You just have to leverage it right 
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Just make sure you put that in the contracts. Otherwise youâll be shutdown and sued to oblivion.
And have fun watching the ant farm get mad they didnât read an agreement they were signing.
If it wasnât so sad, it could be funny.
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Oh, the people who did that were all right around my age. I was a cash only guy scratching my head feeling like a looser for not having a house, a hunting camp, 2 suv, and a boat to tow around on weekends.
Then poof! It was 2008! And everything was gone.
Yeah. Itâs a corporate debt leveraging strategy that is supposed to allow growth at a faster rate than repayment terms, with bankruptcy strategically played in some cases (corporate bankruptcy is a little different).
It doesnât really work in personal finances. But, like IIFYM diets, too many people saw the upside and pigged on donuts instead of blueberries so there wasnât any âgrowthâ, only debt.
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âSophisticated Financial Instruments For Dummiesâ.
Best seller 1999-2006.
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I think what upsets a lot of people is companies hiding behind contracts or policies as agreements, but in reality itâs a âdammed if you do, dammed if you donâtâ situation.
Hiding behind the letter of the law instead acting of the spirit of the law dosenât look smart, it feels cowardly to people.
But Iâm a hypocrite when it comes to that. Since weâre shitting on geese, Iâll use them as example. When California banned foie gras, I had no problem working around that. Iâd buy the whole goose carcass from a farm that had been raised to be foie, but that was not illegal since it wasnât a finished product. Then since I couldnât sell it directly, I sold it as âcomplimentaryâ while charging $55 for a plate of toast points.
But I didnât kill anyone with my legal loopholes.
Itâs the disconnect between approaches to a social contract and how we respect it and each other.
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Sure, and that makes sense. But the sentiment is exaggerated.
I believe the linked and sourced article earlier in the thread mentioned something like 92% of all claims are paid on first pass, then there was a percentage of reviewed but paid claims bringing the total up higher.
I would be curious to see details on denials, and how they came about.
If I had to guess, the majority of denials were simply not part of coverage. Contracts are agreements, and they work both ways. Itâs why they exist.
I donât handle claims but I hear about them. Iâve heard denials pop up after it was found people lied on applications too, and this is a pretty common occurrence among denied claims for both health and life insurance. Applications explicitly ask questions for a reason (revisit risk bands, risk tolerance and legally mandated financial ratios), they also warn that a lie could result in denied coverage upfront, and when people wind up owning their own lies they still blame the insurance company.
Itâs exceedingly rare for an insurance company to simply deny somebody a due claim, because itâs illegal with major ramifications.
There are no loopholes. Only people who feel entitled to more than theyâve agreed to. While still ignoring the fact itâs the surgeon charging them a house.
Keep in mind itâs the providers who ultimately provide or deny treatment.
I know you want to believe insurance is the big evil, and youâll keep towing the narrative line youâve bought, but you have an inaccurate view of the overall scenario.
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Iâd argue that I have a different approach due to life experience.
But thank you for your detailed responses. They have been very interesting to think about.
I would be curious to hear a proposed solution that accounts for legal operating mandates, contractual integrity, price control limitations and financial ratios discussed.
The answer canât just be âpay MOARâ, itâs impossible.
I agree. And youâre the numbers guy, so my approach is less about keeping the insurance market floating, and more about how it is is so disjointed and always passing responsibility on.
For example, my son has floating-harbor syndrome. He has been denied his treatment because his condition is so rare and we had to get 3 medical papers and a primary and a pediatrician to certify it, but we got denied multiple times because it wasnât deemed âmedically necessary.â
Thatâs it. The doctors arenât the ones making that decision. The bean counters are. They canât try to claim a broken industry is helping people when itâs doing the opposite. A provider entered one wrong number on my HSA card and turns it over to collections? Shit, my responsibility to fix. Oh, the wrong state got entered by someone in bluecross and theres no way to fix it, so I have to pay out of pocket for a clerical error? Cool. Iâve maxed out my copays for the year months ago and providers are still calling me about $25 and then tell me I have to call my insurance company because itâs still my responsibility, and we can sort it out after Iâve paid (right . . )
This is why there is so much anger, the whole system is uniquely shittily American and people are fed up because itâs all numbers and no soul. Itâs not a necessary evil, we can actually make changes instead of shrugging and assuming this is how it should be.
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Is that sarcasm?
The irony.
I think itâs Canadian.
People will repeat the myth about European healthcare and its long wait times for medical procedures but how are denials, incorrect denials at that, somehow better? Then you have those who will ask how do we pay for it, a question that wonât get asked when Musk wants to send people to Mars or how we will manage to round up millions of illegals and send them back. Illegals who will be getting free health care while waiting in some detention center for their day in court.
Oh youâre back!
I believe in the death penalty, too. Not going to rehash the ideology behind it.
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The irony is the fat, pasty cracker who was killed is innocent until proven guilty but Mangione isnât.
I donât believe in the death penalty because the state shouldnât have that power over citizens. And we know that innocent people have been executed because of those in the state who have abused that power. Letâs think about that; you have an issue with an overzealous cop and a golfer yet you would trust someone in the justice system with holding the power of life and death over a citizenâs head?
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Distribution of care still isnât insurance, though. Insurance is the financial vehicle mediating and off-setting healthcare costs, per agreed upon terms.
Just looked it up. Heâs lucky to have have parents who care enough to seek out treatment. Iâm sorry to hear youâre facing the challenge.
Efficiency in processing claims in uncommon scenarios probably could be improved across carriers. I understand this would be frustrating, and hearing that there will be a delay or even a decline is a hard pill to swallow. End of day, it does not negate contractual obligation.
This is highly personal, and I understand if you donât want to share, but what specifically was the treatment deemed not medically necessary, and by what justification?
Did the medical professionals themselves offer pro bono work, or steep discounts for the care in question? Not being sarcastic, sometimes they will negotiate their costs with you directly. Iâm curious how they addressed care/cost, or if they sent you packing.
They kind of are though. Like you charge for your services. Maybe someone canât afford you for a wedding, so they get a personal loan. They want prime roast and duck confit, but the loan terms specify Salisbury steak and chicken breasts.
You could offer to discount your services, if you wanted to. So could the butcher (pharma).
Not a perfect analogy but I still donât understand why the cost leaders themselves keep getting a pass in the equation.
I would consider legal action here, especially if itâs dinging your credit and causing hardship elsewhere. Probably oversight, but a problem and liability all the same. Not unique to insurance, however. Itâs unfortunate when an error can have downline ramifications like this.
It was the provider who made the mistake though, right? I again sincerely donât understand why insurance is getting the blame.
If BlueCross made the error, I would add it to the legal consultation conversation with a lawyer. However, the providers also are not working with you.
Framed another way, âwe are going to charge you a shit ton. And we just are, because thatâs what we do. And you expect us to be expensive and since we are going to run billing through your insurance anyways and they will communicate balances with you, youâre just going to blame them. So fuck you, pay us the fortune and good luck. We arenât going to wait for the corrected error. Oh and we fucked up when we punched your info in too, so the bill will be lost in transit and will end up in collections but blame BlueCross anyways. Hereâs a lollipop, see you next timeâ.
It really is a two way street, but initiated by the healthcare industry and their exorbitant costs.
But again, what is the solution? Everybody talks about private vs socialized payment systems, but in the USA why do we pay more for the care itself than any other developed nation? When do we begin a dialogue on the actual cost of care itself, the root of the problem?
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Wow! one post after a short hiatus and you caught your quota for out of context strawmen, red herrings and tangents.
You are not without talent, Zecarlo. I will grant you that.
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Growth hormone therapy, occupational therapy, AAC devices, and some medications.
The reason given was that there was not enough evdence available to justify care.
Which isnât suprising since less than 100 people have been diagnosed with it.
Yeah that is tricky. The process is most likely getting stuck in the medical billing and coding realm. Not my forte but it is a codified system with values assigned to very specifically described instances, which is again unfortunately heavily regulated and results in tied hands. Itâs complicated to get in to a granular conversation about.
Essentially your doctor âtold a storyâ via a coding system, and the insurance company determined from that story that the coverage wasnât necessary.
This is different than a decline, for the record, but follow me. Iâm not arguing who is at fault primarily in this post.
A decline would be a scenario where the doctorâs story did communicate need and insurance still said no.
Itâs nuanced, but important. Sometimes in tricky situations it can be helpful to work with the doctor or medical group who hired the doctor to code things in a way that tells the insurance company coverage is necessary.
A very simple example to illustrate is testosterone replacement therapy. How many guys are hypogonadal for real, and how many âpassedâ the quality of life questionnaire that was written in a way it essentially covered mental health - with testosterone as the prescribed cure?
Itâs all about how you answer and how those answers are coded.
The same guy could go to two clinics and have two different outcomes at insurance based on the docs report, with the exact same labs.
My point is, and you may already be doing this, it may behoove you to get somewhat familiar with the medical billing and coding process. At least enough to have a productive conversation with your sonâs provider about how the story is being translated from his or her office through coding and billing to insurance.
I think the implication of who is who in the insurance vs. health tug-o-war is sort of clear here but Iâm happy to table that given the personal nature and emotion around it.
Itâs possible the billing and coding story is painting the picture correctly and insurance is out of line, and I would double down on the legal angle here if it were me should that be the case.
But, imo, I would sincerely begin researching enough to ask some pointed questions at the doctors office as I am interpreting the scenario.
I hope things clear up for you.