[lotsofpulp]

>So insurance companies spend more so they can collect higher premiums. That's how they make more money. >

If this is correct, then how come there are so many complaints about insurance denying payment for healthcare or the hoops they make patients and doctors jump through for pre authorizations?

If the path to more profit was spend more money, then there would be no reason to question a doctors’ orders? Nor threaten doctors and hospitals with leaving the network if they don’t agree to lower prices?

Yet, one often hears about so and so plan will not have so and so hospital system in network unless they come to an agreement.

[rayiner]

> If this is correct, then how come there are so many complaints about insurance denying payment for healthcare or the hoops they make patients and doctors jump through for pre authorizations?

Because those anecdotes get reader and viewer engagement. Charts comparing how much U.S. insurers pay on average for common procedures compared to, say, the UK NHS, don’t drive forward the narrative.

You should interrogate the media sources you consume and ask why you’re fed so many stories like that, and investigate what the real data is. A few years ago my friend got a continuous glucose monitor for Type 2 diabetes. I looked at the coverage polices for continuous glucose monitoring (for Type 2) for my insurer and some of the other big ones. Turns out that most US insurers, Medicare, and Medicaid in 45 states+DC cover continuous glucose monitors for people who have type 2 even those that don’t use insulin. At the time, most Canadian provincial systems didn’t cover the technology except for Type 1 or people who take insulin. UK NHS was worse, covering it only for Type 1, or Type 2 with certain conditions (such as you’d otherwise need to do 8 or more pin prick tests a day). https://www.diabetes.org.uk/about-diabetes/looking-after-dia...

[onraglanroad]

You should take your own advice and widen your media sources.

Yes, you only get a continuous glucose monitor for free if you really need it on the NHS. If you want one otherwise you need to spend $100. It's not going to bankrupt you.

[rayiner]

That’s the price for one monitor You need to buy a new monitor every 10-15 days. And your point about my media sources doesn’t make sense. As stated, I researched the coverage of continuous glucose monitoring because my friend got prescribed one.

The point isn’t that the UK NHS should cover CGM. I think they shouldn’t; it’s a waste of money unless you really need one. My point was about why the media pays so much attention to denials of coverage while you don’t hear about the over-coverage. You can’t go by the anecdotes. Talking about insurance covering unnecessary procedures doesn’t generate clicks.

[nradov]

Complaints about denied claims or prior authorization requirements should generally be directed at employer HR departments. Most HN users in the USA probably have employer-sponsored group health plans, and often those are self-funded where the insurance company doesn't actually bear any risk but just administers the plan. Commercial insurers would be happy to sell plans that pay every claim that comes in at 100% with zero denials. It would be less work for them. But naturally employers don't want to pay for that, so the HR departments have the insurance carriers impose more restrictive coverage rules to hold down medical expenses.

[lotsofpulp]

> Commercial insurers would be happy to sell plans that pay every claim that comes in at 100% with zero denials. It would be less work for them. But naturally employers don't want to pay for that, so the HR departments have the insurance carriers impose more restrictive coverage rules to hold down medical expenses.

This is not my experience as a buyer of health plans on healthcare.gov, or as a buyer of health plans as an employer (where the employer is not self insuring). The prior authorizations and denials happen all the same.

Additionally, the premiums are the same between employers’ self insured plans and healthcare.gov plans, so the coverage must be similar.

https://www.kff.org/health-costs/how-aca-marketplace-costs-c...

>In 2024, individual market insurance premiums averaged $540 per member per month, slightly below the average $587 per member per month premium for fully-insured employer coverage.

The idea that health insurers can simply spend more to earn more is not passing the smell test.

[nradov]

Your experience is irrelevant. Insurance carriers have some standard default policies but they'll write whatever custom policy that a group buyer is willing to pay for.

[lotsofpulp]

Your claim was

> Commercial insurers would be happy to sell plans that pay every claim that comes in at 100% with zero denials.

And yet I have never seen one of these after buying insurance in 3 different states.

Again, the grandparent claim was that insurance companies can increase profits simply by increasing their expenses. Yet there is no evidence of this, and the fact that everyone has to deal with approval and denial of healthcare coverage means it cannot be true.

[nradov]

You're really missing the point. Have you ever been in charge of employee benefits for a large group buyer? Obviously such plans aren't available to individual consumers but commercial carriers will absolutely customize products for larger customers.

[lotsofpulp]

timtim51251 wrote this:

> The actual reason commercial insurers pay more is that's the only way to can make more profits.

>Because of Obamacare requiring 80% of the money they collect to be spent, the insurance companies just get to keep 20%. So insurance companies spend more so they can collect higher premiums. That's how they make more money.

dmitrgyr wrote this:

> Ding Ding Ding. We have the correct answer. And this was a predicted consequence of that profit cap.

These statements indicate there should exist an insurance plan with a policy to pay for anything and everything. It does not matter what large self insuring employers choose to buy, as there are still significant number of people covered by non employer insured health plans.