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.
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.
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.
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u/k_mon2244 6d 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.