[chrisgeleven]

I fought insurance over this past summer after they declined covering a life saving surgery for my 6-year-old child at the last minute. We were in despair that my child's life was at risk each day we waited because of insurance incompetence.

ChatGPT literally guided me through the whole external appeal process, who to contact outside of normal channels to ask for help / apply pressure, researched questions I had, helped with wording on the appeals, and yes, helped keep me pushing forward at some of the darkest moments when I was grasping for anything, however small, to help keep the pressure up on the insurance company.

I didn't follow everything it suggested blindly. Definitely decided a few times to make decisions that differed from its advice partially or completely, and I sometimes ran suggested next steps by several close friends/family to make sure I wasn't missing something obvious. But the ideas/path ChatGPT suggested, the chasing down different scenarios to rule in/out them, and coaching me through this is what ultimately got movement on our case.

10 days post denial, I was able to get the procedure approved from these efforts.

21 days post denial and 7 days after the decision was reversed, we lucked into a surgery slot that opened up and my child got their life saving surgery. They have recovered and is in the best health of the past 18 months.

This maybe isn't leveling the playing field, at least not entirely. But it gave us a fighting chance on a short timeline and know where to best use our pressure. The hopeful part of me is that many others can use similar techniques to win.

[dweekly]

I am so glad to hear your child got the care they needed.

I've found that people often forget to call their state senator or assemblyperson. It has consistently amazed me how quickly a large company that's sitting on their butts about a topic will move lickety-split once their Government Affairs and/or PR teams are on the thread...

Another tip from having worked at a regulated entity: a physical letter to the CEO mailed to HQ creates a mandatory-response paper trail that will produce a very, very different (better) outcome than e.g. asking to talk to a supervisor while on a call that's not going well.

[Brainfood]

Thank you for sharing. I can personally say this same process has driven me to the brink of sanity. 10 years of managing a chronically ill child’s healthcare with multiple surgeries. Being a developer with the ability to navigate complex problems, social engineer people who have turned into robots, and enough income to make it through unforeseen lump sum payments - I cannot fathom how the average person deals with this. I made more $ than I ever did before to cover the costs and afford the best healthcare possible but the system is designed so we still get screwed and have nothing left. Thankful for the people who dedicate their lives to helping others. To everyone else who can justify profiting off of someone else misery, while being the richest and most advanced society on every other level? I have nothing nice to say to you.

[bmurphy1976]

How comfortable are you with naming and shaming the company? I don't think things are going to change if we don't call this stuff out loudly and publicly.

That's awful but I'm glad you were able to figure this out. I've had my own problems with insurance companies, but nothing to this level. I can't imagine the frustration, especially with YOUR CHILD'S HEALTH on the line.

Five years back I ended up getting surgery for a herniated disc. I was in immense and crippling pain. Before having the surgery, we decided to go through a round epidural shots. I had done that 20 years previously and it resolved the problem, so why wouldn't I?

Turns out my insurance company (who I will name: BCBSIL) delegated the approval for the epidurals through some kind of extra bureaucratic process with a 3rd party. It took days and additional effort on our end to get approved.

I remind you, I was in crippling pain at the time.

The delays getting this approved lead to me taking more Ibuprofen than I would otherwise have taken, which in turn lead to signs of internal bleeding. I had to ease off the Ibuprofen and significantly increase the amount of codeine (a drug which does not sit well with me) just to get by. Now not only did I have to wait for the approval, but I then had to wait for the signs of internal bleeding to go away before the doctor would give me the shot (which was the right call, even though it sucked).

Delays, compounding delays, compounding delays, all while I was absolutely miserable.

Anyway, I finally got approved and got the shot and it kinda helped, but didn't fix the issue. I had a second shot, got worse, and then decided we had no choice but to schedule the surgery.

The most frustrating thing (but something I am glad for) is that the surgery was approved immediately.

It's so maddening how inconsistent the whole thing is.

[like_any_other]

> How comfortable are you with naming and shaming the company?

Don't forget about the individuals responsible. Both the ones that made the denial decision, and the ones that instituted the internal system that incentivizes such denials.

[chrisgeleven]

It was Anthem Blue Cross.

You know, it is one thing if it is you or I as terrible as that is.

But this was a 6-year-old.

[itissid]

A pharmacist once told me that big insurance companies have call centers out in other countries whose job it is to call everyone who has medication approved and any one with misleading line of questioning:"Did you get or approve medication worth $$$$$$..?".

Calling 100's of people Ofc the find one poor guy never heard of such a sum denies this kind of line of questioning. Then the insurance company uses this to deny all claims made by the pharmacy for ALL their patients for that given drug/medication.

The pharmacist told me the mountain of documentary evidence they have to collect to rebut these denials is very large. Once a customer at their pharmacy said he did not want to sign off on a paper that he got a medication, the pharmacist got the customer's ok though to video record his consent, just so he does not have to deal with this mess.

He also mentioned to me that a pharmacist should NEVER pay any kind of reimbursement to an insurance company on a claim that was denied cause that somehow legally can let the insurance company deny future claims. Not entirely sure what exact legal procedure allows them to do that.

[magicalhippo]

Relative recently had their baby come several months early. The baby needed intensive care for a couple of months, and breathing support (CPAP) for another two. Mom lived at the hospital hotel for the duration.

Baby got regular inspections of the heart, lungs and eyes (too much oxygen in the blood can lead to problems with the cornea or something), including after checkout.

They got billed exactly zero.

Both parents even got full pay during the hospital stay, so didn't have to worry about the economy.

Ok, so I pay a fair bit of taxes here in Norway, and some of it is used on stupid stuff. But overall I like knowing my life won't be ruined because of some random event forced me into insolvency.

[diob]

A lot of folks are looking at the higher US comp but aren't correctly pricing in the long-term risk.

You can be fine for years, but a single, major medical event can zero out those salary gains and lead directly to bankruptcy. It's a systemic flaw that isn't obvious until it's your turn to deal with it.

[ksclarke]

The whole time I was reading this, as someone from the U.S., I was wondering what country the writer was from, because it sure as #$@! wasn't written by someone in the U.S. When I got to that part, I was, "Oh. Okay. That makes sense."

[necovek]

> too much oxygen in the blood can lead to problems with the cornea or something

You are likely thinking of ROP (retinopathy of prematurity, where retina starts detaching due to prolonged stay in the incubator).

[seethedeaduu]

The norwegian healthcare is really bad at specific sectors if they deem you as a 2nd class citizen (for example trans healthcare, where there is a lot of malicious gatekeeping and multi-year long waitlists)

[brightball]

In that same vein, I used a public adjuster once after a small electrical fire torched a room in my house. The insurance adjuster was great, his manager was awful and made a difficult experience much worse.

Without getting into details, the moment I realized that he was being intentionally obtuse I started looking into options.

First contacted an attorney who essentially said, “Yes, I can do it but I’m going to cost a lot and the insurance company won’t reimburse you for my time.”

Kept looking and discovered public adjusters were a thing. Did some research, found one who was reputable and he took me on for free. Pretty sure we used net, about 2-4 hours of his time.

He told me exactly what was going to happen, how the insurance company was going to react and it played out exactly as he said.

1. He requested a process to take the valuation of everything damaged in the fire to a 3rd party arbiter.

2. Insurance company will send you a letter saying it’s not time for that yet. We will proceed anyway. And we did.

3. He will nominate 3 arbiters and the insurance company will nominate 3 arbiters. Neither will select either of the others nominees and an independent 3rd party will select one instead.

4. The moment the insurance company realizes the valuation of your things will be outside of their control, they will become extremely agreeable. And they did.

And honestly the only thing I really wanted was another week in a hotel for my family because the company cleaning my house of smoke was short staffed over the holidays. Would have cost them likely $1,000 but instead he escalated the situation dramatically.

[DesiLurker]

thank you for this comment, learnt a new defensive trick today.

[egorfine]

[flagged]

[georgeecollins]

I think the reason is that people know it is a problem but ideologically they really disagree about what to do about it. The impasse creates an opportunity for profit driven actors to fight reforms. Also, democracies do dumb things sometimes. See Brexit.

But also, sometimes people from other countries-- I am thinking parts of Europe-- underestimate how well paid people in the US often are. They compare the averages, like the US only makes 20% more per household, why do they put up with this or that. But that comparison is for the whole country, so imagine if you were comparing all of Europe or China.

I had a friend in Spain at a similar company as mine say, how can you put up with no safety net, etc. But I look at his company and every one at my company at any level gets paid 2-5x as much. So like these are less serious issues if you are paid an extra $1-200k/ year. It doesn't explain the inaction, but I believe it is why a lot of politically influential people don't care.

[willio58]

The United States is a democracy, but more specifically, a representative democracy. That means citizens don’t directly vote on most laws or policies—aside from certain state or local measures—but instead elect representatives to make those decisions on our behalf. The idea is that we trust them to act in our best interests.

You can probably see where the problem comes in. Take, for example, a politician who campaigns on Medicare for All or universal healthcare. To win an election, they often need massive campaign funding—much of which comes from wealthy donors, including those in the medical or pharmaceutical industries. And once in office, they’re targeted by powerful lobbying efforts worth billions of dollars from those same industries.

In the end, the issue is that politicians can legally receive millions in donations and support from industries whose interests might directly conflict with the needs of the people they’re supposed to represent.

Ultimately though, it is known by most people irrespective of party affiliation that medical costs are out of control. One recent example of this collective understanding was when the united healthcare exec was killed. Before there was even a suspect, people generally knew why he was assassinated. Most people in the U.S. have either been directly affected by the insanity that is our healthcare system, or one of their loved ones has. Those that haven’t yet, it’s just a matter of time. It’s just so pervasive.

[dclowd9901]

No one is "putting up with it." We don't have a choice.

The way our government is designed right now, the populace doesn't really have elected representatives. More accurately, they have a corporate bought-and-paid for stooge that managed to be more likeable in a political race than their opponent, so we don't actually have anyone representing our interests _as a country_ at the federal level.

[tptacek]

Scarcity is a fact of every country's health system and you'll quickly find stories with similar fact patterns with e.g. the NHS. There's not a lot to recommend the US system as implemented today, but the problem isn't "insurance-based health care"; lots of countries have insurance-based health care.

[wrs]

Ideologically, just enough voters in the right places believe that unless you’re old, or a military veteran, in which case government healthcare is just fine, your sickness should not be their problem, even if it means they pay more for their own care.

Also, if healthcare wasn’t tied to having a job, then the inherent laziness and moral degeneracy of people without jobs would be encouraged by letting them not be sick. (BTW, being self-employed does not count as “having a job” in this mindset.)

[thatfrenchguy]

Add a French and American person, in the US you hear "insurance did not approve", in France it's more "you can't get an appointment / the surgery provider does not have any spots unless you go to their spots in their private hospital".

The French system is more predictable (because any vaguely sane healthcare system has a price for a code instead of negotiated rates, negotiated rates is the most inefficient way to run this market) & you can get cost estimates though. And in both countries, if you live in a small town in both systems, the healthcare you will receive will suck.

[blitz_skull]

This frame assumes several things:

1. Americans are not displeased with the situation. Ironically, I think this is one place most Americans agree there is a problem. The solution is the hard part because:

2. This presumes a drop-in solution where no one loses. This is where the fight is.

3. This presumes that democracies do what is logical or beneficial for the vast majority, which is a very naive view of democracy.

[codegeek]

Great question. No one "wants" insurance. Everyone wants to be able to get covered for care. The problem is that Govt decided decades ago that Health Insurance is the only way to get care even for mundane things like a regular doctor visit. To make it worse, they tied it to Employers needing to provide insurance. Insurance companies love this bureaucracy and became too powerful over the last few decades.

It is a sad state and I have almost given up on the hope that someday it will change. I m lucky enough to afford healthcare and feel for those who can't.

[wafflebot]

To the extent that U.S. voters want to maintain the status quo, which many (though not most) voters do wish to do, it's largely driven by an individualist mindset in which the worst thing that can happen is somebody else getting something that they didn't "earn".

[mothballed]

In part because hospital bills are monopoly money and most people just play a game of chicken with debt collectors, and the only actually sue a small fraction of the time and mostly either settle for a small fraction, give up besides annoying phone calls, or it gets discharged in bankruptcy.

Almost no one gets a bill from the hospital and just pays it, and in most cases if you do it's totally financially illiterate.

[elif]

We are a "binocracy", where our democratic function has been reduced to a binary choice, and unfortunately both choices have been fully captured by the healthcare industry.

[andy99]

Edit: just saw an earlier better comment saying the same thing: https://news.ycombinator.com/item?id=45737190

Countries with “free” also healthcare ration it and don’t cover everything.

Socialized insurance is still insurance, and at least in Canada it’s the only game in town, so if you have a procedure that is denied or not available your choice is basically to go to the US and pay for it and be in the same position as an uninsured American.

[dragonwriter]

> I have heard the US is a democracy.

It is certainly not a direct democracy where each individual policy is resolved by separate independent voting, no.

> So then insurance-based healthcare is what American people truly want?

Pretty consistently, no, but there is not any single alternative that a majority of the American people prefer recently (for a while, as far back as the 1990s, there was a clear popular majority for universal single-payer), and more importantly, it is not the only issue that factors into people’s voting decisions.

[goodluckchuck]

I think you’re just believing whatever the author says, and not considering the fact that reasonable people can disagree and be wrong and make mistakes. For all we know the procedure was entirely unnecessary and they agreed because he pushed for it. Also, what’s the alternative? The only system where you can go get procedures that authorities think unnecessary is a free market where you self-pay. A government-run system could equally decide that the procedure isn’t recommended.

[tpurves]

America is trapped in a cycle where political parties have discovered that fear and anger drives voters whereas contentment with status quo does not motivate turnout. This leads to a scenario where parties will actively sabotage the resolution of painpoint issues such as immigration, healthcare, gun control etc. so long as it continues to create anger and fear that they can successfully blame on the other party. This behavior extends to voting against their own proposed policies in the interest of seizing/maintaining power over problem solving. And now deliberately creating crises (both real and fictional ones) has become the game-theory dominant strategy in American politics.

[BurningFrog]

In European countries the procedures that are denied or very expensive in the US are often simply not offered. There is a national health budget, and not everything fits in it. The doctors have to tell the patients that there is nothing they can do, and that's that.

The patient ends up just as dead, but there is nothing to get furious about like when the doctors could fix it, but only if someone pays for it.

[lucasban]

One thing also to keep in mind, is that this experience is not uniform throughout the US. Many Americans like -their- employer based insurance, even if they don’t like the system. I personally pay nothing for visits and nominal fees ($1-10) for prescriptions. I have not been hospitalized while on this insurance, but my understanding is that it is relatively low cost. I also have no monthly premium. Meanwhile, my mother works at a small business, pays a significant percentage of her income for insurance from the ACA marketplaces (the public marketplaces created during the Obama administration) with the current subsidies, subsidies that are in question under the current administration. The American healthcare payment system is broken, but we aren’t all living through the worst case scenario experiences that get the attention. Add to that the amount of money and effort that went into turning healthcare reform into yet another partisan issue, and there’s a good recipe for maintaining a broken status quo for a while yet.

[robrenaud]

A lot of employed people like the status quo for the healthcare that they receive.

"In contrast to their largely negative assessments of the quality and coverage of healthcare in the U.S., broad majorities of Americans continue to rate their own healthcare’s quality and coverage positively. Currently, 71% of U.S. adults consider the quality of healthcare they receive to be excellent or good, and 65% say the same of their own coverage. There has been little deviation in these readings since 2001.

Compared with their counterparts, older adults and those with higher incomes register more positive ratings of the quality and coverage of their own healthcare."

https://news.gallup.com/poll/654044/view-healthcare-quality-...

[micromacrofoot]

It's precisely as many have said over decades at this point: the poor in our country hate themselves to the extent that they view being poor as a personal failing, and voting for free services for everyone is therefore dishonorable. I talk to people like this every day and it's frustrating.

[umvi]

> I have heard the US is a democracy

It's not a simple democracy, no (i.e. "enact a national-level vote for every issue and majority vote wins"). It's a constitutional republic where basically you have 50 mini countries each with different weight in the house of representatives and in the electoral college and a bazillion checks and balances that make repealing existing laws and enacting new ones very difficult. I think the majority of Americans do not like the current healthcare status quo, but getting changes that everyone is on board with through the political machinery is very difficult and Americans are polarized and tend to distrust change plans proposed by the opposite party (since parties tend to propose legislation that favors their own first).

[throwforfeds]

> Though why do you Americans put up with all this? I have heard the US is a democracy. So then insurance-based healthcare is what American people truly want?

It's because our politicians are largely owned by our corporations and spend a ridiculous amount of money protecting their interests [1]. We almost had a public option with the original "Obamacare", but it was forced out of the bill [2].

Also, just turn on Fox News for an evening and realize it's been the number one news channel in the US for 20-something years. They've been a right wing corporate propaganda machine for a long time, all while brilliantly portraying themselves as the "underdog" fighting the mainstream media. Americans aren't very educated and take pride in their ignorance, unfortunately. [3]

[1] https://en.wikipedia.org/wiki/Citizens_United_v._FEC

[2] https://en.wikipedia.org/wiki/Public_health_insurance_option

[3] https://www.youtube.com/watch?v=QFgcqB8-AxE

[levocardia]

Why do you put up with long wait times and lower-quality care in your home country?

[ransom1538]

Medicare has a total enrollment of approximately 69 million people, while Medicaid has around 83 million people. That is 152 million people. We already have socialized medicine we just run it poorly and don't apply it to people that can pay.

Moving our system to 340 million people + letting our corporations out of paying would put the US into an economic death spiral. US corporations would love this plan. But at 340 million... I don't see doctor visits but once every 2 years -- many would just die waiting for appointments.

[bko]

US person here.

I have insurance through my employer as do most Americans. And most are happy with their insurance. I can go to the doctor often same day, I can see a specialist and pay just a co-pay of between $25-50.

I had some bills but my out of pocket max is something like $5k, which I have saved up. The benefits of living in the US is that the same kind of work (engineer) pays about 3x as much here and you pay a lot less taxes (save many multiples of my out of pocket max).

So I prefer to live in a vibrant economy and take care of my own insurance.

[msla]

The same way European people put up with the insane NHS and its refusal to care for the people who support it financially and supposedly support it politically.

https://edition.cnn.com/2024/03/13/uk/england-nhs-puberty-bl...

The NHS and its bizarre political agenda is an example of what can happen when a government controls access to health care.

[saghm]

Without making a claim about whether it's what most people actually want or not, there's not much that an individual can do about this by changing their voting preference. The US doesn't have proportional representation, and the overwhelming majority of elections are "first past the post" rather than one of the more "modern" alternatives like ranked choice votes, so in practice very few elections ever swing to anyone outside of the two major political parties (neither of which have a particularly large contingent of politicians who have come out in favor of something like single-payer healthcare). Even for a purely single-issue voter who only cares about this, from a game theoretic perspective you're likely to be essentially throwing your vote away if you vote for someone outside of those two major parties because it's unlikely enough others will.

Presidential elections are even worse because they're determined by electoral college vote rather than popular vote. Even ignoring the potential for "faithless electors", all but two states allocate the entirety of their electoral votes to the candidate who wins the majority of their vote, which means that if you live in a state with a majority who reliably vote for a specific party's candidate every four years, your vote for president is effectively meaningless.

The only obvious way to fix these issues with how elections work would be to elect people who make different decisions about how to run them, which is hard to do because of the issues themselves. The system is self-reinforcing in a way that makes it extremely difficult for the average person to do anything about it, and any desire to do so gets weighed against the concerns about the policies that you might actually get to influence by voting for one of the two candidates who might actually win. At the end of the day, people who are concerned with the fundamental systemic flaws in things like elections and healthcare still likely end up picking pragmatism over principle (with the expected value of a vote for a candidate who is almost guaranteed not to win being lower than one who is might be less desirable than a third-party one but still has an actually realistic chance of winning and is preferable to the other major party candidate) or just check out of the system entirely (with people not bothering to vote at all already being a fairly common phenomenon in the US).

[fallingfrog]

No, we all hate it, but the number of senators and members of congress who would vote to replace it could be counted with one hand. The reason is simple: the insurance companies give those senators millions and millions of dollars and nobody has the cash to beat them. And we've given up at this point.

As the song goes:

"Everybody knows that the dice are loaded

Everybody rolls with their fingers crossed

Everybody knows the war is over

Everybody knows the good guys lost

Everybody knows the fight was fixed

The poor stay poor, the rich get rich

That's how it goes

Everybody knows"

[wouldbecouldbe]

Well there is lot of shit we Europeans put up with, for instance EU moving court every few weeks voor 200m per year. But systems are hard to change.

[somethingsome]

Hum.. At least where I live in europe, you still need to battle with insurances for any non trivial problem.. We get a health care coverage for the common stuff, but many things are not covered, or not covered enough.. Then you need insurances.. And it's always a battle..

Same for other kind of insurances such as issues with the house, etc..

[ziofill]

Non-US person here too. From what I understand the majority of Americans want a single-payer healthcare system, but too many people in government are paid by insurance companies and affiliates to not change how things work.

[BobbyTables2]

Its too easy to convince enough of the population to actively vote against their own interests.

[emeril]

-Democracy in name only

-Currently a dictatorship

-Historically more of plutocracy

-Our history has effectively yielded the current healthcare situation especially since those who would be most vocal tend to have better coverage and thus are less invested especially since the high costs are largely obfuscated

[tracker1]

Just Pharmaceuticals not even all medicine is literally over half of all advertising spend in the US. And that is just the tip of the iceberg and doesn't go into the incestuous and conflicting interest relationships between pharma, pharmacies, medical providers and insurance companies all inter-invested in each-other to simply grow the pie larger since ACA limited profit percentages.

It's the single most powerful lobbying group as a whole, and nearly every politician is bought and paid for by them. Good luck getting a majority or super majority to work against them.

[ponector]

One can argue what people wants is to be ruled by old convicted felon dictator.

[thesuitonym]

The US money machine has one of the most sophisticated propaganda networks in the history of the world working to make sure nothing ever gets better for working class people. In George Orwell's vision of a dystopian future, "The party told you to reject the evidence of your eyes and ears. It was their final, most essential command." In the US, the party didn't even have to issue the command, they just asked a few thousand talking heads to do it.

[zulban]

You've implied the answer to your own question. The USA is not a democracy. The opinions of almost all Americans have no impact on policy. It's a well researched fact.

Having an election day where people vote doesn't mean you live in a democracy.

[baby]

As soon as someone introduce these ideas people think they're a communist. See Mamdani in NY right now.

[bluesounddirect]

Then what sort of feel good stories about AI would we have . The US needs to adopt a single flat income / corp tax, government provided healthcare, and move on to the rest of life.

[j-krieger]

The US is gigantic. Imagine if every EU member, however rich, poor, or corrupt from Bulgaria to Germany had to enact one healthcare system.

[zarmsdos]

Decades of right-wing propaganda, unfortunately. They tend to have an emotional reaction against any sort of socialized anything, including healthcare.

[LeoPanthera]

The US is only ostensibly a democracy. It's not a functioning one, due to widespread voter disenfranchisement.

Voter ID laws, voter roll purges, registration barriers, polling place accessibility, early and mail-in voting restrictions, and perhaps most importantly gerrymandering, misinformation, and intimidation all serve to reduce the power of the ballot box.

And that's before we even get to US citizens in Puerto Rico, Guam, the US Virgin Islands, and American Samoa being unable to vote in Presidential elections at all.

[zzzeek]

not sure why you're getting downmodded. People will say M4A ("medicare for all") polls at super high levels, and they're right, it does. But poll those same people telling them "would you favor that your employer-based healthcare would be rescinded and you would instead get healthcare from a new government controlled plan, where there would be no other options", which is the assumption M4A's viability is based on, and that poll turns right upside down.

[billy99k]

The alternative is no surgery and no choice, which is what happens with government-run healthcare.

[_heimdall]

I don't think this has much to do with being a democracy. I, for one, wouldn't trust our federal government to competently run an efficient, most uncorrupted healthcare system for all.

The incentive structures that have built up around US politicians simply doesn't leave any room for it to realistically happen. Until the incentives are changed I'd vote against nearly any major government program.

[tboyd47]

It's not a democracy. You were told wrong, it's a republic.

[frogperson]

The are advertised as a democracy, but ever since Citizens United was passed we became an Oligarchy. Money now takes the place of votes since the rich can donate unlimited funds to a candidate. Candidates have zero incentive to serve the public.

[FpUser]

Non US as well. Life saving saving surgeries get denied, delayed and otherwise screwed all the time. Not sure where exactly it is worse since absolutely atrocious cases can be found in every G7 country never mind the rest

[qgin]

We have a lot of people being constantly brainwashed that we have the most amazing system in the world and that any attempt to change it is communism.

[fukka42]

Yes, it is what they want.

In the end there are more of them who want to "own the libs", or "not pay for freeloaders" than those who want to contribute to another's child surviving.

[ab_testing]

I think the root cause of the problem is not insurance companies but they definitely do play a part. The real reasons are multiple but can be listed as below.

1 A very high cost of drugs due to no intervention by the government as part of free market philosophy. This means that the same insulin that costs $25 in Canada can be sold for up to $1000 per month. New introduced drugs for Alzheimer's or other diseases can cost up to 50k per year - again because no price controls.

2. Insanely high prices of services due to a captive market - example a ten minute ambulance ride can cost up from $1000 to $5000. The private ambulance companies know they can charge a high base rate because they are connected to a city or municipality via contracts. Bribes as campaign funds are popular here. E.g. a new York based ambulance operator paid 45k in campaign funds to NY's governor elect and got a contract worth one billion dollars

https://www.wkbw.com/news/state-news/report-nysdoh-awards-mu...

3. Overcharging by hospitals for medicines and services again due to a captive audience. The hospitals are free to maintain various price books and you are not told what each service will cost at the time of administration of service. lately the hospitals have been forced to open up their price books but they are so convoluted that no normal human can decipher those prices.

Thus a ten cent aspirin would cost you $25 in the hospital and a MRI can run up to 15k.

4. Very high charges for doctors due to strict control on the number of MD positions and no increase in colleges or D seats over multiple years.

https://www.aamc.org/news/press-releases/new-aamc-report-sho...

5. Insurance companies have a for profit motive and need to extract their profits from premiums paid. Thus they fight tooth and nail to deny procedures and medications and set up convoluted processes for appeals.

6. Extensive fraud on Medicare and other government run health programs especially in durable medical goods and fake billing. In fact one of sitting US senators medical care company was involved in the largest Medicare fraud fines in the US and he still holds his seat.

https://www.justice.gov/archive/opa/pr/2003/June/03_civ_386....

Infact fraud billing Medicare for services not rendered is so popular that even Insurance companies do it

https://oig.hhs.gov/fraud/enforcement/united-states-interven...

Combine all the above factors and you will see why the US consumer gets so little while paying so much for his healthcare.

[ajkjk]

We fucking hate it don't worry

[stronglikedan]

Yes, but we also want universal healthcare. What we don't want is only universal healthcare with death panels like the UK and Canada has. Give us universal health care where we can also get insurance if we want, and we'll vote it in. That's never what comes up though. I firmly believe we could gut medicare/medicaid and the savings from the bureaucratic administration costs alone could pay for universal healthcare.

[nmz]

> incompetence

No, that's the goal. Denying coverage is how insurance companies make money. The less money they give, the more money they keep.

[horns4lyfe]

Insurance companies have become cartoonishly evil. It’s going to get really nasty out there at some point.

[game_the0ry]

Happy to hear this all worked out. Have you thought about reaching out to local news to get the word out? That insurance company should be called out.

[IlikeKitties]

I'm glad you were able to use these tools to help your family though such tough times!

> The hopeful part of me is that many others can use similar techniques to win.

And the realistic part in me says that these tools will be used to deny appeals without a human ever looking into them and making sure you will never get to talk to a human or get approval for anything ever again.

[benmw333]

A few of the sentences don't make sense to me. Who is "they" and "their" in the last two paragraphs?

[apparent]

Seems like GP is trying to refer to the child without reference to sex.

[lotsofpulp]

I was under the impression that if you were to go to an emergency room, life saving surgery would be scheduled regardless of who is paying (or not paying), due to EMTALA. I can't imagine a hospital waiting for an insurance company's approval to pay for a procedure to schedule a child's life saving surgery.

Is this incorrect?

[evan_]

if the kid has a steel spike through his abdomen then they will perform that surgery. If he's having seizures because of a brain tumor all they're required to do is stabilize and release.

[chrisgeleven]

This wasn't an immediate ER situation, at least directly (yet). More of a if this procedure doesn't get done now, at some point in the relatively near future, there will be multiple ER situations, almost certainly multiple hospitalizations, and one of those might go past the point of no return.

And the insurance still played games. Like, it's in your best interest to pay once and get this situation resolved in a scheduled/controlled manner than wait for multiple emergency hospitalizations AND have to pay for this in an emergency situation...you're probably talking at least 2x cost if not more.

[kiitos]

> Is this incorrect?

yep

because "life-saving" isn't a single well-defined boolean condition that can be determined by ER staff as part of triage

> I can't imagine a hospital waiting for an insurance company's approval to pay for a procedure to schedule a child's life saving surgery.

then I guess you've never dealt with major health issues like cancer, blood disease, etc. etc. because what you're describing here happens all the time

[dboreham]

Presumably parent is describing a non-emergency situation.

[heavyset_go]

The other side of this is that your LLM interaction can be leveraged to train adversarial models that find ways to still deny or delay your claim despite your LLM-advised actions.

Insurance companies, or the companies they pay to launder their involvement, would pay a lot more for that than the public would be able to.

[chrisgeleven]

I know, that is a worry I have.

[lanfeust6]

Great story, and encapsulates what I find most powerful about LLMs.

[phyzix5761]

I'm curious, where do you live that denies a child a life saving surgery just because insurance won't cover it? Because in the US there's laws against that.

[heavyset_go]

There's a difference between immediate stabilization, required by law, and life saving surgery in general, not required by law.

If you come in with a gaping head wound and can't pay, by law, hospitals are required to treat you.

If you come in with brain cancer, no one is compelled to give you the radiation, chemotherapy or surgeries you may require, even though it is literally life saving. You are stable, albeit slowly dying, so too bad.

[lelanthran]

> I'm curious, where do you live that denies a child a life saving surgery just because insurance won't cover it? Because in the US there's laws against that.

Maybe I'm just too skeptical, but

a) This is a very new account with exactly 1 other posting 3 months ago, and

b) They don't refer to their child with any sort of gender. They even used slightly awkward sentence construction just to avoid gender. Few parents think of their child as an "it".

So either this is a sleeper bot, or the surgery in question was gender reassignment.

Or this poster routinely refers to their child as an "it", not a "he" or a "her".

[Cub3]

Man that’s terrifying. I can’t imagine going through that due to admin incompetence

The US healthcare system sounds horrific

[ethbr1]

Amazingly happy to hear you were able to drive the process! FWIW, surgical centers usually have to do the exact same thing for their patients (typical role: coordinator), and they do it the same way you did (plus knowing a few counterparties because they work together regularly).

The lack of data standardization in health insurance is atrocious. (In the US, CMS/Congress pushing what it can, but at a glacial pace)

The strongest argument for single payer is that a diverse marketplace has demonstrated a fundamental inability to interoperate.

[miki123211]

This is why AI is an equalizing force.

Eventually, we'll just have a free (or at least much cheaper) psychiatrist in our pocket.

Sure, AI advice is workse than the advice of a competent professional, but it's very often better no advice, and that's what you get if you can't afford the professional.

[ASalazarMX]

I shudder to think when insurance companies use AI to counteract customers using AI to navigate through their system. They'll eventually catch up, and people who don't use any kind of AI will be disadvantaged.

That is, until someone sells them a turnkey AI service to do insurance claims... and decides to play both teams so resolutions come back at pre-AI levels, and the free market(TM) is happy because a new equilibrium has been reached.

Maybe I just need more sleep.

[Sincere6066]

(this thread paid for by OpenAI)