Health Insurance in America

[Emergent, RN]

What do you think of the healthcare insurance industry in America? How has that affected your patients, your family and friends, or yourself?

I was spending time with my physician assistant friend who says that claims are denied quite a bit. I've seen this happen with friends and family of mine. I've heard horror stories from patients. My son told me that when my first granddaughter was born, they had $1,000 that they owe to the hospital. When they went to check out with my second granddaughter 2 years later, the hospital told them they owed $10,000. I can see why there is resentment towards the health insurance industry in the United states from people of all ideological points of view.

[Willofthewisp1]

I was surprised to learn that insurance laws vary from state to state., especially with contraceptives.

[Accolay]

I think medical insurance sucks. I think the stories of people who have to ration their insulin sucks- especially since it costs pennies per dose. I hope that Martin Shkreli and those like him find a nice place in hell. I think it sucks that people forgo medical care due to costs- especially when they have to let their problems get so bad they come in really sick. I think a businesses that only provides catastrophic medical insurance coverage to its employees is hot garbage.

Also ties into businesses that don't provide PTO and make their employees work when they are sick (and make other people sick), or they don't pay enough and people can't afford to take an unpaid day off. And the jobs that make people get a doctors note for missing a day or two of work like they're ten years old? Really?

And that's just insurance. Don't get me started on politicians denying healthcare.

Having a healthy populace is integral for a successful nation.

[NRSKarenRN, BSN, RN]

ProRepublica  10/23/24

"Not Medically Necessary”: Inside the Company Helping America's Biggest Health Insurers Deny Coverage for Care

T. Christian Miller, a reporter at ProPublica, explains how EviCore's tool is manipulated to increase denials and cut costs.

Quote

 

Reporting Highlights

Dialing for Dollars: America's largest insurers hire EviCore to make decisions on whether to pay for care for more than 100 million people.

"The Dial”: EviCore uses an algorithm that allows it to adjust the chances that company doctors will screen prior authorization requests, increasing the possibility of denials.

Lucrative Deals: Some EviCore contracts are based on how deeply the company can reduce spending on medical procedures. It tells insurers that it can provide a 3-to-1 return on investment.

 

...The biggest player is a company called EviCore by Evernorth, which is hired by major American insurance companies and provides coverage to 100 million consumers — about 1 in 3 insured people. It is owned by the insurance giant Cigna.

A ProPublica and Capitol Forum investigation found that EviCore uses an algorithm backed by artificial intelligence, which some insiders call "the dial,” that it can adjust to lead to higher denials. Some contracts ensure the company makes more money the more it cuts health spending. And it issues medical guidelines that doctors have said delay and deny care for patients....

Listen to 11 min interview with author.

[HiddenAngels]

A little reluctant to post on this topic given the current state of affairs with the CEO headlines, but I agree with the above posters.  It does suck.  Most people who come to the hospital needing a fine tuning, it's usually because either they ran out of their meds and couldn't afford the refill or, they never picked them up in the first place due to the out-of-pocket cost being too high.  What bothers me even more than that are the side conversations from some of the physicians that blame patients.  Not everyone is as medically savvy as we are.