[blackeyeblitzar]

Evicore is a highly suspicious company, and the story of the patient who passed away in this article is sad. But I have noticed insurers do this (false claim denials) all on their own too. I and many friends have experienced Aetna routinely denying things that are explicitly covered by their plans and mentioned in the plan documents. They force you into an exhaustive cat and mouse game of chasing their team to reprocess denied claims. But after the initial denial, every conversation goes to some other part of their support team with hour long waiting times (meaning you may have to try multiple times across multiple weeks due to other obligations in your schedule), incompetent staff that barely speak English (making it hard to get the info or action you want), and very loose commitments from Aetna (they’ll promise getting back in 45 business days but even with that they won’t have done anything when you check in weeks later). I think these are purposeful games meant to deter people from successfully filing claims, by exhausting them, or simply shifting their payments into the future. I feel it is criminal. Not just in terms of fraudulent denial but in affecting people’s health by creating stress for them over big medical bills that should be covered.

[scottLobster]

It's not even just insurance companies. My wife and I had a child earlier this year, uncomplicated natural birth, fully covered under insurance. However the hospital initially filed the claim incorrectly, causing the claim to be denied and us to receive a bill in the thousands well in excess of our deductible/coinsurance.

Hours of phone calls to insurance and hospital later, we think we have it resolved but are informed it may take up to 6 weeks to process. Fine, we wait six weeks. Hospital starts threatening to send us to collections for non-payment. Hours of phone calls later it turns out they were waiting on information from insurance that they never received. So six phone calls later we think we've gotten it all sorted out. This time people actually follow through, hospital switches our payment to pending and that's the last we heard of it. Got confirmation that insurance paid out several months later.

Again, the hospital messed up the paperwork, but the burden of solving the problem falls on us, with serious financial consequences if we don't. While we're dealing with a newborn no less. There should really be a law that makes institutions liable for such errors.

Also insurance was a little shady as well. The amount of the outstanding bill should have pushed us over our out-of-pocket-max for the year, but when they finally paid out they marked it as an "adjustment". Which means we're still in the coinsurance part of plan. So we're getting deeply discounted healthcare for the rest of the year, but not free. It's not worth the time for us to run down, and maybe they're doing everything in line with the fine print, but it definitely smells rotten.

[blackeyeblitzar]

Our situation and many friends is the same thing - uncomplicated birth. There was no error in how the claim was filed - just an unexplained denial. Which then led to a long drawn out process that required time and stress. All when you’re trying to focus on your child. I think insurance companies like Aetna target new mothers in particular, knowing they’re too busy and exhausted to deal with hours of phone calls. We deserve and want compensation for that time and stress.

[DangitBobby]

I'm in a similar situation now. I don't understand why the insurance company and the hospital billing staff can't talk to each other, and require me to act as a mediator. At this point it feels malicious.

[a_vanderbilt]

In all practical ways, it is malicious. The system is intentionally designed to pay out as few claims as legally possible and use every legal means to obstruct and draw out the claims process. The U.S. healthcare system as a whole is a bastion of inefficiency and corruption.

[toomuchtodo]

This is the answer.

[Terr_]

> There should really be a law that makes institutions liable for such errors.

Does there need to be an explicit law?

Could one sue in small-claims court for the time and expense damages?

[scottLobster]

Fun thing about small claims (once had to sue a bad landlord, eventually settled out of court), even if you win you have to extract payment. That means you need to figure out which banks have which accounts you want to garnish and contact them, which properties to put liens on, etc or hire a collections firm to do that.

I suppose an institution might be more willing to just pay up and be done with it, but if they want to make it costly they very much can, even if the judge immediately sides with you. Often negates what you would have "won", particularly if you factor in time.

[Terr_]

If nothing else, I assume it could defray any ostensibly-legitimate costs the hospital or service-provider is demanding from you.

[scottLobster]

"Could" is the operative word, just as likely you'll end up exchanging one form of time/money/stress for another. If you want the satisfaction that your money went to the courts/lawyers/collection's agencies rather than the entity who wronged you, fine, but that's about the best you can hope for below a certain dollar amount.

Also you have to prove damages, back when we were suing the landlord I brought up throwing on lost wages for the time I had to take off work to deal with the illegal stuff we were suing over, and our lawyer said "yeah we can try but it's unlikely the judge will award that because you weren't forced to take that time off". There's all sorts of gotchas like that.

That experience really opened my eyes to how the system really does screw the average person. I'm upper middle class and extremely well educated, so is the rest of my family who were supporting us throughout. I can't imagine how someone making the median salary who reads at a 5th grade level would navigate it. That's probably what said scummy landlord was counting on and why he settled when it was clear we weren't easy targets.

The system serves the common man reluctantly at best. Justice is a luxury good.

[maxerickson]

Why is small claims court better than a law flipping the default liability?

It's basically insane that we require individuals to sign a blanket billing authorization prior to receiving care. Perhaps the hospital should have to provide a maximum amount that is at risk (hopefully creating pressure to operate in a sensible way).

[gosub100]

And what voter would ever want things to be this way? What constituent, rich or poor, conservative or liberal, says "ya know, I like paying for healthcare even when I have insurance and I'm going to keep voting for the one who keeps this status quo!" ?

Some very clever people have architectected an effective scam to prevent the democratic system from solving this. And I'm not referring to a republicans vs democrats debate about free socialized care vs hands off privatization. I'm talking about little steps that chip away at the problem like the one you described. Or forcing them to pay first, and only later have a debate about it. Or holding insurance liable for injury resulting from denying coverage. There is plenty of room for improvement and yet the representatives manage to accomplish nothing along these lines.

[aspenmayer]

This reminds me of the recent Disney+ arbitration case...

https://lawandcrime.com/lawsuit/borders-on-the-absurd-dead-w...

[toomuchtodo]

When it appears a legitimate claim is going to be denied, I recommend immediately opening a case with your state’s insurance regulator. If it’s an employer sponsored plan, the Dept of Labor. Success is not assured, but it creates a paper trail for regulators and other interested parties, including attorneys you might eventually involve.

(volunteer patient advocate)

[blackeyeblitzar]

That’s a great tip. I remember wanting to report this to some authority then but just didn’t have the time to deal with it. I wonder if I can still do it now after this has been settled (the claim was eventually paid, months late, after many many hours spent on phone calls).

[toomuchtodo]

You can still file a complaint even if the issue has been resolved. It will be logged.

[fatnoah]

> I and many friends have experienced Aetna routinely denying things that are explicitly covered by their plans and

My dad passed away from cancer over 20 years ago, and this was Aetna's plan even then. Each claim followed the exact same process of deny, approve but pay only pay a fraction, and then finally pay the correct amount. Literally every single claim. My mom built an automation in Excel to track the calls for each claim and to prompt her at the various time intervals required to follow up at each phase.

Personally, I experienced this went I went to the ER with acute abdominal pain and ended up having emergency surgery within a few hours. Naturally, Aetna tried to deny that my ER visit was an actual emergency. On the phone with the rep, I asked them if they new of any non-emergency situations where someone was able to have a surgery scheduled only 4 hours in advance. They agreed that it was an emergency and promptly paid $8k of the $16k bill. After another call several months later, they paid all but $800.