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My wife is a clinical psychologist who used to take insurance. She got tired of not being paid for months for patients she saw. Legally they have 90 days to pay you, but in practice it’s closer to 4-5 months. Every January they claim to have “computer problems related to the new year” and simply lose huge numbers of claims, requiring you to resubmit — oh that claim is more than 90 days old even though it was their system that “lost” it? Sorry, can’t submit! Guess you just worked for free!

She takes cash now. It was an abusive system and I’m not surprised it’s falling apart.

Up and down the board this is the game insurance companies are playing.

For example, I had need for a medical device. My doctors office submitted the claim for that device with documentation of it's necessity 5 times over 6 months before it was finally approved. The prior 4 times it was "You didn't include all the required information" even though each submission was identical.

There's simply far too little oversight on insurance agencies. They are perversely incentivized to give the worst outcomes for everyone which being to command high premiums because of the relatively low amount of competition or threat of "switching" (After all, you are using your employer's insurance. You didn't get to pick it, HR did. And they picked it based on who's cheapest. How did they become the cheapest? A race to the bottom in terms of service).

All of this burdens the whole system with cost and delay.

I'm all for universal healthcare, but if we can't get that can we at least get stronger regulations and punitive measure against insurance companies for playing these games? It's crazy that everyone has stories, regardless of agency, of illegitimate claim denials.

And to be clear, they do this because it saves them money and costs them nothing. By denying by default, a certain percentage of the population and doctors offices will ultimately just go away because of the headache it takes to convince the agency to provide the product you pay for.

It's astounding that the care plan created by myself and my team of doctors is regularly denied by a statistician at Blue Cross Blue Shield.

This means my care is ultimately in the hands of someone with zero medical training.

Astounding.

I would love, love for it to become a thing for Employers to put your money in a special type of account (similar to a Roth 401k) where the only thing you can do with it is buy insurance on the open market.

Heck, even have a list of 2-3 'preferred' plans that employees can choose from, if they don't want to do all the research. But seeing all that money go into their pay-stub, and then right back out for insurance is going to be very, very eye opening to people who currently just have their employer pay it, and they ever see it in their check.

Yep, I've submitted for prescription reimbursement for compounded medication. I submitted photocopies with just the dates and signatures changed - the formula and everything was the same. One time they gave me the full $45 in reimbursement. The next time it was $17 (cost of the prescription med without the other ingredients or compounding). The third time they gave me $1. I tried asking why each was different. They had no explaination but were emphatic that they paid the correct amounts.
> My doctors office submitted the claim for that device with documentation of it's necessity 5 times over 6 months before it was finally approved

I have had a profoundly deviated septum since childhood. A couple of years ago I went to an ENT to get it fixed. "Yup, 90% deviated on the right side." "Great, when do we schedule surgery?"

"Well, first, I prescribe you these two nasal sprays so that you can come back in four weeks and tell me they didn't fix your breathing, so I can tell the insurer that so they can approve surgery."

The CMS Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule (CMS-0057-P) may solve some of those problems starting in 2026.

https://www.cms.gov/priorities/key-initiatives/burden-reduct...

Also a practicing clinician and this is such a terrible problem that goes well beyond what you’ve described

Someone comes in and has insurance “x”. “Am I in network?” I don’t know. Probably. I take those plans most of the time. I check Navinet, or provider express, or one of the many other insurance benefits verification websites because the various insurers can’t agree on one centralized platform for this.

It says you’re good and I’m in network, great! Or you checked the provider directory online and I’m listed. Most of the time we’re okay. Sometimes this is out of date though (the “computer issues” you mentioned). The only way to truly be sure is to call the insurance company and have them check their systems which I simply don’t have time to do, sorry, or submit billing. This is why I and basically every healthcare practitioner have the policy that you are ultimately responsible to verify your benefits.

So we meet and it’s fine and I collect your copay. Then I submit billing. Then we meet again weekly. Then the insurance takes four fucking months to process your intake session only to come back and say “hey wait, this actually isn’t covered because it’s technically out of network so neither are the 15 sessions that happened afterward”. Now you suddenly owe me 2-3 grand out of pocket and I either have to collect that, probably worsening your mental health by adding a signicant sudden expense, or write it off and basically say goodbye to any renumeration for the 16 hours of work I did. I will ask you to appeal of course.

This isn’t even a “rare exception” situation. It comes up like once a month and I run an independent solo outpatient practice. Low volume.

It’s a fucking nightmare. I get why your wife went to out of pocket. I don’t blame her. but then it’s the conflict of making services less accessible. My patients often have no clue how to submit for reimbursement and insurers seem to purposely make this a difficult process. It really just sucks. I tend to work with lower income populations that really rely on insurance coverage so it’s not an option to go cash only for me but I definitely understand those who do. the system we have is deeply flawed, maybe irreparably.

The only setting that alleviated this was larger settings. Major healthcare networks/hospitals, large agencies, etc. it still came up but less often and when it did there was an army of billing staff to appeal. But the downside is that imo care was inherently compromised in these settings due to demands placed on staff. There were benefits of having teams, training resources, increased supervision, etc. but all of these were outweighed by significant overhead costs and productivity demands. For perspective moving to private work allowed me to earn 35% more while working 20% less within the first year. I’m not struggling to make ends meet and I’m not constantly flirting with burnout anymore. So imo those institutions aren’t the solution unless they can make real systemic changes

Even beyond insurance, the system is fucked. My wife finished her master's program and started working under supervision. But, of course, the only places which offer supervision are (generally) community mental health centers. So my wife was fresh out of school, with a client load of 55 people, getting paid $20/hr -- and those 55 people were generally the people with the least resources and support, thus some of the most challenging non-inpatient clients you'll find in mental health.

Beyond that, she learned that these community mental health centers, despite being nonprofits, are still aiming to constantly reduce costs; in her first six months, she saw many support structures for both clients and clinicians cut. This included laying off most of the case management staff, expecting the counselors to pick up the slack. She rarely even had time to keep her (legally-required) notes.

She lasted less than a year before quitting. She's not sure she'll ever go back.

Counselors are being squeezed from both sides here: They either burn out early, or the insurance companies fuck them over in perpetuity.

> Then the insurance takes four fucking months to process your intake session only to come back and say “hey wait, this actually isn’t covered because it’s technically out of network so neither are the 15 sessions that happened afterward”. Now you suddenly owe me 2-3 grand out of pocket and I either have to collect that, probably worsening your mental health by adding a signicant sudden expense, or write it off and basically say goodbye to any renumeration for the 16 hours of work I did. I will ask you to appeal of course.

Not a clinician but did (previously) work in software developing claims benefit management software.

One of the parts of the recent Surprise Billing reforms was that if a patient "could reasonably believe" that they were in network (and in particular, the prominent example of note being the insurer's website or a provider they use lists the provider as being in-network, because they ostensibly have control or input thereinto), then the insurer was obligated to remunerate the claim as being in-network.

i.e. if insurance's directory says "sure, provider X is in-network", they don't get to turn around after you use their service and say "You know what, they're not, so this is uncovered/out-of-network".

In my experience, this isn't anything special about therapists.

Going through the listings for any kind of doctor in your health plan is a nightmare. When I needed to see a primary care physician, it took two hours of calling 10+ listed offices to find one that was actually a primary care physician, was still practicing in the geographic area, was accepting new patients, and still accepted my health insurance (apparently dropping plans is common?). And the earliest they could see me was in 6 weeks.

It was the exact same type of experience when I needed to see a particular type of specialist, except the earliest appointment I could find was in 3 months.

The insurance companies just don't update their lists for any type of doctor, as far as I can tell. Whether this is due to sheer incompetence or deliberate deception or some combination of the two, I couldn't tell you.

Why in the world is the whole network thing even legal? It’s seems like a way to guarantee certain doctors and insurance companies a steady stream of cash flow without having to compete with one another. It is a hilariously corrupt system, but that’s par for the course with the medical industry. One of the only professions where you can charge people to have provided no solutions to their problems. Image a mechanic who tells you your misfiring engine and squeaky breaks are nothing and then charges you a few grand for the pleasure of them being obviously wrong.
Aside from such a scheme dominating a particular region and being a potential playground for other anticompetitive practices, nothing about the idea in general strikes me as inherently anticompetitive.

Insurance cos can still compete on the merits of their networks and, in theory but sadly I think not in practice, these schemes could work in favor of the patients if the insurance company uses their network to balance cost with service quality.

A very dominant one could effectively rule a region as a cartel, though.

> Why in the world is the whole network thing even legal?

The answer is on some of the other comments on this page. Insurance companies make reimbursement so difficult that some doctors do not want to accept the insurance.

> Why in the world is the whole network thing even legal?

Lobbyists

most professions that bill by the hour work this way? squeaky brakes isn't a plausible example, but this isn't uncommon for electrical issues in luxury cars. the mechanic spends days/weeks chasing it down and eventually asks you if you want to keep paying them to look. if you say no, you still have to pay for the time they already spent. if you say yes, there's no guarantee they eventually fix it. or they come up with a root cause and give an estimate to fix. you still pay if they're "obviously wrong".
Honestly this is why I really like having Kaiser as my insurance provider (for those who don't know, Kaiser is an HMO that is both the insurance provider AND the hospital/doctors office/pharmacy. You get all your care from them).

Some people don't like not having choices for doctors, but I would much rather just have one system to deal with. I don't have to print out medical records like I have to for my wife and kids (they are on a different plan), or call a bunch of different providers to find care, or go back and forth as two different providers say the other side is the one that has to do anything. I never have to argue with my insurance provider about paying for something, I never have to wonder if something will be covered.

What do you do if you don't like your doctor? Or your doctor just gets it wrong? Are you just screwed?

For example, a therapist is a very personal thing and I'd imagine you might have to try many to get it right. Psychiatry is as much an art as a science, so it's not like they're fungible.

Or what if, say, your internist dismisses your heart problems as anxiety, but you'd like to see a specialist because you know the difference and it's not just anxiety. That's it? Not allowed?

Oh yes. Physical therapy after a car accident. "Start immediately" say ER and PCP.

Only PT available to me? "Sure, I can see you in 10-12 weeks from now..."

My insurance automatically assigned the geographically closest doctor as my PCP.

That person was actually a nurse at the local high school.

Easier to just look for doctors on Google and call them and ask if they take your insurance. Hit rate is very high.
Why do I get the impression that the economy in 2023 is based on primarily fake things? So many things are either illusions, legal grifts, and outright ripoffs. This isn't anything new per se, but I think we may have gone beyond a critical threshold. Will the chickens come home to roost, or have things become so simulated that too many people believe ambiguously in the system for it to fail?
It’s basically the guaranteed end state of a society that both highly values individualism and has been kneecapping regulations/regulators/rule of law for decades.

You don’t need a very high proportion of the population to poison the well with bad behavior enough that everyone just accepts that as regular behavior and then even the ethical portion of your society starts engaging in the bad acts.

One of the main benefits for having a government is to go in and regulate bad behavior away that would never occur organically because each individual actor in society loses far too much trying to fix the situation on their own to rationally try.

The chickens won't come home to roost in anything like a dramatic moment of reconing. The USA will just slowly become more and more like many Latin American countries that should be prosperous in theory, and for some of their people there is incredible prosperity, but for most people it just appears like the only way to get ahead is to join some kind of thinly veiled racket masquerading as "business" or whatever.
History teaches us things can change fast. Think USSR in 1984. At some point things are going to give.

We have the technical means to provide a decent life for everyone. And I mean everyone, including illegal immigrants sneaking across the border. And we could do all that while everyone struggles less.

So yea. Most jobs are fake and stupid and don't need to be done. The ones that need doing could be given more support, distributed more evenly.

This was a mainstream economic viewpoint less than a century ago. What happened?

It won't fall over (there are still lots of real things out there), but it's pretty much just basic economics. If you can make a fake thing instead of a real thing for significantly less cost, but could sell it for a similar price, why would you make the real thing?
Ultimate capitalism is to sell nothing for money.
How long will we Americans submit to these rent-seeking vampire insurance companies? Single-payer now, please.
We'll never be rid of it. It's politically impossible to get rid of. And I don't mean "political" as in D vs R.

The amount of money we spend on healthcare in excess of the OECD average is more than we spend on the military. 10% ish of that is the entire yearly profit of the healthcare industry. The other 90% is raw inefficiency. And where does that 90% go? Mostly to salaries. Eliminate our inefficient system, and you eliminate millions of middle class jobs.

No politician will do it. They may talk about it and campaign on it knowing it won't happen. But they will never pull the trigger because it would be political suicide.

Also, if you want to know more than you ever needed to about the US healthcare system and why it is so expensive I highly recommend this report: https://www.mckinsey.com/~/media/mckinsey/industries/healthc...

I've lived with Swedish, German and now Czech healthcare in addition to American (with very good health insurance). I'd choose any of them over the American system. I find other Americans' fear of change to such a terrible and expensive system very confusing.
Imagine any single one of those companies being the single payer insurance you are forced into. They (government included) become far worse. Rationing care, deciding who lives or does, underpaying doctors and nurses till the best ones quit and the remaining have any care burned out of them. That’s what’s happened in other countries and regions and every time there is a surge or a more complicated care you and loved ones are left to die or deprived of care options.
With USDA captured by agricultural interests, and FDA by pharmaceutical lobby, what’s to prevent the regulatory capture of this new single-payer agency?
So the answer to "rent seeking vampire insurance companies" is a rent seeking vampire government agency?

No thank you.

The answer to government created problems isn't a government created department.

All you have to do is look at all of history to see the results of increased government power. Look at the lies of the unaffordable care act. look at the fact that things the government promises as "free" become unaffordable and worse.

I wouldn't necessary blame the insurance. My primary care doc gave me 10 referrals to psychiatric nurse practitioners but zero were taking new patients. I asked someone who'd written review articles on my condition to do the same and he said he would but I think he did some looking and came up short and ghosted me.
> I wouldn't necessary blame the insurance.

Why not? They're the ones who are gatekeeping the product (their network) at the same time as they're selling access to their network (this is considered one of the "features" on which insurance companies compete and sell their product).

Not to mention that, as mentioned in the article, insurers are legally required to maintain a sufficiently large network to enable their patients to receive care in a timely manner.

If insurance companies want to restrict patients and limit them to seeking care from providers within a preapproved, artificially limited network, then it's totally fair to criticize them for not ensuring that their network is sufficiently large and accessible to be practically usable by patients.

Insurance is collecting premiums for care that can’t be provided. I blame them.
Yes. All the time. First you have to find a therapist that actually exists. Then you need to find one who returns a simple email or phone call. Then one who is willing to take you on as a client, and finally one who actually has the tools to help. And each step is hell for someone with any of several conditions that might have been why they were seeking a therapist in the first place. It's no wonder we have a crisis - if that's even the word for something that has been going on so long.
Speaking from the clinician side insurance cos often make joining the network difficult and slow. It can take months. They very rarely reach out to get new providers to joint their networks when their subscribers are struggling to find clinicians. I’m pretty sure they just don’t tbh but I don’t know that definitively

Additionally certain insurers may pay terribly. Most insurers in my area pay about the same but one pays about 65% less than the average. It works out to less than minimum wage after I pay my overhead. No thanks, not joining that network.

The sooner we eliminate the insurance middlemen the better. Thankfully a bunch of cash-only networks are spreading.
I went to zoomcare recently, which is a clinic that does cash and/or insurance. They claim that without insurance the max for a simple visit is $200. With insurance they charged me over $300, a hundred more than people without coverage. When I asked how that was possible they laughed and said. “You know how insurance companies are.”

No the fuck I don’t. How can they get away with charging more for someone with coverage than without? What exactly is the point of my insurance if that’s the case?

Eliminating insurance would certainly help at this point - UHC alone is a wonderful proof of just how horrible that road is... but fee-for-service care directly paid for by customers needs to go. A reasonable level of healthcare is important and should be accessible to everyone.
This is true of every provider list of every insurance company I’ve ever used. It’s laughable bad.

“That doctor hasn’t been at this office in ten years” “Not taking new patients”

I hate the health insurance system in the USA so much. It's just horrendously bad. I had a kid enter this world at right about the same time I changed jobs. That resulted in changing health insurance. On paper, this should have been a little expensive but fine because I paid extra money for Cobra to extend my coverage until the new plan kicked in. But it was such a mess.

I was making phonecalls and sending emails and logging in to weird web portals with two different insurance companies, Cobra (which was managed by some mysterious other entity??), two different HR departments, and the finance people at the hospital for months trying to deal with this stuff. The hospital we were at was in-network for both insurance companies, but no one was communicating with each other (and apparently one doctor involved was not in-network, so there were extra charges, which is such bullshit).

Why is my employer involved with my healthcare costs anyway? It's genuinely a Kafka-esque nightmare.

Anyway, any presidential or congressional candidate that opposes universal healthcare doesn't get my vote, ever. Sorry Biden, but you don't automatically get my vote just because I disagree with the republican platform.

Even better, they refuse to remove therapists who no longer take insurance even after multiple attempts and letters requesting removal. It's a fun scam.
It’s unlikely this is as interesting as the headline suggests.

Maintaining a list of professionals is challenging. There are very simple input problems with this kind of data.

The professional, in this case a therapist, but it really doesn’t matter what they do, just isn’t going to keep their portal updated on the insurance network aggregator.

The insurance companies can’t make the anyone update their listing, and the professionals don’t have incentives. They’re full up on work so there’s no real need for them to do anything to get clients.

This is a bog-standard supply and demand problem.

It’s that interesting and this is a laughable attempt at apologism.
Many of the problems here might be a good use of simple AI to call / verify and keep on top of all these providers…
Oh heavens no