It's no secret that most Americans barely tolerate their insurance plans, whether they have issues with their co-payment or their ever-rising premiums. Some of us are resigned that this is the way it has to be, while others look to Europe for examples of socialized, universal healthcare. Although I do have good insurance, I've had my fair share of run-ins with claims processors trying to cut corners or override doctor's orders. It's frustrating to see prices going up while the quality of service doesn't improve. I think something needs to change and the first step to implementing change is exposing what's wrong in the first place.
1. Claims processors lack proper qualification
If you've ever been told by a doctor that you need to have surgery or receive a certain treatment, only to be told that your insurance refuses to cover it, you can thank a claim processor for that. A claim processor's job is to either approve or deny claims by determining medical necessity, cost control, lack of coverage, or lack of prior authorization (via your insurance company) to be eligible for the treatment.
The people responsible for sorting through this information are often not trained medical professionals and are not always required to have anything more than a high school diploma. That means the person denying a claim for a patient's chemotherapy or life-saving medication could be freshly out of high school with no medical knowledge whatsoever. When taking that into account, they hardly seem qualified to make decisions that could mean life or death for certain people.
2. Hospitals have the upper hand in negotiations
In America, since we have a "free-market" in terms of health insurance, hospitals have a plethora of insurance companies to choose from. If a hospital is especially powerful, they can afford to deny insurance that expects to pay less for their services because they have hundreds of other insurances to choose from, which often stops insurance companies from being more aggressive negotiators. When facing the choice of either losing a major hospital contract or lowering prices for their customers, then the choice is obvious. They will almost always choose to protect their bottom line, thus driving up premiums for their customers.
3. Definitions of "medical necessity" are too restrictive
In an ideal world, if a doctor says that something is medically necessary, insurance companies would listen and cover the treatment. Unfortunately, that is not always the case. Since a treatment must be deemed medically necessary, it's important to determine what that really means. The definition is very vague, thus allowing insurance companies to bend it to fit their needs (aka their bottom line). Some companies have been involved in lawsuits filed against them for denying life-saving Hepatitis C medication that they deemed medically unnecessary.
4. Prioritizing the bottom line
5. Requiring patients to "fail first"
I've personally experienced this, even with supposedly "good" insurance. I've tried several anti-depressants in the past few years, all of them having various negative side effects. After trying and hating the most popular anti-depressants on the market I decided to do my own research and investigate newer medications with fewer side effects. When my doctor prescribed it, I went to the pharmacy only to be told that I had not tried enough of my insurance's "preferred" anti-depressants to qualify to try the new one. That's right, insurance companies have their own formulary (list of preferred medicines) that you must try, fail, and document the failure of before you can get authorization to try something different. The phenomenon is commonly referred to as "fail first" or "step therapy" if you prefer euphemisms. This is dangerous and time-consuming; forcing patients to compromise their health to save money is unethical. When dealing with chronic illness especially, the time spent taking medications that won't work can also mean that the illness has time to progress.
6. Not encouraging preventive care
Preventive care refers to any practice that could potentially prevent disease so it could range from something like using condoms to prevent STIs or seeing a nutritionist to lose weight and prevent heart disease. Preventing conditions like these could save the patient thousands of dollars in medical bills. However, as I said earlier, insurance companies are not trying to save their customers money. According to a study done by the CDC "financial incentives do not align with a focus on preventing chronic diseases. Currently, most providers, including hospitals and physicians, are paid to treat rather than to prevent disease". Since doctors and hospitals are paid to treat sick people, these institutions risk losing a potential patient by preventing disease in the first place.
7. Giving incentives to deny claims
As mentioned earlier, insurance companies have a low-profit margin, so it comes as no surprise that they try their hardest to deny claims, even ones that are completely valid. According to Justice.org, health insurance companies have "rewarded employees who successfully denied claims, replaced employees who would not, and when all else failed, engaged in outright fraud to avoid paying claims." This is nothing short of unethical and encourages claims processors to deny claims for no reason at all other than pocketing more money. There's no telling what other vulgar practices insurance companies engage in that the public isn't yet privy to, but we have to start advocating for more ethical practices when it comes to our health.