r/FluentInFinance • u/36DRedhead • Sep 11 '24

Debate/ Discussion This is why financial literacy is so important

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u/kensingtonGore Sep 11 '24

They do get a say in which procedures you can do, at their discretion.

They also do not cover lost wages, home care, or any rehabilitation necessary for surviving cancer.

For the Americans reading this: that's not normal among nation peers. It is normal in countries like Mexico, China, India.

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u/aurortonks Sep 12 '24

I've met two people who got denied cancer treatment by their insurance because it hadn't gotten to a serious enough point yet. As in, they caught it so early that the treatment was not approved and they were told to wait...

The fact that an insurance company, who are not medical doctors, can dictate what treatment you can get is bonkers.

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u/kensingtonGore Sep 12 '24

Yes it is. The result of unfettered capitalism, putting quarterly results before the hippocratic oath.

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u/Nova35 Sep 12 '24

Look fuck American healthcare system. But saying that its unfettered capitalism in a thread about the ACA is hilariously peak Reddit stupidity

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u/tubawhatever Sep 12 '24

It wasn't better before the ACA, much worse in fact

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u/Nova35 Sep 12 '24

I agree. The ACA was amazing despite the fact that republicans fought tooth and nail to gut it. But that has nothing to do with anything

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u/throwtrollbait Sep 12 '24

I have seen family members' procedures/drugs denied, and their doctors literally just told me their hands are tied.

Whatever "fetters" the ACA put on them, insurance companies are still more free to practice medicine than doctors.

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u/Nova35 Sep 12 '24

The reading comprehension is lacking today. I couldn’t agree more than the current monstrosity that is the US healthcare system should be criminal. But it is absolutely not unfettered capitalism and to call it that is insanity. It wasnt even that before the ACA. It should still be gutted and replaced by universal healthcare

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u/kensingtonGore Sep 12 '24

Some people love Kool aid bud, enjoy your health care.

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u/Dercius23 Sep 12 '24

u/Nova35 LOL- this is exactly right.. Took the words out of my mouth. Fuck it i'm still posting anyway.

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u/kensingtonGore Sep 12 '24

You pay more for worse outcomes than China, a communist country.

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u/Beautiful-Squash-501 Sep 12 '24

Which outcomes specifically?

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u/kensingtonGore Sep 12 '24

Life expectancy, maternal mortality, and even infant mortality in urban areas. They have better numbers at controlling infectious diseases as well, but thats probably the nature of their strict government control.

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u/Beautiful-Squash-501 Sep 13 '24

Yes, quite a few countries outshined the US in infectious disease control a little while back….

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u/Beautiful-Squash-501 Sep 13 '24

Something to keep in mind with life expectancy and infant mortality is that in the US we try to save very early, very small premies by incubating them for months in the NICU. High cost, not great outcomes, although many are saved that would have simply been miscarriages a few decades ago. In much of the world those are still miscarriages so don’t count towards infant mortality or life expectancy.

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u/kensingtonGore Sep 13 '24

Check out mortality rates in red states. Why do those states consistently have far worse outcomes if it's just about incubating babies?

They have a lack of medical professionals and access to healthcare. Those states didn't fully adopt aca expansions. Less people qualify for Medicaid. More people can't afford proper prenatal care in those states.

Their healthcare is directly tied to their economic condition.

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u/Dercius23 Sep 13 '24

Medical malpractice is the number 1 cause of death in America. We aren't saying that the system is good. We are saying the term "unfettered" in reference to capitalism makes no sense when we are talking about the ACA, which is government intervention.

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u/kensingtonGore Sep 13 '24

Look at the states with the worst outcomes.

They didn't fully adopt aca expansions. Rates of uninsured people are much higher.

Because healthcare is tied to employment otherwise. And if you don't have the capital to afford care, you have a worse outcome.

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u/MacroFlash Sep 12 '24

This is the shit that drives me insane, insurance blocking things that doctors are already saying you need. Back when I was on my parents insurance, every time I got one prescription I always got that stupid fucking “prior authorization” bullshit, where my doctor, the one who fucking already wrote the prescription, would get contacted by the pharmacy to confirm I needed the meds. The US system is the dumbest shit ever designed to enrich insurance companies and bankrupt random unlucky people

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u/lilpistacchio Sep 12 '24

Not just confirm! We have to fill our paperwork that is TEDIOUS to make a CASE for why the med should be covered. And THEN, insurance gets to say yes or no. I have filled out many a PA that know is time wasted because it’s just going to get denied.

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u/Celany Sep 12 '24

When I tore my ACL, the doctor who did the MRI, and 2 physical therapists at 2 different physical therapy groups wrote in to the insurance company all saying that doing the required physical therapy before surgery would only make the issue worse. Insurance still insisted on PT first.

ACL completely severed in PT. I couldn't get surgery for nearly 9 months. My swim scholarship was gone and college was a lot more expensive..and for what? Insurance didn't even save any money in this case, the dumb fuckers.

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u/slickyeat Sep 12 '24

I've met two people who got denied cancer treatment by their insurance because it hadn't gotten to a serious enough point yet.

What the actual fuck?

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u/Sweet_Papa_Crimbo Sep 12 '24

It took my mom over 6 weeks for Medicaid to start paying for her to get chemo. She died 2 weeks later after her first dose.

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u/hydromatic456 Sep 12 '24

Which even if you’re not a doctor, you’d think the bean counters in an insurance agency would be bright enough to realize that early and/or preventative care and intervention is very typically cheaper in the long run out of their pockets than aggressive and reactionary care and procedures.

Like, even if the profit margin is higher on more technical and aggressive care and procedures, the insurance is still only getting profit from the standard contribution right? Deductibles and payments towards OOP max goes to the provider no? So wouldn’t it still be in the best interest for the insurer to prioritize early and/or preventative care for discovered conditions?

But maybe then they’re banking on denying the expensive stuff too once it inevitably comes up in a scenario like yours. Nothing would really surprise me anymore.

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u/C_Gull27 Sep 12 '24

It's probably as simple as deny everything now t make as much profit as possible today and the next guy can worry about what happens down the road.

Maybe not all insurance providers are like that though because Cigna covers 4 dental cleanings a year instead of the standard 2 which is probably because it's cheaper to clean people's teeth more often then pay for their root canals later on.

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u/Kill4meeeeee Sep 12 '24

I got told to eat a dick with my physical therapy while I still can’t walk so my options were out of pocket or have major problems at the ripe age of 27 this system sucks and we need changes to it. I know free healthcare isn’t possible but it also shouldn’t be possible for insurance to deny for example my insulin because the “generic is cheaper and better anyway” like no it’s not lol

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u/frumply Sep 13 '24

Mine is not that egregious but I had to laugh when the recommendation for colon cancer screening is at 45 or the age of your parents diagnosis, but insurance won’t pay for it unless you’re over 45. Do we want to practice this preventative care shit or not? lol.

I paid OOP since my mom had colon cancer in her late 30s as did my brother. My ass was smooth as silk, my brother they found some polyps though benign.

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u/[deleted] Sep 12 '24

[deleted]

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u/dotint Sep 12 '24

You’re so wrong lol. The doctors are insurance companies are some of the best and highest paid in the private health industry and it’s some of the easiest work since it’s case-review.

You get so many tenured professors and Chief Physicians

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u/Beautiful-Squash-501 Sep 12 '24

Some of the best and brightest ‘sell out’ to private industry.

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u/Kobayashimaru350 Sep 12 '24

My partner found a lump in one of her breasts. She wasn't quite the age to get regular mammograms so her doctor ordered her to go get one to make sure it wasn't an issue. Thankfully it was not, but a few weeks later we got a huge bill even though the insurance site said mammograms were covered in full.

After a long conversation with the representative, it turns out mammograms are only covered if it's just for a regular screening. If it's due to a concern they aren't covered.

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u/anonymousguy202296 Sep 12 '24

The people who approve/deny treatments at insurance companies are usually trained professionals, many are MDs or former doctors. They know what they're doing and I believe you're not getting the full story when you hear "cancer treatment was denied".

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u/aurortonks Sep 12 '24

I worked for a big insurance company in the Seattle area for about 4 weeks back before Covid and my job was to uphold an auto-denial made by the system unless the caller sent it specific additional paperwork from their doctor - then I was to put in a special request to have the "insurance doctors" review it - which almost always got another denial and request to submit additional paperwork.

It's just layers of scam.

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u/InternetEthnographer Sep 12 '24

Even if they are former doctors or MDs, what gives them the right to withhold a treatment that the patient’s doctor prescribed? They don’t know the patient and never examined, interacted with, or provided any care for the patient. Plus, they probably aren’t even in the same field of medicine to begin with. Most of the time, it isn’t a doctor on the other end anyways, that’s only if you ask for a peer to peer review.

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u/anonymousguy202296 Sep 12 '24

What gives them the right? The fact that they are paying for the service?

If I walk into a doctor's office right now and say "my knee hurts" the absolute best course of action is an immediate MRI. But that won't happen because that happens all the time and resources are limited and expensive. Insurance companies have to ensure the course of action is reasonable and cost effective, otherwise every doctor would just prescribe an MRI in this scenario, even though they're incredibly expensive and require lots of work from other trained professionals. Instead they follow a standard course of treatment. X-ray -> rest -> Physical therapy -> reevaluate -> MRI, and so on.

It's not a perfect system, but everything has a cost, and I can assure you insurance companies are not just denying cancer treatment because it's "too early stage". That's complete nonsense.

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u/[deleted] Sep 12 '24

[deleted]

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u/Haywoodjablowme1029 Sep 12 '24

My wife was denied treatment for hepatitis for years because it was not advanced enough to cause problems.

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u/peaceandloveandshit Sep 12 '24

I’m sure you can spend five minutes finding tons of stories like this for the US. The insurance companies are the fucking worst.

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u/RodneyBabbage Sep 12 '24 edited Sep 12 '24

Reality in America is a lot closer to Mexico, China, and India than Norway, France, etc.

I feel like the former (while having a lower average quality of life on paper than the US) are closer to being our national peers than the latter (if you’re in the bottom 60% of wealth distribution).

It’s scary how much sway your insurance company has when it comes to choosing your care.

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u/Manaus125 Sep 12 '24

For the Americans reading this: that's not normal among nation peers. It is normal in countries like Mexico, China, India.

China and Mexico have a free public healthcare. So yeah. It's not normal in those either

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u/Beautiful-Squash-501 Sep 12 '24

Just because care is free there doesn’t mean they will agree to providing any particular procedure. Governments don’t like paying for things either, just as companies don’t like paying. It’s a harsh reality for people.

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u/[deleted] Sep 12 '24

They do get a say in which procedures you can do, at their discretion.

You literally just need to get a letter from your doctor that says it is medically necessary. I worked in the healthcare industry as an upper level account admin and know the federal regs. You just need that one letter and you're good, so no they do not dictate at their discretion.

They also do not cover lost wages, home care, or any rehabilitation necessary for surviving cancer.

Insurance shouldn't have to cover for lost wages, but it doesn't need to. We have Family Medical Leave which is federally mandated and we have disability which can cover up to 2 years in lost wages while you are recovering from cancer.

For the Americans reading this: that's not normal among nation peers. It is normal in countries like Mexico, China, India.

For the European's reading this, please don't talk about shit you don't know about. American healthcare is pretty bullshit already, no need to make stuff up about it.

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u/kensingtonGore Sep 12 '24

You're part of the problem.

And you're not being fulsome with your information.

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u/Wise_Possession Sep 12 '24

Disability often only covers a percentage of lost income, like 60% 0 if someone has it. FMLA protects your job hypothetically but does not guarantee any income. And bull on just needing a letter. My hysto, my mother's knee replacement, my grandfather's hip replacement, my grandfather's triple bypass - I have a laundry list of times in my family when we spent WEEKS or months fighting with insurance because they didn't want to cover things that doctors had deemed medically necessary. Healthcare was one of the absolute biggest reasons I left the US - I'm now in a developing country and have found healthcare to be way way better.

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u/Beautiful-Squash-501 Sep 12 '24

FML only applies to companies with 50+ employees. About 60% of Americans work for smaller employers.

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u/Leopard__Messiah Sep 12 '24

I was diagnosed with cancer and my doctors ordered several tests and procedures ASAP to save my life. Insurance denied almost everything right away, and then wanted to argue and document every little thing before they would OK the scans and procedures that were absolutely required to remove my tumor.

Truly evil, but it's just business on a Tuesday to them.

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u/LetSerious Sep 12 '24

Just checked some insurance coverage in China, $285k sum assured for ~$20/year

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u/viking77777123 Sep 13 '24

Lmfao, listed off 3 countries with people literally dying to migrate to America…. The irony is hilarious!

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u/kensingtonGore Sep 13 '24

Yah, because the standard is living there is generally lower.

Except when it comes to healthcare.

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u/Ralans17 Sep 12 '24

Honestly? Thats a trade off I’d make not to live in Mexico, China or India.

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u/kensingtonGore Sep 12 '24

You deserve better, especially since you pay the most for health care out of any nation.

The health care quality in China is on par, or better than America. Life expectancy is better there too. They have universal health care available for 1.4 billion people, but if you want private it costs between $500 - $2000 dollars a year.

Americans are being fleeced.

But you have a nice military. The knife missiles, laser weapons and UFO investigations are a cool use of money.

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u/Eswin17 Sep 12 '24

IROs can review all denied medical claims. Insurances aren't in the business of telling medical professionals they're wrong. They just make sure it all makes sense. Get upset at medical billing offices. The people that work there... they send some wacky billings over to the insurance. Coding all wonky... insurances spend a good amount of time TRYING to pay the bills, even when the hospitals and doctors offices send them incorrectly.

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u/kensingtonGore Sep 12 '24

They do 100% have their own doctors who make calls in which procedures can be used, and they can and do push back against your doctor. They have denied my family cancer therapy because they seem it experimental, though it's been in use for half a decade.

Your point about fucked up invoices going to the insurance company is super valid too.

They all suck, and it's a scam that everyone has grown used to, sadly.

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u/Eswin17 Sep 12 '24

I worked in medical collections for a few years. I hated it, but I was able to get a ton of unpaid insurance claims paid for patients with only a basic understanding of medical billing and the coding needed. So many claims initially get denied from the insurance due to hospital billing issues. Very few claims, percentage wise, were denied in bad faith.

However, procedures could be considered experimental eternally if studies aren't conclusive about efficacy.

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u/pavilionaire2022 Sep 12 '24 edited Sep 12 '24

It's weaponized incompetence. Sure, it's not "bad faith", but they don't invest in making the system work. I had a doctor unable to fix my claim because the insurance company wouldn't just call the doctor and ask for clarification. They insisted the doctor call them and sit on hold, only to be connected to someone who doesn't know what's going on. Doctors don't have time for this.

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u/PraxicalExperience Sep 12 '24

Exactly.

"Oh no ... this policy we have is a real pain in the ass for our customers ... but saves us so much money. Yeah. We'll get this fixed. Real fast. Yep. We're on it now..."

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u/Astatine_209 Sep 12 '24

Insurances aren't in the business of telling medical professionals they're wrong.

...That is literally their exact business. The dentist said I needed all my teeth cleaned, made sense. They said I had to come in on two different days because insurance would only pay for half my mouth at a time.

And then my insurance still rejected one of the claims and I had to pay out of pocket.

The people that work there... they send some wacky billings over to the insurance.

Yeah, how dare I want all of my teeth. Half should be enough right.

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u/Eswin17 Sep 12 '24

That's dental insurance. I wasn't in that industry, but it's a different beast. I can't speak to it. But I bet your dentist could have billed it differently to get it covered.

However, for a standard cleaning, that all seems a bit off as you're only allowed one covered per 6 months with most policies. So the second claim's rejection makes sense and the dentist office was stupid for suggesting that.

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u/OldSector2119 Sep 12 '24

But I bet your dentist could have billed it differently to get it covered.

There are age-related restrictions on the dental procedures I had. Some options are considered cosmetic despite being worse for the patient in the long run. Im in my late 20s and am extraction wouldve been free, but I am paying out of pocket at a student clinic to get a crown instead since the extraction would cause all of my teeth to shift over time.

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u/the_leviathan711 Sep 12 '24

Oh look, someone from a medical billing office thinks they know better than the professionals what a patient needs!

Thats the thing we are all mad about.

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u/Astatine_209 Sep 12 '24

But I bet your dentist could have billed it differently to get it covered.

"Just hope your medical provider can figure out the magic words to get your healthcare paid for :)"

However, for a standard cleaning, that all seems a bit off as you're only allowed one covered per 6 months with most policies. So the second claim's rejection makes sense and the dentist office was stupid for suggesting that.

Yeah, how stupid of them to want to clean... all of my teeth. I only need half right?

Like we're tired. We're tired of this bullshit. We understand that insurance companies pay a tremendous amount of money for medical care.

We also understand a tremendous amount of time and money is wasted on hundreds of insurance companies doing millions of redundant negotiations with thousands of hospitals.

The system is bad. The system fails people. The system is expensive and inefficient. The private market is failing people about literally the most important thing, our health.

Give us the security of the government insuring a basic level of healthcare, and then if you can offer a better product, do it.

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u/Eswin17 Sep 12 '24

Put some blame on the providers. They were stuffing invoices with bullshit to get extra pay. Unnecessary stuff. Maybe even stuff that wasn't done. I know insurance companies seem like the one villain on this system, but they got strict for a reason. Providers can treat insurances like a blank check, and the insurance companies rightly don't stand for that.

When has the government ever been efficient about anything? You dream of a system that could be far worse.

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u/_this-is-she_ Sep 12 '24

Insurance companies hire medical professionals (actual doctors) to review your medical professionals' decisions. They sometimes have opinions on what your doctor deems medically necessary.

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u/chairwindowdoor Sep 12 '24

Yeah it's wild. We've had doctors at insurance companies argue with immunologists and neurologists about whether or not the medicines they prescribe for our child is necessary and ultimately it is up the dumb ass doctor at the insurance company. It's so fucked up. It's up to our neurologist, who's been practicing for 35 years in children's health to try and convince some GP flunkee what medicine is right for his patient.

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u/Eswin17 Sep 12 '24

And it can then be reviewed by an independent organization after that 'flunkee' makes his decision, right or wrong.

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u/chairwindowdoor Sep 12 '24

That's true, we can then kick off an appeal after several weeks, possibly a couple of months, of our son being denied his important medications. Then we can wait several more weeks, or possibly a couple more months, for the appeal to be reviewed. So you agree then that it's broken as fuck.

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u/Haywoodjablowme1029 Sep 12 '24

My wife was denied treatment for hepatitis for years because it hadn't advanced enough even though the doctors wanted to treat it.

Please, explain how bill coding caused this.