>The popular image of a denial is an insurer overruling a doctor on whether a treatment is needed. That is the exception. Only about 5% of denied in-network claims were turned down because the care was deemed not medically necessary. The rest were administrative, for an excluded service, for a missing referral or prior authorization, or for a reason the insurer never specified.
When an insurance company denies a health claim overruling a doctor, it can be necessarily concluded that either:
1. somehow the company knows more about the patient's condition and the doctor is wrong
2. the doctor is defrauding the system and the insurance company caught the doctor cheating
3. the company is defrauding its clients.
There is no middle ground honestly, and yet "5% of denied in-network claims were turned down because the care was deemed not medically necessary".
This is absolutely crazy and evil. I would expect a few thousand cases annually and probably for million of cases you get denied what you pay for because "we detected your doctor is wrong and we're not paying".
>In fact the single largest category, 36% of denials, was an unexplained "other." A system that rejects tens of millions of claims a year and files more than 1/3 of those rejections under no stated reason is hard for an outsider, or a member, to audit.
I can't even imagine getting lifesaving care denied because of "other". I didn't know things were so grim in the USA and honestly now I'm kinda surprised that more people are not getting "Luigi'd".
> 5% of denied in-network claims were turned down because the care was deemed not medically necessary".
I think the truth is murkier than what you're providing. With the caveat that I am presenting a strong case here that likely isn't what occurs most of the time, consider this:
A person may require long-term therapy after an illness. There are data suggesting that beginning this therapy works better once you attain a certain level of clinical recovery in the hospital. There are also data suggesting that it's better to begin the long-term therapy as early as possible.
Both sets of data are, on their face, credible. There is no obvious reason to always believe one set of data over another. Reasonable people can make reasonable arguments to reasonable listeners for either case. Note that this does not mean that there is not a 'correct' interpretation for any given person's clinical situation!
So what does your insurance company favor? Obviously it will always favor the less expensive option, and there will be no way for them to be convinced otherwise because the underlying question is just not well-determined.
There is absolutely a middle ground? The healthcare system, like any system, has an incentive structure. Doctors are incentivized to prescribe treatments, because that's how they make money for themselves and their practice. Doctors are not angels sent from heaven, they're people like you and me, and they respond to incentives like you and me. It's also well known that people strongly prefer receiving treatment over not receiving treatment, even when the cost to their health of receiving that treatment outweighs the expected benefit! Given that people push their doctors into prescribing treatments, and doctors are incentivized to go along with it... you would obviously expect some proportion of prescribed treatments to not be medically necessary. 5% sounds about right. And the kicker is that denying these treatments improves health outcomes for the general population, because those medical resources can get routed to the people who actually need them. Every successful public health system has an opposing force built in to it to limit the spurious consumption of scare medical resources, because without such a force costs balloon and the system becomes unsustainable. Not to defend the US healthcare system of course, our cost problem is worse than anywhere else...
You ever been to an obstinate DMV? Dealt with an obstinate permitting office? They all act like this. They unilaterally concoct rules that make it hard for honest people doing honest things to get the outcomes they ought to.
Healthcare ain't no different. Bureaucracy gonna bureaucracy.
Before everyone wants to throw a rock at another CEO...
> Only about 5% of denied in-network claims were turned down because the care was deemed not medically necessary. The rest were administrative, for an excluded service, for a missing referral or prior authorization, or for a reason the insurer never specified.
I worked in health tech for a while, and I can tell you the muck around a lot with ICD/CPT codes to maximize billing along with other shenanigans. There was actually a project at an innovation center at a well-known medical center which leveraged ML to maximize the amount of codes they could bill for without being rejected. The same kind of thing is often done by physicians who want to juice insurance.
Be mad--very mad--at hospitals and drug cos. As providers, they present themselves as patient advocates, but they're responsible for the outrageous healthcare costs. The dollar amount paid out by US insurance companies is maybe 2x that of other OECD countries, but the healthcare we get back from providers is trash (and extortive) by comparison.
I like the US healthcare system as much as anyone, but this analysis seems to border on useless. Even examining by the type of claim does not control for validity of those claims.
s/like/dislike would have made it easier to understand at the expense of missing out on the (possibly accidental) sarcasm which makes the comment more rewarding to those who got it
People like to complain about things and have very unrealistic perceptions of what other systems are like. It's also really unpopular online to say good things about the US healthcare system. It definitely has some issues, but it also does some things really, really well.
These are, of course, anecdotes, but here some things from my life:
- Next day MRI for my wife after she injured her back at the gym. Had it been more serious she would have been seen the same day.
- Friend's kid was diagnosed with leukemia. They were admitted to the cancer ward the next day, where they stayed for months. The room was large, with a pull out double bed for my friend and his wife to sleep on. The same thing happened with my cousin when she was diagnosed with a brain tumor.
- Our kids were both born at one of the "poor" hospitals in the largest city in our state. We were the only ones on the floor who shared the same last name, and most patients did not speak English. It was excellent. We had our own room (with bathroom, shower, small bed for me to sleep on), great staff, etc.
- Urgent care available 7 days a week at numerous locations within a 5-10 minute drive from my home. Typically a 15-20 minute wait for things like stitches, burns, dislocated fingers, etc.
- Nice pharmacies all over the place, which also provide things like vaccinations. Lots of our medications are now just shipped to our house directly
- The small surgeries I've needed have been done within 2-3 weeks of meeting with my primary care doctor. If they would have been more serious, the timeline would have been significantly shorter, within a day or two. Things like colonoscopies are also available within a number of weeks.
- The hospital system we use has done a really good job embracing technology. The app/website they offer can be used to view all of your test results, message the doctors or nurses, schedule appointments, etc
If patients and doctors start using LLMs to strategize how to maximize claim approval rate, I wonder how would the insurance companies react to it. Would it start getting more strict and start requesting for more evidence?
When I went to an in-network ENT (that I found on my insurer's website) they were billed $850 for my 10-minute exam. The insurance said they'd pay $550. So I got to pay the rest. And this is gold coverage with an already-met deductible. You just never know what the roulette wheel is going to hand out.
Makes me think of that study a few years ago that found most Americans couldn't afford an unexpected $400 medical bill.
Good thing the moral hazard of getting unnecessary healthcare that your doctor ordered for you is controlled for.
Perhaps someone should also control the moral hazard of the people owning and running this racket getting unnecessary amounts of money, or an unnecessary seat at the table.
The moral hazard is making a product with nearly totally inelastic demand a multi layered adversarial free market with structural price opacity. Thanks Reagan!
Reagan hasn't been president for close to 40 years and died more than 20 years ago. At what point do we accept responsibility for this instead of blaming dead presidents?
You might be surprised just how durable the effects of 40-year-old decisions are. You can actually see changes to the very degree completion-rates, when partitioned by field of study. Particularly, education and physics fields (as classified by NCES), have absolutely cratered from the mid 70s to the mid 80s, while business fields became dominant. And if you need data, I actually published an entire (and entirely too long) essay, analyzing the NCES data from 1970 to 2011 (a sequel post for 2011 to present is planned), yesterday[0][1]. Healthcare tends to boom and bust[2] in cycles, and those cycles are _inversely_ correlated with engineering, informatics (the most elegant term for what we call "computer and information sciences"), and business.
[2]: In both the economic sense, and in the completion-rate sense, because those two things are correlated. And they have been correlated since the 1980s, because a lot of the healthcare industry became de-regulated and more profitable as a result, since at least 1978 (when hospitals were de-forbidden from making profits).
Everyone is in on the grift in the industry. Obama wanted to go single payer but realized 10% of america would be out of a job if we streamlined the bureaucracy
Obama proposed and pushed for single payer and it was voted down in the senate. Specifically, if you want to blame someone, it was Joe Lieberman who would have been the deciding vote, and he killed it.
Joe Lieberman realized that he was from a state with massive moneymaking insurance operations. Had nothing to do with Obama streamlining bureaucracy.
What we have today isn't insurance in any meaningful sense. Traditional insurance is about pricing risk: healthier people pay less, higher-risk people pay more, and the pool works because premiums reflect actuarial reality.
The Affordable Care Act largely banned that. Insurers can no longer use health status or pre-existing conditions to set rates (via "community rating" and guaranteed issue rules). The result is that everyone effectively pays into a giant, heavily regulated pool. There's a finite amount of money in that pool, so someone has to ration care. That job now falls to the insurance companies, who deny or delay procedures, medications, and treatments.
Health insurers aren't saints — but the core problem is structural. When you remove risk pricing while mandating coverage, adverse selection and cost shifting are inevitable. The ACA patched one serious issue (pre-existing conditions) by breaking the fundamental mechanism that makes insurance sustainable.
We need to be honest about the tradeoffs instead of pretending this is still "insurance."
>The popular image of a denial is an insurer overruling a doctor on whether a treatment is needed. That is the exception. Only about 5% of denied in-network claims were turned down because the care was deemed not medically necessary. The rest were administrative, for an excluded service, for a missing referral or prior authorization, or for a reason the insurer never specified.
When an insurance company denies a health claim overruling a doctor, it can be necessarily concluded that either:
1. somehow the company knows more about the patient's condition and the doctor is wrong
2. the doctor is defrauding the system and the insurance company caught the doctor cheating
3. the company is defrauding its clients.
There is no middle ground honestly, and yet "5% of denied in-network claims were turned down because the care was deemed not medically necessary".
This is absolutely crazy and evil. I would expect a few thousand cases annually and probably for million of cases you get denied what you pay for because "we detected your doctor is wrong and we're not paying".
>In fact the single largest category, 36% of denials, was an unexplained "other." A system that rejects tens of millions of claims a year and files more than 1/3 of those rejections under no stated reason is hard for an outsider, or a member, to audit.
I can't even imagine getting lifesaving care denied because of "other". I didn't know things were so grim in the USA and honestly now I'm kinda surprised that more people are not getting "Luigi'd".
It should be noted that they use the term “medically necessary” which is a very low standard.
There is also “medically reasonable”.
For example getting your teeth cleaned professionally is not medically necessary. But it’s medically reasonable.
I don’t want a health insurance that only does “Medically necessary” things.
4. It's something that might help a bit, but the patient would still be fine without. Ie, a disagreement over what "necessary" means.
> 5% of denied in-network claims were turned down because the care was deemed not medically necessary".
I think the truth is murkier than what you're providing. With the caveat that I am presenting a strong case here that likely isn't what occurs most of the time, consider this:
A person may require long-term therapy after an illness. There are data suggesting that beginning this therapy works better once you attain a certain level of clinical recovery in the hospital. There are also data suggesting that it's better to begin the long-term therapy as early as possible.
Both sets of data are, on their face, credible. There is no obvious reason to always believe one set of data over another. Reasonable people can make reasonable arguments to reasonable listeners for either case. Note that this does not mean that there is not a 'correct' interpretation for any given person's clinical situation!
So what does your insurance company favor? Obviously it will always favor the less expensive option, and there will be no way for them to be convinced otherwise because the underlying question is just not well-determined.
There is absolutely a middle ground? The healthcare system, like any system, has an incentive structure. Doctors are incentivized to prescribe treatments, because that's how they make money for themselves and their practice. Doctors are not angels sent from heaven, they're people like you and me, and they respond to incentives like you and me. It's also well known that people strongly prefer receiving treatment over not receiving treatment, even when the cost to their health of receiving that treatment outweighs the expected benefit! Given that people push their doctors into prescribing treatments, and doctors are incentivized to go along with it... you would obviously expect some proportion of prescribed treatments to not be medically necessary. 5% sounds about right. And the kicker is that denying these treatments improves health outcomes for the general population, because those medical resources can get routed to the people who actually need them. Every successful public health system has an opposing force built in to it to limit the spurious consumption of scare medical resources, because without such a force costs balloon and the system becomes unsustainable. Not to defend the US healthcare system of course, our cost problem is worse than anywhere else...
You ever been to an obstinate DMV? Dealt with an obstinate permitting office? They all act like this. They unilaterally concoct rules that make it hard for honest people doing honest things to get the outcomes they ought to.
Healthcare ain't no different. Bureaucracy gonna bureaucracy.
Before everyone wants to throw a rock at another CEO...
> Only about 5% of denied in-network claims were turned down because the care was deemed not medically necessary. The rest were administrative, for an excluded service, for a missing referral or prior authorization, or for a reason the insurer never specified.
I worked in health tech for a while, and I can tell you the muck around a lot with ICD/CPT codes to maximize billing along with other shenanigans. There was actually a project at an innovation center at a well-known medical center which leveraged ML to maximize the amount of codes they could bill for without being rejected. The same kind of thing is often done by physicians who want to juice insurance.
Be mad--very mad--at hospitals and drug cos. As providers, they present themselves as patient advocates, but they're responsible for the outrageous healthcare costs. The dollar amount paid out by US insurance companies is maybe 2x that of other OECD countries, but the healthcare we get back from providers is trash (and extortive) by comparison.
I like the US healthcare system as much as anyone, but this analysis seems to border on useless. Even examining by the type of claim does not control for validity of those claims.
> I like the US healthcare system as much as anyone
I can't tell if you're being serious. I'm not American but all of my American friends tell me the US healthcare system is an absolute nightmare
That phrasing may not translate well. "as much as anyone" means "Most people don't like it, and I don't like it either.".
My criticism of the analysis is not a defense of US healthcare.
s/like/dislike would have made it easier to understand at the expense of missing out on the (possibly accidental) sarcasm which makes the comment more rewarding to those who got it
People like to complain about things and have very unrealistic perceptions of what other systems are like. It's also really unpopular online to say good things about the US healthcare system. It definitely has some issues, but it also does some things really, really well.
These are, of course, anecdotes, but here some things from my life:
- Next day MRI for my wife after she injured her back at the gym. Had it been more serious she would have been seen the same day.
- Friend's kid was diagnosed with leukemia. They were admitted to the cancer ward the next day, where they stayed for months. The room was large, with a pull out double bed for my friend and his wife to sleep on. The same thing happened with my cousin when she was diagnosed with a brain tumor.
- Our kids were both born at one of the "poor" hospitals in the largest city in our state. We were the only ones on the floor who shared the same last name, and most patients did not speak English. It was excellent. We had our own room (with bathroom, shower, small bed for me to sleep on), great staff, etc.
- Urgent care available 7 days a week at numerous locations within a 5-10 minute drive from my home. Typically a 15-20 minute wait for things like stitches, burns, dislocated fingers, etc.
- Nice pharmacies all over the place, which also provide things like vaccinations. Lots of our medications are now just shipped to our house directly
- The small surgeries I've needed have been done within 2-3 weeks of meeting with my primary care doctor. If they would have been more serious, the timeline would have been significantly shorter, within a day or two. Things like colonoscopies are also available within a number of weeks.
- The hospital system we use has done a really good job embracing technology. The app/website they offer can be used to view all of your test results, message the doctors or nurses, schedule appointments, etc
'as much as anyone' = they don't like it
It’s definitely a sarcastic comment lol.
If patients and doctors start using LLMs to strategize how to maximize claim approval rate, I wonder how would the insurance companies react to it. Would it start getting more strict and start requesting for more evidence?
Hospitals and some doctors already do - it isn’t a one-sided problem with insurance as the only group optimizing for their desired outcome.
When I went to an in-network ENT (that I found on my insurer's website) they were billed $850 for my 10-minute exam. The insurance said they'd pay $550. So I got to pay the rest. And this is gold coverage with an already-met deductible. You just never know what the roulette wheel is going to hand out.
Makes me think of that study a few years ago that found most Americans couldn't afford an unexpected $400 medical bill.
Did you try looking for a less-expensive ENT?
Good thing the moral hazard of getting unnecessary healthcare that your doctor ordered for you is controlled for.
Perhaps someone should also control the moral hazard of the people owning and running this racket getting unnecessary amounts of money, or an unnecessary seat at the table.
The moral hazard is making a product with nearly totally inelastic demand a multi layered adversarial free market with structural price opacity. Thanks Reagan!
Reagan hasn't been president for close to 40 years and died more than 20 years ago. At what point do we accept responsibility for this instead of blaming dead presidents?
You might be surprised just how durable the effects of 40-year-old decisions are. You can actually see changes to the very degree completion-rates, when partitioned by field of study. Particularly, education and physics fields (as classified by NCES), have absolutely cratered from the mid 70s to the mid 80s, while business fields became dominant. And if you need data, I actually published an entire (and entirely too long) essay, analyzing the NCES data from 1970 to 2011 (a sequel post for 2011 to present is planned), yesterday[0][1]. Healthcare tends to boom and bust[2] in cycles, and those cycles are _inversely_ correlated with engineering, informatics (the most elegant term for what we call "computer and information sciences"), and business.
[0]: https://galacticbeyond.com/two-percent-programmer/
[1]: https://web.archive.org/web/20260620162923/https://galacticb...
[2]: In both the economic sense, and in the completion-rate sense, because those two things are correlated. And they have been correlated since the 1980s, because a lot of the healthcare industry became de-regulated and more profitable as a result, since at least 1978 (when hospitals were de-forbidden from making profits).
Had me in the first half there
Everyone is in on the grift in the industry. Obama wanted to go single payer but realized 10% of america would be out of a job if we streamlined the bureaucracy
Obama proposed and pushed for single payer and it was voted down in the senate. Specifically, if you want to blame someone, it was Joe Lieberman who would have been the deciding vote, and he killed it.
Joe Lieberman realized that he was from a state with massive moneymaking insurance operations. Had nothing to do with Obama streamlining bureaucracy.
Nah, the problem was that the blue dog democrat congresscritters (holding usually red districts) would have been out of a job.
So instead of single payer, everyone got the ACA, and then the blue dog dems lost their jobs anyways.
What we have today isn't insurance in any meaningful sense. Traditional insurance is about pricing risk: healthier people pay less, higher-risk people pay more, and the pool works because premiums reflect actuarial reality.
The Affordable Care Act largely banned that. Insurers can no longer use health status or pre-existing conditions to set rates (via "community rating" and guaranteed issue rules). The result is that everyone effectively pays into a giant, heavily regulated pool. There's a finite amount of money in that pool, so someone has to ration care. That job now falls to the insurance companies, who deny or delay procedures, medications, and treatments.
Health insurers aren't saints — but the core problem is structural. When you remove risk pricing while mandating coverage, adverse selection and cost shifting are inevitable. The ACA patched one serious issue (pre-existing conditions) by breaking the fundamental mechanism that makes insurance sustainable.
We need to be honest about the tradeoffs instead of pretending this is still "insurance."