and the employers.

Don't think for a moment that employers don't like the whole open enrollment system too. Even if they CLAIM it is a PITA, it lets them only have to deal with this work for newly-qualified employees, separations, and otherwise only once a year.

Either way, it's of no benefit only harmful to the actual consumers of the insurance. But since individuals aren't the customers, that doesn't matter.

djehuti,

Which is why I’ve long said that to solve the US problems we need to remove the tax breaks for company sponsored health insurance. Once that happens I can actually decide which insurance company is the best for me.

That will never happen. Healthcare being tied to employment is what keeps people from quitting shit jobs.

snooggums,
snooggums avatar

Sure, because there job is to ease the monetary burden of suffering events.

Their job is to extract profits from people who need healthcare, and ease the monetary burden on the business by denying as many claims as possible to increase profits. Preventative care would benefit them in the long run along with the population that they 'serve', but short term profits don't care about the long term.

Uranium3006,
Uranium3006 avatar

people switch insurance when they switch jobs so the math is deny and let it' be another insurance company's problem

snooggums,
snooggums avatar

You might know this, just adding it as context.

Prior to Obamacare insurance companies would deny things like cancer when you switched insurances by calling it a 'preexisting condition'. As in you had cancer before signing up for their insurance.

Companies loved this because it made their employees afraid to leave because their current insurance might cover their treatments, but switching jobs most likely mean that their new insurance wouldn't.

evatronic,

The requirement to honor a “Certificate of Credible Coverage” with like a 30-day gap was a fucking godsend, and even then, health plans still didn’t have to cover any minimum set of services, medications, procedures, etc. like they do under the ACA. Insurance providers were free to just be like, “No, we don’t cover chemo at all, period, fuck off.” But more common, by far, was simply not covering prescriptions. Like, at all. You go to the doctor, get fixed up, and here’s to hoping the meds they want to give you are generic, because you’re paying out of pocket.

NOT_RICK,
@NOT_RICK@lemmy.world avatar

Government run single payor is a way around it. I will cackle like a supervillain the day all these leeches lose their bullshit jobs.

quindraco,

Despite this, every time you point it out, people come out of the weeds to defend health insurance.

ChemicalPilgrim,

But I thought if we had universal healthcare there would be death panels deciding whether gradma got her medicine! Now you’re telling me its the private insurers that do that?

superduperenigma,

Now you’re telling me its the private insurers that do that?

Always has been.

ChemicalPilgrim,

I was being ironic

SpaceNoodle,

Hence the meme response.

Semi-Hemi-Demigod,
Semi-Hemi-Demigod avatar

Medicare for All would have evil government death panels. Health insurance is evil corporate death panels, which are better because reasons.

lolola,
@lolola@lemmy.blahaj.zone avatar

Well it’s obviously better because if consumers get mad about the decisions from the death panel at company A, they can just go to company B. Like if you don’t like McDonald’s, you can just go to Burger King instead.

Except there might not be a Burger King restaurant (let’s say in Burger King’s “network”) anywhere near where you live. And your employer already decided that everyone on the payroll has to eat at McDonald’s, and trying to deviate from that is a gigantic expensive hassle for some reason. And you’re basically locked into a single burger chain for the year, except for a tiny window of time when you can elect to switch. And you’re on the verge of starvation.

deegeese,

They were outraged that the death panels wouldn’t be able to use profit motive any more.

evatronic,

I want my death panels incentivized by … keeping me alive to keep paying taxes, instead of incentivized to reduce costs and increase short-term profits.

bluGill,
bluGill avatar

Everyone does that. Unless you are filthy rich you cannot afford whatever medical costs you might have. Private insurance means you get to choose which death panel decides your case - except that the way insurance is setup in the US you don't get that choice.

maynarkh,

Okay, stupid question, as an European I don’t know if that’s the case with our insurance. Sure there may be waiting times for organ donors or whatnot, but healthcare is not going to put me into debt. I’ve had one in a million illnesses in my family where one has to stay at a hospital for months before and after a complex surgery, but it never has been a money issue.

bluGill,
bluGill avatar

Most beople have health insurance here and don't go into debt. it is a minority that run into problems.

you may not be allowed some expensive care, but your doctor won't tell you it is an option elsewhere as you can't get it. If you have such a condition you could go to a different country for care, but odds are you don't as such things are rare.

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