Insurance companies have figured out that they can make big profits by denying surgeries and other care that doctors recommend for their patients. This happens under Medicare Advantage, programs where private insurance companies offer care that replaces Medicare. The CEOs of this industry are paid multiple millions.
The New York Times produced a video about this.
Should your insurance company be allowed to stop you from getting a treatment — even if your doctor says it’s necessary?
Doctors are often required to get insurance permission before providing medical care. This process is called prior authorization and it can be used by profit-seeking insurance companies to create intentional barriers between patients and the health care they need.
At best, it’s just a minor bureaucratic headache. At worst, people have died.
Prior authorization has been around for decades, but doctors say its use has increased in recent years and now rank it as one of the top issues in health care.
To produce the Opinion Video above, we spoke to more than 50 doctors and patients. They shared horror stories about a seemingly trivial process that inflicts enormous pain, on a daily basis. The video also explains how a process that is supposed to save money actually inflates U.S. health care costs while enriching insurance companies.
Medicare Advantage was imposed by GWBush & GOP into traditional Medicare to gradually privatize Medicare. It initially offers lower monthly premiums but if/when an elder needs extensive health care, it pays little to nothing. I had 2 friends whose parents chose MEdicare Advantage and when they both needed hospitalization, it was no advantage. They spent hundreds of thousands of dollars on their medical care when they needed it the most.
Don’t buy Medicare Advantage.
I recently encountered a re-prior-authorization delay, waiting for the insurance company to re-authorize the refill of a prescription I’d been using for more than a year that, obviously, they’d authorized when I first got it. The AMA has issued an informative piece on the subject: “What doctors wish patients knew about prior authorization.”
Medicare Advantage is the worst of vulture capitalism that may even result in needless death for those that get sucked into their endless marketing machine. Sure, they will offer unsuspecting seniors a free lunch to listen to their spiel, but MA will ration their access to costly procedures and medicine if they become seriously ill. Big insurance should not stand between doctors and patients.
In California we are a group of public school unionized educators working with the California Nurses to introduce Cal Cares single payer health for all in California. This plan has been developed for many years and has been modeled after the best single healthcare systems worldwide.
CTA wrote about the push for Single Payer in California and how it would help all students and families here:
https://www.cta.org/educator/posts/single-payer-health-care-public-education
This is a link to the California Educators Single Payer Toolkit for any educator to get involved:
https://docs.google.com/document/d/14isJ321qTBZ5-z6xo39qx04ONuvJBSODQEEX_bArjRI/mobilebasic?
Lastly, this is a link to an upcoming webinar for California educators to find out more about the benefits of single payer healthcare and to get more of our locals and our representatives to push for this fundamentally more comprehensive approach to healthcare:
https://zoom.us/webinar/register/WN_0dI4u9kGRemb72OKE2fpWg?fbclid=IwAR3cR59DWbeJ0UCayzMtT-nlsRnqji-kOXvoxLeW8r0CkwCVBaSXVxSFKOg_aem_AUzoT0aQ1NRYE10ptiZ9fuXR8lKUvUqYNu7ZvNz_XwdRD1gExtm9faZ2EaTIBG_XkLY#/registration
Please spread the word to other California educators!
Good for California! Maybe other states will follow, if we cannot get a national plan.
In NY State it was Public and Private Sector Unions who killed an M4all proposal in 2019. When Tim Ryan said atv the Presidential debates in 2020 “What about those great Union Healthcare plans”. He forgot to add, if they can keep them!
It’s not just Medicare Advantage that requires pre-auth. Most insurance companies (for working people) require it for surgeries, meds, durable medical equipment, chemo, radiology etc. It’s been this way for at least 25 yrs. Oh, how I wish I could have back all those hours I spent listening to bad Muzak while waiting for a customer service representative (NOT a medical professional) to try and deny my patient what they deserve in the way of good healthcare by checking off boxes on a scripted worksheet.
Now, even if one has an insurance plan that doesn’t require a pre-auth, the patient still wants to know how much out of pocket they will be required to pay after co-pays, deductibles, and insurance reimbursement. It’s a predatory business that needs to be regulated by the government, yet the insurance businesses are big political donors. Kleptocratic Oligarchy
I know someone (we were together 14 years and this was early in year four) who was in an accident that did a lot of damage to her.
Sylvia was stopped at a red light when a car traveling 70 mph drivin by an 18 year old without a driver’s license, (he’d had it taken away), without insurance, without a job, and without working brakes for the unregistered, unlicensed car, slammed into her car’s rear, caving it in from the trunk to the back of the front seats.
the worst: brain surgery
The least: jaw surgery
The most: pain — never ending pain
We were both teachers and met at the same school where we still taught. Her health insurance was through that school district that paid a health insurance company to manage our health care plan.
The brain surgery was approved and she survived that. The list of stuff that could go wrong was terrifying. She could have lost the ability to talk. She could have ended up paralyzed. Her sense of taste was altered and her favorite foods all tasted bitter, terrible, so she had to find other foods that she could eat without barfing.
No details on what they did when they went inside her brain for several hours. I don’t want anyone to lose their appetite and any sleep. I will share this. They ran her blood through a machine to lower its temperature to almost freezing to shrink her brain first to provide more room to move around in there.
The jaw surgeries were also approved, but before the major surgery, she had to go through several minor surgeries. All were approved by the insurance company ahead of time. After she had all the minor jaw surgeries, and healed from them, the major one would take place.
I won’t go into details of what she went through during those surgeries to rebuild her jaw so her teeth would match again and she could eat, because some people that read this might lose sleep.
After the minor surgeries, three years later, Sylvia’s doctor said he’d have to get approval from the insurance company again.
AGAIN!
The 2nd time, the insurance company denied the final surgery. The last surgery was the one that would align her jaw so her teeth would line up and she could eat solid food again. Three years mostly on a liquid, semi solid diet.
And the insurance company denied the surgery that would finally allow her to eat regular food again.
The insurance company’s contract with the school district didn’t allow a anyone on the plan to take them to court. We had to go through negotiations and arbitration first.
That took three more years, before we could go to court.
Before we hired a lawyer, that’s when the insurance company said, since they’d already approved it six years earlier (we had that approval letter as evidence and we were already talking to lawyers) they’d agree to allow the final surgery.
Medicare Advantage plans sometimes refuse to authorize procedures prescribed by doctors. No doubt these refusals are sometimes unjustified; insurance companies have been successfully sued hundreds/thousands of times on those grounds.
But original Medicare does not give doctors and patients carte blanche to do whatever the doctors say. That’s because Medicare and Medicaid fraud has been estimated at over $100 billion per year, resulting from providers submitting claims for unjustified services and medical equipment. There are many cases of doctors being convicted of Medicare fraud. It’s wishful thinking to believe that eliminating private insurance companies would lead to Utopia for the Medicare program.
One commenter here advocates for a statewide single-payer plan in California. Other states have considerd that idea and dismissed it as wildly impractical. The taxes required to finance such a program would make a state uncompetitive for private sector businesses; Vermont concluded exactly that. To have any chance of working successfully, single-payer would have to be done at the federal government level.
All the other wealthy democracies have some form or version of universal health care, everyone is covered. Of course the GOP screams socialism, socialism, we can’t have that universal health care in the US. We do have universal healthcare for those 65 and older, Medicare. We should have Medicare for all but the GOP stands in the way of that ever happening. What will it take to have Medicare for all? It took strong Democratic presidents plus Democratic control of the legislature to get Social Security, Medicare and Medicaid.
My hospital told me it had a prior authorization from my Medicare Advantage plan. Then the hospital submitted its bill to the MA under a different, unauthorized code. I just received a notice that the entire claim was being denied and that I was responsible for it.
So, now I have this $27,000 bill. Lovely.
Bob,
You have my sympathy. That problem is the hospital’s fault. The paperwork in our medical system is mindboggling. My advice is to not pay the bill and inform all parties of the facts. You won’t have to pay that bill.
Thanks, Mr. Maxwell. I am working through this, on their schedule, ofc. We shall see whether it ends up destroying my credit.
While I was in the hospital, I never saw the same doctor twice. The last guy who stopped in for 30 seconds to see me is the one, I think, who put the entire stay in under a code that had not been preapproved. He spent a total of maybe a minute thinking about my case.
This was a day after a person from the hospital’s business office assured me that I had nothing to worry about because the hospital had a preauthorization to cover the expenses.
That’s horrible. If you had prior authorization, the insurance should cover the costs.
The authorization was for a different treatment code. The last doc who signed off on the bill put in a different code, which had not been approved.
Wow. Electronically you should have all the emails/paperwork, Bob. I agree with Larry: wait them out and show them the proof. The doctor in the short video of Diane’s link talked about the paperwork being a full time job that actually has to be switched around to prevent burnout.
So sorry you’re going through this. Hopefully the procedure(s) went well. Good luck and wonder if there’s a way to give a heads up to the powers that be who determine credit ratings.
Thanks. It’s a nasty process. Basically, everyone says the equivalent of it is what it is. I intend to fight this. The whole process stinks to high heaven, and no one takes any responsibility for anything.
But yes, I have this all documented, and I’m going to fight it.
Bob Shepherd,
The lead story today in The New York Times is about patients who get stuck with big bills while insurers get big fees. Exactly your story.
Weeks after undergoing heart surgery, Gail Lawson found herself back in an operating room. Her incision wasn’t healing, and an infection was spreading.
At a hospital in Ridgewood, N.J., Dr. Sidney Rabinowitz performed a complex, hourslong procedure to repair tissue and close the wound. While recuperating, Ms. Lawson phoned the doctor’s office in a panic. He returned the call himself and squeezed her in for an appointment the next day.
“He was just so good with me, so patient, so kind,” she said.
But the doctor was not in her insurance plan’s network of providers, leaving his bill open to negotiation by her insurer. Once back on her feet, Ms. Lawson received a letter from the insurer, UnitedHealthcare, advising that Dr. Rabinowitz would be paid $5,449.27 — a small fraction of what he had billed the insurance company. That left Ms. Lawson with a bill of more than $100,000.
“I’m thinking to myself, ‘But this is why I had insurance,’” said Ms. Lawson, who is fighting UnitedHealthcare over the balance. “They take out, what, $300 or $400 a month? Well, why aren’t you people paying these bills?”
The answer is a little-known data analytics firm called MultiPlan. It works with UnitedHealthcare, Cigna, Aetna and other big insurers to decide how much so-called out-of-network medical providers should be paid. It promises to help contain medical costs using fair and independent analysis.
But a New York Times investigation, based on interviews and confidential documents, shows that MultiPlan and the insurance companies have a large and mostly hidden financial incentive to cut those reimbursements as much as possible, even if it means saddling patients with large bills. The formula for MultiPlan and the insurance companies is simple: The smaller the reimbursement, the larger their fee.
Health Insurers’ Lucrative, Little-Known Alliance: 5 Takeaways
April 7, 2024
Here’s how it works: The most common way Americans get health coverage is through employers that “self-fund,” meaning they pay for their workers’ medical care with their own money. The employers contract with insurance companies to administer the plans and process claims. Most medical visits are with providers in a plan’s network, with rates set in advance.
But when employees see a provider outside the network, as Ms. Lawson did, many insurance companies consult with MultiPlan, which typically recommends that the employer pay less than the provider billed. The difference between the bill and the sum actually paid amounts to a savings for the employer. But, The Times found, it means big money for MultiPlan and the insurer, since both companies often charge the employer a percentage of the savings as a processing fee.
How MultiPlan and Insurers Make Money on Fees
MultiPlan and health insurers typically receive a percentage of the “savings” on each claim, creating an incentive to recommend lower payments.
In recent years, the nation’s largest insurer by revenue, UnitedHealthcare, has reaped an annual windfall of about $1 billion in fees from out-of-network savings programs, including its work with MultiPlan, according to testimony by two of its executives. Last year alone, MultiPlan told investors, it identified nearly $23 billion in bills from various insurers that it recommended not be paid.
MultiPlan and the insurers say they are combating rampant overbilling by some doctors and hospitals, a chronic problem that research has linked to rising health care costs and regulators are examining. Yet the little-understood financial incentive for insurers and MultiPlan has left patients across the country with unexpectedly large bills, as they are sometimes asked to pick up what their plans didn’t pay, The Times found. In addition, providers have seen their pay slashed, and employers have been hit with high fees, records and interviews show.
In some instances, the fees paid to an insurance company and MultiPlan for processing a claim far exceeded the amount paid to providers who treated the patient. Court records show, for example, that Cigna took in nearly $4.47 million from employers for processing claims from eight addiction treatment centers in California, while the centers received $2.56 million. MultiPlan pocketed $1.22 million.
Our health”care” system is a disgrace.
!!!!
Unreal. Or too real. Got my backing here, Bob (for what it’s worth).
Bad enough to need the medical service. Then they slam your ass for the $$$. Wish I could offer my help, but not my field of expertise.
MA is known for playing with codes. Their usual ploy is to ‘upcode’ a routine procedure in order to get Medicare to pay more, but what happened to you is outrageous. So sorry, Bob! You should have an appeal process. Medicare has such a process. Medicare is very clear about what is allowed or refused, and supplement plans have to pay if Medicare approves the procedure.
Thanks for posting this Diane. I put it up on the Facebook page for our UFT resistance to the switchover and mentioned the short video when you scroll down the article. It’s short and very effective.
A very good friend of mine is a retired physical therapist. His last 8 years of work were spent managing a clinic. He said it was often impossible to give his patients the therapy that was needed due to minimization or outright denials of service by the insurance companies.
The more exposure on this, the better. And for any retired NYC teachers who are reading this: Check your ballot for the entire Retiree Advocate/UFT slate in the coming election. The people you are voting for know their stuff and will stand up for you. I’ve known Bennett Fischer (running for Chapter Leader) as a good friend and teacher/union colleague for forty years. He’ll be perfect for the job!
The retirees’ fight against Medicare Advantage has been amazing. All credit to Marianne Pizzitola, a retired EMS, who has been effective and relentless.
In a big way, Diane. I’ve been contributing to the legal team from the gitgo. I don’t think Mulgrew/Adams expected this kind of coordinated effort. 🥂
I’m affected. I’m on the retiree plan. I will never give up Medicare.
Privatization always leads to big profits, worse service.
I just read an article in the Philadelphia Inquirer this morning about the privatization of water supplies in Pennsylvania. Many districts are falling for it, expecting to get more efficient service. Maybe they are but the cost of water is soaring.
Water’s a very big issue and it’s only going to worsen in areas that aren’t used to the changes. Hopefully local, city, state, and federal governments take the lead to create educated and equitable distribution plans. Couldn’t agree more about the privatization aspect. The prime goal is profit. On the backs of the people.
I read all of the comments and agree that the U.S. has horrible insurance for ALL of its citizens. Other countries can have good insurance but the GOP screams about us getting it. [I have an Aetna Medicare Advantage PPO provided for retirees in Illinois. Aetna is on the stock exchange to make even more money. It was privately bought by CVS Pharmacy to make money for CVS Pharmacy.]
When I was working at the International School of Kuala Lumpur in Malaysia, I’d call and make a doctor’s appointment. Arrive and sign a paper and never received a bill in all the 9 years I was in Kuala Lumpur.
I came down with a rare nerve disease called Neurofibromatosis Type 2. I arrived in K.L. for my next year of teaching. This was for the 2006-07 school year. Unfortunately my hearing had gotten so bad that I couldn’t teach music. Two subs covered my elementary beginning band and K-5 classroom music.
It took a lot of paperwork, but eventually the school’s insurance company agreed to pay me $36,000 per year until I reached age 65. THIS WAS AN AMERICAN INSURANCE COMPANY!! I received a check in the mail each month.
Good insurance is available but not for people living in the U.S.