6. Not encouraging preventive care | The Odyssey Online
Start writing a post
Health and Wellness

7 Ways Health Insurance Companies Fail Americans Every Single Day

If we want to get the most out of our healthcare, we need to be aware of what our insurance companies are doing behind closed doors.

4014
7 Ways Health Insurance Companies Fail Americans Every Single Day

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

It's no secret that Americans pay more than any other country in the world for healthcare. According to Vox, if America's healthcare system broke off from the rest of the economy, it would be "the fifth largest economy in the world." However, insurance companies have a very small profit margin — about 3.2 percent — comparison with the rest of the healthcare industry at 15.4 percent. You can imagine that since their profit margin is so slim, that protecting their bottom line is even more important than the average business.

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.

Report this Content
Relationships

Power of Love Letters

I don't think I say it enough...

444610
Illistrated image of a letter with 2 red hearts
StableDiffusion

To My Loving Boyfriend,

  • Thank you for all that you do for me
  • Thank you for working through disagreements with me
  • Thank you for always supporting me
  • I appreciate you more than words can express
  • You have helped me grow and become a better person
  • I can't wait to see where life takes us next
  • I promise to cherish every moment with you
  • Thank you for being my best friend and confidante
  • I love you and everything you do

To start off, here's something I don't say nearly enough: thank you. Thank you, thank you, thank you from the bottom of my heart. You do so much for me that I can't even put into words how much I appreciate everything you do - and have done - for me over the course of our relationship so far. While every couple has their fair share of tiffs and disagreements, thank you for getting through all of them with me and making us a better couple at the other end. With any argument, we don't just throw in the towel and say we're done, but we work towards a solution that puts us in a greater place each day. Thank you for always working with me and never giving up on us.

Keep Reading...Show less
Lifestyle

11 Signs You Grew Up In Hauppauge, NY

Because no one ever really leaves.

18132
Map of Hauppauge, New York
Google

Ah, yes, good old Hauppauge. We are that town in the dead center of Long Island that barely anyone knows how to pronounce unless they're from the town itself or live in a nearby area. Hauppauge is home to people of all kinds. We always have new families joining the community but honestly, the majority of the town is filled with people who never leave (high school alumni) and elders who have raised their kids here. Around the town, there are some just some landmarks and places that only the people of Hauppauge will ever understand the importance or even the annoyance of.

Keep Reading...Show less
Lifestyle

Moana's Top 10 Life Tips

"Moana" is filled with life lessons that involve far more than finding true love as many other Disney movies do.

42386
Animated image of a woman with long dark hair and tattoos
StableDiffusion

1. It's easy to be fooled by shiny things.

Digital image of shiny gemstones in cased in gold. shiny things StableDiffusion

Tamatoa created a liar filled with shiny things simply for the purpose of tricking fish to enter and become his food. He too experiences a lesson in how easy it is to be tricked by shiny things when Moana distracts him by covering herself in glowing algae so Maui can grab his hook.

Keep Reading...Show less
Student Life

7 Types Of Students You Will Meet In College

You wish you could be #5, but you know you're probably a #6.

21780
cool group of lazy college students in class
StableDiffusion

There are thousands of universities around the world, and each school boasts its own traditions and slogans. Some schools pride themselves on sports, while others emphasize their research facilities. While there is a myriad of differences among each and every school, there will always these seven types of students in class.

Keep Reading...Show less
Featured

15 Rhyme Without Reason Greek Life Function Ideas

When you have no ideas for what to wear to this date function

322197
A dog and a frog
Healthy Pets

I am going to a rhyme without reason date function and I have looked at so many different rhyming words and I figured there need to be a new list of words. At these functions, there are usually at least two rockers and boxers and an umpteenth amount of dogs and frogs. I have come up with a list of creative and unique ideas for these functions.

If you like what you see, get a shopping cart going with these costumes.

Keep Reading...Show less

Subscribe to Our Newsletter

Facebook Comments