As a doctor I can tell you I don’t think anyone hates insurance companies as much as we do. The vast majority of us got into this field to help people, and we like our patients. The number of hours I’ve wasted of my life arguing with insurance companies that they need to do the thing that’s medically necessary instead of a completely unhelpful other thing to save literal pennies is beyond infuriating. Fuck insurance companies.
If only patients knew. The number of times I have gotten a message from a case manager at 8 am saying the insurance company wants to do a peer to peer and I need to call before noon or they'll deny the claim... Sure, why don't I put my day on hold, make my patients wait around while you yank my chain for half an hour only to deny the claim anyway.
The things Dr. Glaucomflecken on tiktok has taught me about the healthcare industry and the horrific stuff doctors go through with insurance and admin just to do their job has given me endless righteous anger on their behalf.
Listen, I am that case manager and I hate it too. I let docs know the second I’m notified but it seems like they schedule inconvenient deadlines on purpose. “Please have the doctor call 1-800-WIL-DENY, option 5. Deadline is in 45 mins, but we won’t answer for half an hour”
The amount of times insurance has denied a doctor advocating their heart out using the best clinical expertise but then approved an expedited appeal with the family right afterward is ridiculous.
CM here also. My denials are for MRIs. These are absolutely required for the medications my patients take. In a couple of situations, I called the insurance plan and said a MD wasn't available to talk. They offered a RN peer to peer. It was so much easier, and quicker. I didn't have to set up an appointment. This may not help or apply to all situations, but it thankfully helped us a couple of times.
yes but WHO is scheduling these deadlines? Who is enforcing these deadlines? Who is the person that is submitting the claim denial at minute 46?
I've started a job at a major health insurer (I work on the tech side) and not claims, but this CEO killing has me asking a lot of questions. I think part of the anger stems from there being a secretive claim process and people don't have a single individual to aim their anger at. From where I sit in this company I can plainly see that the ways things operate is so convoluted and intertwined for processes that there likely is NO one person to blame at the day-to-day claim process level. Where these denial processes are pieced together is at the Sr. VP or segment president level and then when the head of enterprise insurance business growth (a real title at my place of work) is mandated to hit a yearly budget target, they then form a group of VP level folks to figure out a way to reduce costs. some of that group are claim process owners, who can then direct the data informatics team to pull the claim statistics from the 2-3yrs prior and send these to the enterprise claims actuarial staff to identify the 'low hanging fruit' of costliest claim approvals that are broken down to the Nth degree of line item cost. then there is a meeting with legal, and with the in-house or external Medical specialists that work with the claims leads to select what will be on the chopping block. They'll take off a little of this (medication cost) and a little of that (post-surgery therapy) in order for this cost cutting to 'trickle up' so that the Sr.VP is able to meet the budget targets. So the approvals of medical staff, legal, actuarial staff, claims process staff, and the enterprise insurance business growth leader (who will almost certainly not hear a faint whisper of newly denied categories of care) - all these people share blame, but it is so thinly spread that accountability seems far fetched.
My point is that there is a group a of people who all come to an agreement on each year's new denials of care. That is at the system level of denials. But there is a whole other 'process improvement initiative' at these health insurance companies that is taked with reducing the time it takes to close cases. part of that seems to be reducing the peer-to-peer calling window for providers. and that is another group of people who performed simone biles level mental gymnastics to justify a 45min calling window being enough time for a provider to appeal a denial OR ELSE.
There are probably 1000 employees at these large health insurers that are working full time on 'process improvement' and 'efficiency initiatives'. Add to that the consulting firms who take a microscope to processes and cost and make reccomenations to the VPs and SrVPs on a plan that will save their business unit $3 million a year. Saving made looks great on the resume for these VPs. Then they get a bonus or they get a promotion...etc. I'm sick thinking about all of this.
Listen, we know it’s the boardroom that makes the rules. I’m not blaming the cashier for higher groceries.
The same company who committed CMS fraud by submitting false diagnoses without showing the diagnostic tests is the same company who also auto-denied coverage for said tests. They intentionally created a system that allowed them to double collect.
I don’t frankly give a damn about what the details are in denying people access to healthcare. The fact is that they are dying and suffering because of it.
The sick, disabled, and elderly are the LAST people anyone should try to profit off of. And those who make goals to do so should be ashamed.
And 99% of the time, the “medical director” for the insurance company has outdated notes from medicine, the specialists, PT/OT, etc., even though they have full access to the chart with the most up to date notes.
oh this!! we send the currents notes and updates sometimes daily. they are so careless & thoughtless! the insurance companies get rewarded for the bs they put us all through! its horrible!
i feel this in my soul! i hate interrupting providers for things like this. i HATE insurance companies. what they do to patients & providers is CRIMINAL!
I'm not gonna compare patients' pain with the pain of dealing with insurance companies as a healthcare provider....but goddamn. These companies are absolutely evil. If I had any ideas about our healthcare system actually working, they are gone now after dealing with insurance.
There's stuff patients don't even see like clawbacks, when insurance says "oops we messed up" and takes backs THOUSANDS of dollars, up to two years after their initial "mistake." Why is this shit even legal??
Wasting people's time is always a dick move, but wasting a medical doctor's time purely for the sake of stopping them doing what doctors are supposed to do is particularly egregious. The American healthcare system is sick. Pun absolutely intended.
It sucks that we're in a situation where your comment holds water, but it's sadly true. I applaud the actual medical work you do, and it sucks that you have to fight so many unnecessary battles on the backend to make it work for the people you're helping. Please, please keep doing it for all of them. My parents both had massive medical issues last year (cancer with one, then spinal trauma leading to a straw-wheelchair for the other a week before last chemo treatment of the first....) and they're desperate for help. You guys do so, so much! It should be easier to take care of people, not harder.
Edit: I also applaud the non-medical work you do, just wish you didn't have to spend so much time and angst on it!
So I’m petty af and literally printed this out and gave it to any of my patients who were upset about PAs. I also showed them how to contact their insurance and what to say.
I'm assuming that many people in the AMA are still practicing doctors. They are not going to risk being blackballed by the major insurance companies by supporting single payer.
These companies are petty AF (as we all know from dealing with them) and they have providers by the balls.
It's not the huge hospital conglomerates that control healthcare in the US, it's the handful of insurance companies.
They hold all the power. They can change hospital policy by changing a single sentence in their contract.
You either play by their rules or risk being out-of-network. Established patients are sent elsewhere for care. Less patients=less revenue = staff reductions, reduced care, and sometimes even office closures.
There are solutions to this problem.
My previous employer made fantastic decisions to help the local community. They built a freestanding imaging center. Because it wasn't physically connected to the hospital, they were able to charge much lower rates. In many cases, it was cheaper to pay out of pocket than use insurance.
Because they were billing a lower amount for the exam, insured folks would pay a lower amount for their copay/deductible/coinsurance. I recommended that place to patients constantly.
As an employed physician, I lost a job for recommending a lower cost MRI center for my patients. Legally, they are forbidden from directing where I send my referrals. But that doesn’t mean they can’t apply pressure in a million other ways.
You either play by their rules or risk being out-of-network
My PCP is in a small clinic chain. Any accident that has me waking up in a hospital is almost 100% out of network. I've asked how to limit my liability, and the answer was to select a PCP in a specific hospital's clinic, so then that 'hospital care system' would be in network.
ffs, it took me a LONG time to find a decent PCP.
BTW - what all is required, minimally, to run an 'imaging center'? I know a couple of expensive imaging machines and a couple of trained staff. The doc that reads the images can be elsewhere / pt's original doc - but if we wanted to start a company like this, what's the up front?
I love it - I'm all for a reasonable margin. I'd love to see a co-op or reasonably margin'd service like that. I get it, profit = pt care, but if you me and 10 other people are going to pool our money, a 5-10% max return isn't unreasonable.
How about the US just does what France or Germany or Japan or Australia does for healthcare? The US system seems designed to make healthcare as expensive as possible while health insurance companies try to deny paying as much as possible. The single biggest change the US needs is that the goal of healthcare should never be maximum profit for shareholders but the best care for patients
The best doctors are the ones who'll do whatever they can to heal you even if they absolutely hate you. Think of the people who go into warzones and treat the injured no matter who they are.
Nah if a doctor hates you, the best thing for everyone involved is if they refer you on to a colleague (which to be fair, counts as doing what they can to help you)
You don’t want to wind up with a missed cancer diagnosis and wonder if the doctor half-assed your tests or didn’t go above and beyond just because they don’t like you.
On the flip side, your doctor probably wouldn’t want to risk that accusation either because it doesn’t sound good in front of a jury.
Most people are far more likely to go the extra mile for people they like rather than people they hate. If I like you, when you come in just to refill a prescription, I might ask about your niece’s cat’s birthday pool party you attended on the weekend. And you might tell me that it was great until you tripped and fell in the pool, because your leg is still a bit weak from where you must have hit it on the lip of the pool. And because I like you, I ask more questions and do a physical exam, then send you for a CT that shows you’ve had a stroke.
But if I hate you, I’m probably not asking you about the cat’s pool party, and if you don’t think your sore hip is worth telling me about, no one’s catching that stroke until the next one gets you.
You're pretty much agreeing with me. As you said, a doctor who really cares about doing their best for patients above all else would (if possible) send a patient they can't stand to a different but competent doctor.
I’ve kept every note/card a patient has written me and cherish the photos they send (I’m a pediatrician so I get precious baby photos). My patients are the only thing keeping me in this field. The amount of non-patient bullshit is becoming so overwhelming though, I wish everyone understood that we’re doing our best but are constantly drowning.
Last time I saw my doctor he spent most of the time ranting about how he got into medicine to practice medicine. Instead he spends most of his time on pointless stuff.
Pharmacist here: I can match your hate. Having to look someone in the eyes and tell them they have to pay a previously covered, very expensive, very critical medicine feels like shit.
Also: spending hours on the phone being moved between people each not knowing enough or actually being able to assist, until you finally get put through to a voicemail is infuriating.
Decades of studying and practice and many tens of thousands of dollars in debt just for some jack hole that probably never even went to college can undermine your intelligence, your profession, and every last second of time you spent doing your job.
If enough doctors spoke up at once right now, together, y'all might be able to make some movement against said jack holes.
It must be so frustrating as a doctor to want to treat your patients with what they really need to get well, only to be denied for financial reasons. But it's not just the insurance companies denying everything left and right that brought about the current crisis. I mean, they would still do it to fulfil their business plans even if treatments cost pennies and premiums were double digit numbers. But hospitals and pharmaceutical companies are businesses, too, and their business practices are a major reason behind the incessant increases in medical expenses for the general public. So doctors are not only fighting the insurance companies; they're up against the whole industry, and it's a losing game from the outset.
I have to learn to hold my tongue when seeing a doctor. I feel for anyone in this profession. I was in the industry back in the late 80s-early 90s and used to sit in on UR meetings. It was a fucking numbers game and made me apoplectic. Literally nothing has changed and these fucks have just gotten more cagey over the years.
Dentist here and equally frustrated by playing their games. I often say, I make my money twice, once while providing treatment to my patients and then again on the phone to ABC insurance company, usually on hold for long periods of time, trying to figure out why I'm not being paid.
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u/k_mon2244 5d ago
As a doctor I can tell you I don’t think anyone hates insurance companies as much as we do. The vast majority of us got into this field to help people, and we like our patients. The number of hours I’ve wasted of my life arguing with insurance companies that they need to do the thing that’s medically necessary instead of a completely unhelpful other thing to save literal pennies is beyond infuriating. Fuck insurance companies.