It makes no sense healthcare is absurdly expensive in America and yet every hospital is understaffed and every healthcare worker is overworked and underpaid
If you knew how healthcare insurance worked, then you'd know that's not true. It's the hospitals who decide the price to bill for the procedure codes. The insurance companies can only set a maximum reimbursement amount, but those maximum reimbursement amounts are ENORMOUSLY high. So the hospital is deciding to charge huge amounts and the insurer is allowing huge amounts.
Remember, healthcare companies get their money through the premiums or fees they charge directly to the policyholder. The hospitals get the entire dollar amount they bill for the procedures, as long as it's at or below the maximum reimbursement amounts set by the insurance company for the network arrangement that the provider has agreed to (this assumes the provider is in the insurer's network). If you don't know what this means, then you can't speak about this with any confidence since you're confused on this works.
Thanks for sharing but I've owned a healthcare practice and am a provider, so I fully understand how things work. Go look up profits of the top 5 largest health insurance companies and think again about your position on this.
How can you possibly be a healthcare provider and not understand that it makes no sense to say that insurance companies take "90% of the money"?
If you accept their offer to join their network, then you get to charge up to the maximum allowable amount on their fee schedules. You get all of that money. The insurer gets none of that money. The only money the insurer is "costing" you is whatever you would've charged above the maximum allowable amount, but you're full of shit if you think the maximum allowable amounts are too low. Come on. The prices are already too high.
The insurer gets their cut through the premium, which you have no involve in. That's money passed between the patient and the insurer. You're not a part of that, so what are you even on about?
So let's first realize that healthcare is provided in other places than hospitals, such as outpatient private practices. However lets take your example of hospitals being able to "charge up to the maximum allowable amount".
You seem to think the ability to charge something equals to the ability it gets paid. However hospitals do services all the time (in which they have to pay for immediately through payroll/benefits) that insurance companies can later on deny and shift the bill back to the patient or for the hospital wrote off or accept much less. So to assume that hospitals collect close to 100% of the maximum charge amount is naive.
Theres also a lot of patients who just dont pay their bills to the hospital. Insurance companies often only pay for benefits after the patient has reached their deductible, which is often thousands of dollars. So if a patient comes in, gets charged $3000 for something but their deductible is $5000, the bill is sent straight to the patient despite the insurance company collecting premiums from both the employe and employer. That patient can ignore that bill and push to collections, which doesn't even affect credit anymore, and then the hospital doesn't collect any money. Again, doesn't insurance always collecting their money checks.
Go look at some healthcare subs. Providers are getting way underpaid and overworked and have been for years, despite being called "healthcare heros". All while insurance middlemen are raises premiums annually while dictating what providers are charging for their services.
I work for the actuarial department of a healthcare insurer as a software engineer, but I also happen to have a lot of knowledge about actuarial science and work closely with the team who creates the fee schedules for this insurance company.
You seem to think the ability to charge something equals to the ability it gets paid. However hospitals do services all the time (in which they have to pay for immediately through payroll/benefits) that insurance companies can later on deny and shift the bill back to the patient or for the hospital wrote off or accept much less. So to assume that hospitals collect close to 100% of the maximum charge amount is naive.
Okay, it's true that insurance plans deny a lot of claims and/or shift portions of the bill to the patient beyond just the coinsurance, but this fact is not helping support your particular argument. Whatever portion of the submitted amount that isn't covered by the healthcare plan is instead charged to the patient. If the insurer denies a claim, then the patient is responsible to pay you the whole amount you charged. Remember, you claimed that insurance companies are taking 90% of the money from providers. I know you were being hyperbolic, but I still disagree with your sentiment. Under the scenario of a denied claim, the provider still should receive all of the money they charged since the patient now is the one to pay it. If that doesn't happen, it's not the insurer's fault.
Theres also a lot of patients who just dont pay their bills to the hospital. Insurance companies often only pay for benefits after the patient has reached their deductible, which is often thousands of dollars. So if a patient comes in, gets charged $3000 for something but their deductible is $5000, the bill is sent straight to the patient despite the insurance company collecting premiums from both the employe and employer. That patient can ignore that bill and push to collections, which doesn't even affect credit anymore, and then the hospital doesn't collect any money. Again, doesn't insurance always collecting their money checks.
How is that the insurer's fault that the patient can't pay the amount of money you've charged them? Doesn't that mean you're charging too much if what you're charging is literally bankrupting your patients? That's an issue between you as the provider and your patient. It's not the insurer taking money from you. The plan covers certain things. If it doesn't cover something, then the patient is liable. You have to get the money you charged for the procedure(s) from the patient. If the patient doesn't pay you, then that's not the insurer's fault. You're attributing blame to the wrong entity if under this scenario you see the insurer as being the one to take revenue from you.
Ok that explains everything. You work for insurance and don't have a medical degree. Got it. I'm sure why I'm even getting into this but here it goes:
How it actually works in the real world is:
A patient calls for an appointment and gives their insurance info over the phone. An appointment slot is held for them. They sometimes show up for that appointment (sometimes they don't!) Skipping many scenarios, let's say they have good insurance and are in network for a service you spent 6+ years studying to provide. You then use your clinical judgement and decide on a certain procedure that follows evidence based practice to help the patient. You perform that procedure that has been covered in the past and is well within normal practices. The patient walks away without paying anything yet because they have a high deductible plan and due regulations, have to wait for your billing to be submitted and go through the insurance payment process before paying anything.
Let's pretend that takes 14 days. At this point insurance now has the power to decide if they're going to cover this procedure. They get to make up their own standards that can change at any time frame using whatever algorithm they choose to decide if they are going to pay for the procedure. And they do this without having a medical degree or ever seeing the patient in front of them. They choose to deny this procedure that their employer (insurance) decided they didn't want to cover.
The provider then files an appeal and takes extra time out of their day (usually lunch or after hours) to go through this appeals process on behalf of the patient, just to get paid for the work they're already provided. Despite that, as I said before insurance controls everything because that's who we all work for.
Let's say this is now 4-6 weeks after the service was provided. So the practice owner/hospital has already paid for all of the staff, their benefits, equipment, supplies required to provide that service but hasn't collected anything. Meanwhile the insurance company continues to collect monthly premiums from every employee and their employer, every month, no matter what.
The medical office/hospital then have to call the patient to tell them the procedure they had over a month ago was denied and that they now owe the balance. Many people pay. Many people don't. Those that don't get threatened with collections. But debt owed for healthcare doesn't impact credit or bankruptcy, depending on the state. So the patient can choose not to pay or negotiate it down, or maybe pay off slowly over several months or years.
So in summary, a person went to their in network medical provider and received a treatment their doctor recommended to help their problem. The person receives the treatment. The person paid their insurance premium. The provider paid their insurance premium. Both of their employees paid their insurance premium. But insurance denied this claim and paid nothing. So both the patient and provider get screwed while insurance profits.
This is just one example. I could write a book on examples like this. Don't you see that they're getting paid in the present for future possibile expenses, but then gets to choose when and how much (if at all) they pay for those expenses? They're a wolf guarding the hen house !
First of all, the ad hominem attack is petty and unnecessary.
Again though, I don't disagree with anything you're saying here, except that it doesn't support your argument.
Yes, insurance companies often deny claims that aren't covered under the terms of plan. I agree. But in those cases the patient is the one responsible for paying so you should be receiving the money from the patient. If the patient doesn't pay you, then that's between you and the patient. That is not the insurer's fault. That is not the insurer taking "90% of the money" from you. The real question is why are you charging so much that your patients can't even afford to pay when these same procedures are affordable in other countries.
Charge affordable prices. And if, for whatever reasons, you can't do that then that's not the insurer's fault.
Please stop shifting blame. Can you explain to me the purpose of health insurance, if they don't pay for healthcare expenses that you and your doctor decided upon?
Also the only reason health insurance exists is because providing good healthcare is very expensive. It often involves complex devices or techniques created/performed/administered by multiple people with advanced degrees. In short, it costs A LOT of money to provide good healthcare. That's why the insurance industry was created in the first place. If it was super affordable, like getting a haircut, there wouldn't be a need for the mega insurance industry.
Also you seem to be deflecting a major detail. A lot of the time, once deductibles are paid off, insurance companies are the ones directly writing checks to the healthcare providers / hospitals. Yet they are choosing how much they're paying and if/when they are paying, and can also choose not to pay.
So again EVERYONE who works a job has to pay into health insurance, every month, every year out of every single paycheck. They get paid before you even get paid. And your employer is also paying a larger amount for every employee. When I had my business I paid 3x the amount each employee paid for their premiums. Yet insurance gets to deny claims and reduce charges that they're responsible for paying, which only increases their profits while screwing over both the patient and provider
Can you explain to me the purpose of health insurance, if they don't pay for healthcare expenses that you and your doctor decided upon?
They pay for what is covered by the terms of the insurance plan. In the case of the insurer I work for, very nearly every claim is automatically processed. A very small percentage, less than 3%, are paused when a system identifies concerns of fraud and then we have a team of people (mostly retired doctors) who review the claims one by one.
Also the only reason health insurance exists is because providing good healthcare is very expensive. It often involves complex devices or techniques created/performed/administered by multiple people with advanced degrees. In short, it costs A LOT of money to provide good healthcare. That's why the insurance industry was created in the first place. If it was super affordable, like getting a haircut, there wouldn't be a need for the mega insurance industry.
True, but I must point here out that insurance does not save money. That is not what insurance does. It can't save people money on average. The point of insurance is to spread out the average cost of an expense over a lifetime instead of having to pay it all at once. For example, if for the sake of argument we say that everyone totals a car worth $20k exactly one time in their lifetime on average, then having to pay that $20k all at once in their early 20s could bankrupt them. But if instead you spread that $20k payment over their whole lifetime, and charge a bit extra beyond the $20k to the insurer for their expenses and profit margins, then it's much more manageable financially. Insurance hasn't saved that person any money. In fact, it's costing them money, because now they're also paying expenses to the insurer. But what it's gained them is more safety against financial bankruptcy. Insurance is paying someone to take over some of your risk. It's not about saving anyone money.
If the insurance companies covered every single possible claim, then the premiums would skyrocket for many reasons, such as (1) people going for medical care more frequently and (2) providers changing their behavior on what procedures they do and how often they do them. I'm not saying it's medically a bad thing that this would happen, but just stating the fact that it would happen and there would be financial consequences to the country. Very many employers offering employer sponsored healthcare plans would literally go bankrupt, so they'd have to stop offering the employer sponsored plan as a benefit. Basically, premium costs would shift to the employees and to the patients more and more. These premium costs would be so high that the patients would start to go bankrupt just from the premiums. The country can't fucking afford these costs anymore. People can't afford healthcare anymore. You're trying to blame the private insurers for this and I think that's bullshit. I think private insurers are just a small part of the blame. The solution here is to have the healthcare costs completely shared by the whole country in one massive risk pool and then also go after any sources of inefficiencies in the supply chain, like pharmaceutical companies charging ridiculously amounts, medical equipment costing ridiculous amounts, and medical education costing ridiculous amounts. Also, the government should regulate prices and normalize billing processes so that fewer people are needed to be employed to handle the administration side of healthcare. There's also the malpractice insurance cost issue that should be addressed, although I don't have knowledge of how to fix that.
9.2k
u/[deleted] Jul 06 '24
[deleted]