I cannot believe market pressures cannot make the process more efficient. Therefore there must be laws in the way leading to needless bloat.
...assuming it is needless bloat.
Beerina, I typically really enjoy your posts. Sometimes I agree with you, a lot of times I don't, but even when I don't, I tend think you make good arguments, and I can understand your point of view even if I don't necessarily agree with it.
However, I always cringe when you chime in on health care issues because you really have no idea what you're talking about.
This is not an issue about laws. Yes there are some laws like HIPPA (which involves privacy laws to protect patient information), but the amount of paperwork that the patients and health care providers deal with from insurance is issued by NO ONE but the insurance company itself. And literally every WEEK we get some insurance or another which is instilling some new completely unnecessary process that we have to deal with, and we are continuously hiring more people just to deal with it. Oh, but do they start paying us more even though the only reason we had to hire someone is because of the new ridiculous amount of paperwork the gave to us? Absolutely not. SO then the price of care for the patient goes up to pay that new person's salary.
It is in the insurances FISCAL INTEREST to make things as complicated as possible. That is because the more things that get missed or filed incorrectly, the more claims they get to deny. The more claims they deny, the more money they keep in their pocket. The whole "competition" thing doesn't work for a couple reasons.
I'm a financial counselor at one of the top hospitals in the country, and my working experience is entirely in finance at top hospitals. Every single insurance company, large and small, I have EVER worked with, has enormously unnecessarily bloated and complicated procedures. Some do it worse than others. Some do it in different areas than others. So for instance, one insurance company might give you no trouble ever when it comes to infusion and injectable drugs, but their high tech scanning coverage is a nightmare, whereas with another company, it's vice versa. also, they are so inconsistant. You'll have an identical insurance policy, with two patients with the same diagnosis getting the same treatment. One person they'll approve, the other they'll deny, or require enormous amounts of paperwork to get him authorized. The ONLY insurance companies I have ever encountered where things go without a hitch aren't insurances you can choose to buy. So for instance, insurance for professional sports players, or an insurance plan that only serves a certain kind of worker (like a postal worker) in a certain region. So there's no real competition when they ALL do it to some degree or another. This is exactly the reason we aren't allowed to recommend an insurance carrier to our patients. You may have one guy who is chronically ill and has a BCBS of Mass HMO policy for twenty years and never has a problem, and yet another guy with the exact same insurance and condition but has nothing BUT problems.
The other thing is that most people get their insurance through their work, they don't get to just chose it themselves because privately bought insurance plans simply aren't affordable for most people. And your employer, more often than not, isn't looking for the plan with the best services, but the most affordable. So again, the whole "competition" thing doesn't really work the way it does when you have an individual trying to decide which car to buy.
Now I don't have any problem with insurance companies requiring authorizations for services. Insurance fraud is a huge problem, and it's simply fiscally responsible for an insurance to want to make darned sure you need that MRI that you're going to bill them for thousands of dollars on.
But its the WAY in which they do it. They make the process SO complicated, and requiring so much paperwork and so much information that really is simply not necessary. And they have so many loopholes written into their contracts to get out of paying claims, you wouldn't believe it. I used to work in denied claims, and it's just unbelievable. So for instance, you'll get your authorization for your patient, but oh, you didn't mail this notarized form that you have to sign in triplicate to this place in order to finalize it, even though no one at the insurance company ever told you you needed to do that in the first place. Another example: you have a patient coming in for chemotherapy infusions and consultations. So you get your authorization for the consultation, and for each individual chemotherapy drug. So you submit the claim, and it denies, *because you didn't get an individual authorization for the needle used to administer the chemotherapy* and then they deny the WHOLE claim. I've seen claims for tens of thousands of dollars get denied because we didn't have an authorization for needle and tubing that costs $80. And again, no one ever told you oh, you need to get an authorization for the needle, even though it is implicit in getting chemotherapy authorization that you'd need a needle to actually disperse it. And sometimes claims would just deny for no reason. We'd have an authorization on file. I'd have a letter that says I have an authorization on file for all the services that we need. It gets denied. I appeal it, it gets denied again, saying "no authorization on file" even though I mailed them in a copy of the authorization. My second level appeal gets denied. At that point, you need to take it to court to fight it, and most patients and health care providers don't have the time or the money to do so, so the health care provider just writes it off. You simply cannot conceive of the amount of money our hospital writes off every year from denied insurance claims.
And they also put restrictions on how long you have to appeal. Because there are SO many patients with SO many appeals that need to get done, and the appeals process is often so involved, that it's simply not humanly possible to appeal all the claims you need to in the time period you're given to do so. Then, oh look, its 60 days. It doesn't matter that they denied it for no reason and we can prove it, because we didn't get our appeal in within 60 days, so now you can't get that denial overturned no matter what.
Bigred, I'm not saying there aren't incompetant health care staffers. But it's not as easy as it looks. You have no idea how much behind the scenes work needs to be done to keep up with the ridiculous, enormous amount of paperwork and red tape we have to deal with from the insurance companies. And then there is our own legal requirements. Yes, we have to send out huge numbers of forms with a lot of verbose language. Sometimes that's due to insurances. But also, patients will sue hospitals at the drop of the hat if they think it can either get them out of paying their bills, or get them some cash. We need to cover our own butts because if we don't, patients will use any little excuse of how we didn't inform them enough and now they should either get to sue us or not pay.
Here's where healthcare is different than other industries, Beerina. When I was a teenager and worked at Barnes and Noble, we made money by selling stuff. It was in our interest to make sure the customer got whatever book they needed. In healthcare, it is in their fiscal interest NOT to give you the service (health care) they are supposed to supply you with, because that just is money lost for them. And the whole competition thing doesn't really work when 1. More often than not, its your employer, not you, who picks your plan and 2. They ALL DO IT.
Even I have excellent insurance coverage with very, very comprehensive coverage that cost me a pretty penny to make sure I had the best and most wide reaching kind of plan available. Yet even with what in my experience has been the absolute best insurance, when I had my own chronic health condition several years ago, my treatment was denied as "not medically necessary" and my parents had to pay tens of thousands of dollars out of pocket.
Which let me make clear, doesn't make me think government insurance is the magic answer, because working with medicaid and other government insurance, many of them do the exact same things as the private insurances do. Sure it's good in that if you can get medicaid, it's better than no coverage at all, but it's still fraught with the same problems, which makes it so frustrating. It's not a matter of private insurances vs public. We have huge issues with Medicare denying claims.
It's all a big mess and I don't see things getting better any time soon.
*edit: I just want to add that when I talk about the above, I am talking about major insurance companies that cost a lot of money and are top ranked. There is still competition between them and the insurances that are below them, that's true. There are plenty of discount, cheap insurances that people get that offer pretty poor coverage. When you go shopping around for the cheapest insurance available and don't bother to even check what it covers...then while I have sympathy for your situation, it's really a matter of "you get what you paid for." What makes me so mad is that what I describe above is how it works even with the top ranked insurances, the best insurances on the market. Yes, they are the biggest because they provide better services than the REALLY crappy insurances, so competition does work in that sense. But competition doesn't magically make them stop denying claims or cut down on their ridiculous paperwork and procedures. The differences between them and the crappy insurances is typically that with the big guys, you can at least try to get your Avastin therapy (or whatever it is you need), whereas with the crappy insurance, Avastin (or whatever) simply isn't covered at all so you can't even TRY to get it.
ed, frankly.