this post was submitted on 11 Dec 2024
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Insurance claims are approved or denied by medical professionals. In the state of NY it's even required for a specialist to approve or deny specialist care.
Some doctors are just absolute scum.
My insurance's tactic to this sort of demand is to just completely ignore my requests/demands. They log an acknowledgement of my action, and then never do anything with it, ever.
That's when you hope your state has a bureau of insurance or something similar that you can complain and appeal to, and then hope that the person assigned to your case isn't prejudiced against the procedures in question, such as reproductive care or trans-related care, or isn't prejudiced against you for being pretty much any minority.
What a mindfield to navigate when we're at our most vulnerable.
Like, my life is already busy as fuck, without enough time to do everything I need to do. I have an ever present list of things that require my attention next. Ain't nobody got time for this shit!
They are done by medical professionals who have no obligation or incentive to serve the best interests of the patient. If your doctor fucks up, he can be found liable. If the insurance doctor fucks up, there is no liability whatsoever. Cases have been brought to court and then immediately thrown out because there is no legal basis for holding them accountable.
Medical professionals that spend an average of 6 seconds per case. And keep getting caught with revoked/expired licenses. And well outside their area of expertise (the classic example is failed dentists deciding on cancer treatments).
Except in this case, they used AI to help them make decisions. The lawsuit is still ongoing so I shouldn't speak in definitive terms, but considering the circumstances and evidence I think it's pretty clear than they have tried to automate some processes and didn't audit them properly.
Did it not work as intended, though?
I mean I'm pretty sure it wasn't meant to be a method of committing suicide
There is a lot of crap that they’re able to instantly deny through your plan’s terms and conditions.
It’s worth reading the plan summary of what won’t be covered, even if it’s prescribed treatment. Some of the shit that’s hidden in there is fucked up.
This year someone in my family started to have to pay out of pocket for their GLP1s because their diseases didn’t progress far enough for the treatment to be covered. They’d rather you hurry up and die than pay for expensive drugs that keep you alive for longer.
If they have cardiovascular disease or kidney disease, those are getting added as indications for the GLP-1's so they might be able to resubmit the authorization/claim with those diagnosis codes added to get it covered.
Yeah, but the problem is, if tests / labs show the precursor indicators for those diseases, and you have a family history, they’ll still deny until you actually have the something like a heart attack or stroke.
GLP-1s are the hot new thing, but it’s pretty common for insurance companies to deny expensive preventative care, even after all other avenues have been thoroughly explored.
In my family medicine rotation a couple months ago, we got it approved for someone with pre-diabetes, high blood pressure, and stage 2/3 kidney disease (which is not very advanced. A lot of people over the age of 35-40 can technically fall into stage 1/2.)
We just changed insurance and were able to get through with one provider that valued preventative care more, but our new insurance company is a complete pain in the ass. And the person in my family dealing with the insurance company actually works for the company and knows all the ins and outs.
They even give their own employees crap policies.
This is entirely unsurprising. Hopefully they can wrangle something functional out of the insurance at some point.
I don't have a source. But i've read they are incentivized to go through as many claims as they can, and not to approve too many.
Even if this were the case (it is not in any real sense, see your other replies), the fact that it is done by a for profit entity that will lose money by approving a claim all but ensures the process will not be neutral or correct.