Absolutely! There should be a groundswell of outrage. The insurance business needs to be regulated. Period. They’ve gotten by with this crap for far too long. It’s not insurance. It’s a game. Can you imagine your job every single day is to see how you can screw someone over legally?
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During my short stint with a company that provided insurance consulting services to employers, I worked with some self insured companies. I recall one company that was very proud of providing excellent benefits. They started having complaints from employees about services not being covered. We ended up finding out that the insurance company did not have the benefit information properly loaded into their system … resulting in quite a few procedures not being covered that should have been. The benefits administrator was livid. I can’t help but wonder how a company that didn’t have such a great benefits department might have just accepted things as they were, with employees getting denied coverage and the company not actually getting what they paid for.
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Regulation will not happen any time soon, unfortunately.
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Hmmm . . . I don’t believe that considering the deaths and hardship caused by unjustified insurance company denials and delays is “looking at it the wrong way.”
I also don’t believe that “the real question” is whether the company’s profits are excessive. It is not purely an economic efficiency issue when people are dying as a result of the decision making.
When people buy health insurance, they are putting their lives in the hands of their insurers, and their insurers are accepting that awesome responsibility, contractually and ethically. This duty to provide the contracted care without unjustifiable delays or denials ought to trancend concerns about how much profit is enough, and how much profit is too much.
As @eyemgh said, it is not the subscriber’s fault if the insurance company is willing to unjustifiably deny and deny claims in order to make a buck.
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Well, here goes. We have AARP UHC Medicare Advantage. My husband has had two major back surgeries, countless pain management therapies and ongoing prescriptions and we have never heard a peep from UHC. I am knocking on wood here like crazy. Someone mentioned it as related to travel but we do not travel overseas anymore.
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Yeah, our oldest son went through a period of “I’m young and healthy, I don’t need insurance.” Lord. He got as cheap a thing as he could find with an enormous deductible…catastrophic plan in short.
Based on my own employment experience working in medical insurance, it absolutely is a regulated industry. Federal and state regulations all over the place.
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Thanks for this! My employer has always been open that we are self insured. I’ve been here almost 30 years and that was the party line (and probably rightfully so) why our insurance was so expensive compared to many others, and increased every single year in the '90s, '00s, '10s. We are self-insured and we are an old and sickly workforce. And they’ve been very open about how much they contribute each month to each plan. They clearly spell it out on the open enrollment documents and then it’s printed on every pay stub!
But, they’ve never said anything about who is the party responsible for denying claims. Interesting…
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That isn’t necessarily a bad thing, assuming the plans have the same general coverage for procedures and in-network doctors. We have 3 plans at work. An old style, co-pay that most people call the “good insurance,” and then 2 high deductible plans with $3200 per person or $5000 per person deductibles. Between the premium difference plus the $2K my employer kicks into my HSA, I save $9000/year from the get go. The “good plan” still has a $2000 per person deductible. Most years our family’s out of pocket total bills were around $500! I have saved over $100K over the years by doing the high deductible plan.
Plus, if you really compare the plans, if you have a catastrophic event, the high deductible plans also saves you $$$ over the other plan. My max total out of pocket is the deductible, because after that everything is covered 100% (unless out of network)… on the other plan, the out of pocket max is higher than my deductible.
But NO insurance is definitely a mistake!
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There’s regulation and then there’s enforcement. If regulations are not enforced, is an industry really regulated?
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And it’s not just private insurance. From the linked article: “Nor are these hurdles unique to private health insurance. Clark found that government-provided insurers, like Medicare and Medicaid, preside over their own, often seemingly impenetrable bureaucracies for appeals—a point ostensibly acknowledged by federal health officials.”
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There is significant regulation in the private health insurance market. Note I am not making a judgment statement that it’s too much or too little or just right.
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It’s such a tough tightrope to walk. Medicare fraud (incl errors and abuse) is estimated to be $60B per year, each year, with all those policies, procedures, prior auths, etc. etc.
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Sure! Send it off to preschool w your kid who has a nut allergy!
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Umm…no. I sent my S to school with an Epi Pen for years. I had to hand carry it to the school nurse with paperwork completed. It had to be in the original packaging. No way would this have been accepted. I don’t know where the “many people” who do this are.
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Exactly, there are actually very few. Ironically, I am one of them. I was traveling abroad w a friend who has a bee allergy in a place w killer bees. Airline misplaced her luggage/EpiPen. I bought her a vial of generic epinephrine and a syringe. Calculated her dose in fractions of a mL (NEVER a whole vial of course!), made a plan for scoring and breaking neck of said glass vial, drawing up and administering correct amount in an emergency. I was so nervous! …and I am a doctor.
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You are a good friend. I have an epipen for a cashew allergy, but I have had it since the 1970s when it was called a “bee sting kit” (!) for that reason.
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Well, to be clear – they can, but not every employer will want to get so involved.
Don’t EpiPens expire? I thought that was part of the problem for ppl…having to continuously buy them only to not use.
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Which is why the health care industry should not be for profit!!
Wait, though – I’m not suggesting that every self-insured employer plan decides every claim. That what the employer is paying the insurance company to do. But in that unique case, where I worked for a very prestigious, “high touch,” employees-alway-come-first employer, that was the case.
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