[Aurornis]

> The law firm says the surgeon made false claims. (Which claims? Were they false?)

The letter seems clear to me, and unfortunately for the doctor they have receipts (phone call recordings and the paperwork)

The biggest problem for the doctor is that they have a record of the doctor conceding that the wrong paperwork was submitted by her office (hence the call) and that the UHC rep asked for her to call back when convenient (not in the middle of surgery).

I think the UHC doctor got carried away, assumed all mistakes were on UHC’s end rather than her own admin staff, and then went to TikTok to tell a viral story with an exaggerated (at best) version of events.

> Alas, I guess "big company vs plucky surgeon in social media spat" is a simple script that requires no work, we don't need to be curious about who the hero(ine) and the villain are.

This mentality that we must pick a side, where one side is good and the other side is bad, is a huge problem with social media ragebait.

We can admit that the surgeon was wrong to make a viral TikTok with information that was somewhere between very misleading and an outright lie. Admitting this doesn’t make UHC the good guy or the hero.

You don’t have to pick a side. You shouldn’t automatically assume viral TikToks are true because they are targeted at companies you dislike.

[nineplay]

> the UHC rep asked for her to call back when convenient (not in the middle of surgery)

I'll echo the above poster - when an insurance rep calls us we drop everything on the floor and rush to answer it because otherwise they will continue to deny our claim and not get back for weeks. Then they reject our claim because it's now outside their 3 month window.

[legitster]

In this case though, the claim should have been denied because it was filed incorrectly.

Is there also a reason the surgeon themselves needs to get on the phone with insurance? Isn't that what the rest of the staff is for?

[nineplay]

> the claim should have been denied because it was filed incorrectly

Spoken like someone who has never spent hours online with an insurance company. They have told me that they can't see uploaded forms due to a 'glitch'. They have told me fields were missing when I am looking at the same forms and telling them where the field is and what it contains. They have been carefully instructed to tell lie after lie after lie hoping that the consumer finally gives up.

[roenxi]

That seems a bit incredible because it suggests that they would be denying 100% of their claims. If they're going to start lying about a form being filled out correctly in one instance, why ever stop? They can just keep lying forever on all claims.

I've had weird experiences online arguing (about shoplifting, as it happened) with people (I assume teenagers) on Discord who seemed to have a genuine belief that buying insurance was a magic positive-sum process for dealing with damages. They hadn't/didn't make the link that the insurer pays out approximately what they take in from premiums. That experience applied to medical insurance leaves me with a strong suspicion that UHC gets a lot of hate because they are the cheap option and people haven't cottoned on to the sad reality that if they want their claims paid out they can't go with the provider that is cheap because it denies a lot of claims. UHC's margins are there but don't seem to be that impressive. It wouldn't be surprising if they have to push back fairly hard or become insufficiently profitable.

[nineplay]

These companies - every company - know how to maximize profit. They know how many claims they can deny, they know what kind of claims they can deny, they know who is or isn't likely to fight back.

Hint - the people with the fewest resource are the least able to fight back.

UHC shouldn't have margins. Healthcare and profit are a deadly combination.

[IG_Semmelweiss]

the mistake in your assumption is that they are the "cheap" option.

UHC have all kinds of plans, both cheap and expensive, and their denial rates are high, regardless of what plans are purchased.

[roenxi]

Knowing the general madness of US healthcare, I want to stress this isn't rhetorical.

So why are people going with UHC?

EDIT I want to reply to 2 replies with the same comment, so I'll put it here - if the companies are paying & buying known-dodgy insurance, then why aren't they going with a cheap option?

[legitster]

No, but my newborn had to go to the ER once and it kicked off 18 months of billing disputes with the hospital. And the thing I learned was the depths of incompetence, malice, and laziness that a hospital billing department was capable of.

One of the key lessons - if a doctor submits an incorrect billing code, insurance can't do anything to change it. If a doctor doesn't want to work with insurance to fix the codes, you as a patient have so few options to do anything.

[nineplay]

I'm very sorry to hear that, I've been through any number of ER visits with my child. I have not personally had any issues with hospital billing departments, so perhaps I have been lucky. It is only the insurance I've had problems from.

[legitster]

But it's not the only billing problem I have had. A hospital billed us double for an emergency c-section (once for the mother, and again for the child) and hit us with $300k in claims. A dermatologist once faked a surgery and sent it to my insurance. And don't even get me started on the exploitative agreements hospitals sign with ambulance companies.

We're not even people who spend a lot of time in hospitals - but we are pretty close to a 100% hit rate for billing issues with hospitals. Even during times in my life when I didn't have insurance.

I get that people kind of ascribe all sorts of medical billing problems to insurance companies. But I think a lot of it is kind of ignorance comes from inept hospital management shifting blame. And often doctors and practitioners themselves are very removed and unaware of the awful billing at their own practices.

[y33t]

I've seen the same damned thing. Even when the state has previously gotten involved on behalf of a patient, I've seen insurance try to deny a surgery less than an hour before it was scheduled. Patient's husband called up the state and they said to not worry about it, they'd handle it. But even still, insurance companies do not stop trying it. The penalties they get are a joke to them. Executives need to face criminal penalties and be locked up in federal prison. Fuck it put em in Gitmo, those people are terrorizing us all.

[nineplay]

The goal is to wear you out and it's the context missing from the discussion. An external observer could look at any of my contested insurance claims and say 'They asked for more information, you gave it to them, the claim was approved, so what is the problem?"

What's missing is all the days I had to get up, check on my claim, and call them because the claim was still denied and they sure weren't going to call me.

What's missing is the hours I spent on the phone with them taking them step-by-step through the same issue each time.

[IG_Semmelweiss]

its called Peer to Peer.

This happens all the time.

Most independent doctors billing OON may also need to speak with 3rd party claims processor, in all likelyhood. Same is true for some WC/NF/Lien claims

[franktankbank]

I like how this case hinges on whether the call center employee said "at your convenience". It seems like its double edged to even admit such a thing.

[TheCoelacanth]

It also matters whether they are actually reachable at your convenience. A lot of business are virtually impossible to actually talk to unless you answer their call. They say to call back at your convenience, but you will only get their voicemail or an infinite waiting queue.

[nineplay]

The call center employee said 'at your convivence' knowing full well that they'd never be available at a convenient time.

[gruez]

Why? They presumably have recordings so it's unlikely to going to devolve to a "he said she said" situation, and I'm not sure how else you would rephrase "at your convenience" so the doctor wouldn't scrub out. Does every interaction need a 1 paragraph disclaimer to guard against a social media shitstorm?

[franktankbank]

The fact that a Doctor has to be worried about this shit at all is damning. The fact that a patient doesn't even pick their insurance (mostly tied to employer HR) is damning. The fact that a group can own the whole vertical is damning. The whole mechanism is a knot and anything less than untying it is going to have scary consequences I think.

[lotsofpulp]

It was 2024, it should not hinge on that at all. We have asynchronous communications, a timestamped email should be all the proof required.

If UNH requires others to communicate with them via complicated phone trees that waste callers' time, then that means UNH is automatically at fault.

[franktankbank]

Precisely!

[IG_Semmelweiss]

Agree.

You have pesky PHI in the middle. Funny how of all things, PHI hasn't done a thing to prevent data leaks in healthcare, but it has done fairly well in hindering all async communications with payors.

[lotsofpulp]

That’s not an excuse. There are messaging systems inside electronic medical record software they can use. If my healthcare provider can communicate to me via a website and show me all my labs and results and even synchronize with the Apple health app on my phone, surely, a doctor should be able to message an employee of the managed care organization.

[nradov]

Right. Specifically all modern EHR applications now support DirectTrust Direct Secure Messaging. This is basically just regular email with standardized encryption and other added security features necessary to make it HIPAA compliant.

https://directtrust.org/what-we-do/direct-secure-messaging

[IG_Semmelweiss]

its not an excuse, it is an observation based on fact

[IG_Semmelweiss]

I think the false claims were on the Tiktok, but the crux that i detect is the issue "UHC called doctor out of OR" is likely true even if UHC didn't intend it that way.

>>The letter seems clear to me

Where is the letter?

>> doctor conceding that the wrong paperwork was submitted by her office (hence the call)

That is a strong assumption to make. The tack you are taking is that one of the 2 parties noticed a wrong PA was requested (and approved) and tried to do something about it, preop. That's the assumption. IF the PA was fine, and that's 100% shenanigans by UHC. Less likely, but still very possible.

[karuselli]

Starts at 0:07 into the doctor’s video here (I don’t think she posted the document outside of this format): https://x.com/epottermd/status/1888397730784883096?s=46

[ranger_danger]

Thank you for such a well articulated response, I agree with you.

I am not a surgeon but I have experience standing right next to them during surgeries. In my opinion, they already know that there is never a need to take a phone call from an insurance company during a case. Other reasons for a call may exist, sure, that part is not out of the ordinary... but insurance approval would have already happened before the case had ever started. Plus the overnight stay is not part of the billing for the surgery itself anyways.

[legitster]

If anything, the doctor is admitting to a potential crime! Medical providers aren't supposed to deny procedures based on insurance coverage. Even if UHC called during surgery to say the claim was denied, it's the doctor's choice to do the surgery of not.

[mlyle]

> Medical providers aren't supposed to deny procedures based on insurance coverage.

This is false. There's EMTALA, which requires that emergency services will be provided until a patient can be transferred. But doctors absolutely refuse to provide services based on ability to pay all the time.

[legitster]

Good point. But as the original story made the rounds on social media, it got exaggerated to make it sound like this was a life-threatening surgery. Knowing that it was a routine call and it was a plastic surgery procedure definitely deflates the scandal of the whole thing.

[ceejayoz]

Removing a brain tumor is "life-threatening surgery", but it won't be subject to EMTALA requirements.

[nradov]

Well that would depend on the facts of a particular case. If a patient presents at the ER with a brain tumor which is causing severe symptoms such as unstable vital signs then under EMTALA the hospital might be legally required to remove the tumor regardless of the patient's ability to pay.

[ceejayoz]

No; the tumor itself would be non-emergent. The symptoms it causes - pain, for example - would be treated, then the patient would be discharged with a suggestion of a follow up with oncology.

[ceejayoz]

> Medical providers aren't supposed to deny procedures based on insurance coverage.

Only in a very specific, narrow set of circumstances.

https://en.wikipedia.org/wiki/Emergency_Medical_Treatment_an...

It only applies to emergency assessment and stabilizing care, and only if the facility accepts Medicare patients.

[xp84]

As far as I'm concerned, I still appreciate the propaganda value of a story even if it's full of half-truths like this one, because it's time for a reckoning for these companies. There's a tiny, like 1% chance, that someday we'll have the opportunity to institute single payer and kill these businesses full of sickening, greedy ghouls overnight, and anything that helps convince people of their sins so that they won't doubt that it's worth doing, I'm okay with. They've earned it with their many, many, 100% factual bad deeds. And they've never been above lying.

I admit that taking this attitude toward falsehoods isn't 100% ethical, judged by itself, but if it helps to end a system that has killed many thousands and will continue to do until it is abolished, this is a rare case where I'm ok with the ends justifying the means.

[gruez]

>As far as I'm concerned, I still appreciate the propaganda value of a story even if it's full of half-truths like this one, because it's time for a reckoning for these companies.

Just like "2 weeks to flatten the curve" and "masks don't work"? There's no way that "the ends justifies the means, a little lie to advance our cause" would backfire, right?

[xp84]

Indeed, I didn't like the dishonesty there. There's probably many situations where you're absolutely right. It's just that my hatred for this industry is too strong to grant them any quarter even when they're technically in the right.

Because the fact is true that even though they probably didn't demand to speak to the surgeon immediately, there's a reason the staff deemed it worth pulling her from surgery, and it's because if she didn't get to talk to the caller right now when they were on the phone, it could be any number of days before the matter could be resolved, and the hospital may not be willing to proceed if the insurance company is going to deny the claim, since that could saddle the patient with an unexpected $10,000 bill. In this way, our shitty system, designed on purpose by companies like UHC, forced most of this to happen.

[gruez]

>Indeed, I didn't like the dishonesty there. There's probably many situations where you're absolutely right. It's just that my hatred for this industry is too strong to grant them any quarter even when they're technically in the right.

You know what's arguably worse than insurance companies? Racists. So when there's a mysterious flu coming out of China and racists are latching onto it as a way to hate on Chinese people (eg. "China flu"), we better downplay it[1] so we don't give them any rhetorical ammo.

[1] https://www.cnn.com/asia/live-news/coronavirus-outbreak-01-2...

>there's a reason the staff deemed it worth pulling her from surgery [...]

Sounds like you're giving infinite charity to the doctor/staff and not allowing for any possibility that any sort of mistake on their end. Is this based off of any facts, or your "hatred for this industry is too strong to grant them any quarter even when they're technically in the right"?

[lovich]

You linked an article titled “No Clear Evidence Wuhan Coronavirus Can Spread Before People Show Symptoms” from _January 27 2020_.

The headline is accurate, at that point in time nothing about the virus was clear. The only portion of this article that even tries to downplay anything about China is this portion which as far as I know is still accurate.

> On the call with reporters, Messonnier also seemed to allay concerns that the virus could be transmitted via packages sent from China. Coronaviruses like SARS and MERS tend to have poor survivability, and there’s “very low, if any risk” that a product shipped at ambient temperatures over a period of days or weeks could spread such a virus.

> “We don’t know for sure if this virus will behave exactly the same way,” Messonnier said, but there’s no evidence to support transmission of the virus via imported goods.

Why are you trying to paint that as doctors lying?

[gruez]

>Why are you trying to paint that as doctors lying?

the exact wording I use was "downplay", not "lying".

>The headline is accurate, at that point in time nothing about the virus was clear. The only portion of this article that even tries to downplay anything about China is this portion which as far as I know is still accurate.

Even though the headline is technically accurate, the "downplay" part comes from the CDC trying to imply that the risk was low.

"Messonnier repeated her message that the immediate risk to the US public is low at this point."

[xp84]

I'm sure there was a technical mistake on the doc's end! But it's because UHC wants absolutely everyone to make 'mistakes' constantly, because every mistake delays or avoids a payment. Even a delayed payment moves an expense forward, maybe even into a new period, while the revenues are always captured promptly when your employer pays your premium. So, UHC's processes are purposely designed to add as much uncertainty and to be as easy as possible to derail.

The system insurance companies designed works something like this:

Provider: Enters patient ID, procedure code, date, etc. into the insurance billing system.

Insurance company: Applies an automated check to find reasons why this claim might be denied. For example: "Our records show that you amputated her right arm yesterday, so we can't pay for wrist surgery with a date of today" or "automatically deny all claims for XXXXXX as 'not medically necessary' and wait for them to appeal by following a separate process". If it finds any reasons, claim is denied. Some limited info is sent to the provider or patient, usually with a lot of latency.

Doctor or Patient: Must play a game with the insurance company to figure out (1) why insurance company thinks [insert wrong belief] (2) how to satisfactorily prove to them otherwise and (3) why despite after solving 1 and 2, the claim is still showing as denied. Providers are overwhelmed with hundreds of instances of this at all times, so they can't always handle doing this for you, and patients often lack the documentation, medical knowledge, and legal definitions in the policy, to be able to advocate for themselves.

If it were designed by anyone other than a bunch of ghouls looking to profit off killing people, there would be good ways to asynchronously but promptly enumerate and solve the problems that prevent claims from being paid. This would be tricky to build, but not impossible if the parties involved wanted to cure disease and save lives more than they wanted to be rich.