So is it just sampling bias that we hear constant stories outside the US of everything from broken legs to cancer patients being denied coverage or being covered but having life destroying out of pocket costs? Because it really is constant.
There’s 330M people in the US and 365 days in a year, so you can hear about one mistake every day and it’s still an extremely minute error rate.
It would be nice if someone brought data to the discussion.
And specifically about health insurers erroneously denying coverage. I have first hand knowledge from a doctor at an insurance company that audits other doctors’ work at the same insurance company to ensure they are not erroneously denying claims, as there are heavy penalties from state governments and CMS.
That is a separate conversation from out of pocket costs destroying someone’s life that has nothing to do with health insurers and everything to do with how much US voters are willing to have their taxes go to those with less.
> The ACA guarantees external appeal rights to enrollees in all non-grandfathered private health plans. When issuers uphold denials at the internal appeal level, consumers have the option of requesting an independent review by an outside entity, whose decision is binding. Consumers also can bypass internal appeal and go directly to external review in emergencies and certain other circumstances. Consumers seldom avail themselves of external review.
The point was there’s a lot of people with a lot of transactions in healthcare happening, so “hearing” about it constantly doesn’t mean anything.
And yes, I know the link doesn’t have statistics in erroneous denials of coverage (I couldn’t find it anywhere quickly), but it did note that the law requires insurers to abide by an external reviewer’s decision.
Surely if there were that many erroneous denials of coverage, there would be lots of people clamoring to get it overturned via the external reviews.
It’s probably just the case that most denials are justified (in the legal sense) that the requested healthcare lacked sufficient documentation, did not have efficacy data, was using brand name medicine instead of generic, etc.
I agree that there would be plenty of horror stories to fill the news, even if such events were extremely rare, but multiplied by 300 million.
However, many people's "hearing" is a slightly less biased sample than that. It's that every American they have personally talked to about any visit to a hospital seems to have a horror story about (at very least) crazy bills, hours on the phone with insurers for months to years afterwards, etc. That's also not unbiased since people like telling these stories, but at least the denominator is two digits not seven. (The stories may also not reflect the latest reality, as you say.)
Just to re-iterate, my original comment scrolling up was specifically responding to this claim:
> We don't get this nonsense where the insurer tries to deny us and hope that we don't dispute.
Restated, this is claiming that health insurers in the US erroneously deny coverage as a policy. And that is the specific statement I am saying is untrue.
The crazy bills are true, you should of course budget to be able to afford the out of pocket maximum for healthcare costs in any given year. The hours on the phone might also be true, but I know how complicated of a topic US healthcare is (perhaps needlessly, but it is what it is).
Personally, I have more issues with the healthcare providers than with the insurance companies. The insurance company has picked the phone pretty quickly when I call, and tell me the price of a procedure they have negotiated with the provider if I give them the code for it. You can even search it online on a map to shop around the prices.
The problem that I have in US healthcare is that no healthcare provider is willing to give me a code, even for simple checkups or X-rays or what have you, where everything is known in advance. The healthcare providers don't want to risk
And to finish, I'll provide with an anecdote about one of my experiences with healthcare:
My wife gets an ultrasound. The healthcare provider charges $15 for "towels" used to clean up the gel they put on my wife for the ultrasound. In reality, it was a few pieces of paper towel. The insurance company denies to pay for the towels, so we get a bill for $15. I call the healthcare provider and asked why I'm being charged $15 for a few pieces of paper towels. The person in the billing department says to ignore the bill and not pay it.
As a consumer, what am I to understand here? That healthcare providers are overcharging? Or maybe insurers are underpaying (or paying late, or causing too much paperwork) so that healthcare providers are overcharging to make up for some of that? Or healthcare provider is just charging and collecting payment from anyone who doesn't contest, and letting it go for anyone who does?
I inquired multiple times as to all the charges that will be had during the ultrasound. It's a completely routine procedure with no unexpected costs, but the healthcare provider told me they can't give me the codes they will bill. Had I been provided the codes beforehand, I would have brought my own paper towels to wipe the gel off. So I can conclude that the healthcare provider was not really trying to recoup paper towel costs.
"Restated, this is claiming that health insurers in the US erroneously deny coverage as a policy. And that is the specific statement I am saying is untrue."
The policy may not be explicitly stated, but having dealt ( and likely having have to deal with both this year ) with medical issues ( and related bills ) in US, to me it is clear that everything is stacked against the recipient of healthcare benefits. In other words, actions speak louder than words. The moment I have to spend multiple hours a day, faxing stuff, confirming receipt, complaining, contacting various overseeing bodies, I think the unstated policy is pretty simple. Deny and delay is a tactic. And it works. Not everyone can devote time and energy to this. It is exhausting.
"The problem that I have in US healthcare is that no healthcare provider is willing to give me a code, even for simple checkups or X-rays or what have you, where everything is known in advance. The healthcare providers don't want to risk"
I am willing to agree here. There is a fair amount of issues that are created for a patient by the providers ( coding, communication with insurer or lack thereof, now standard 'you are responsible for everything insurance doesn't pay' clause and my current favorite 'some of the providers in our hospital may bill you separately' ). It usually takes some yelling to get some of the charges to 'reasonable' level and I have the feeling the only reason I got away with it is, because the election was in full swing and no one wanted another crazy hospital story.
So is it just sampling bias that we hear constant stories outside the US of everything from broken legs to cancer patients being denied coverage or being covered but having life destroying out of pocket costs? Because it really is constant.