Various healthcare

[Marvin the Martian]

First, the drug companies have a competitor, Four Thieves Vinegar Collective. They teach groups how to make their versions of the same drugs that big pharma makes. For example, there is a drug that costs $1000 per pill that cures Hep-C. Doesn't treat, cures. But it takes 84 pills. So insurance never pays for it, they pay for the much cheaper pill that treats Hep-C making it so one can live with the disease forever. Obviously, I think most would rather it be cured—the cost of the cure for the collective to make, 80 cents a pill.

‘Right to Repair for Your Body’: The Rise of DIY, Pirated Medicine

Four Thieves Vinegar Collective has made DIY medicine cheaper and more accessible to the masses.

www.404media.co

Another drug they work with is Daraprim. Now this one was $13.50 a pill until a hedge fund startup bought the rights and it went to $750. So this is different than above, this isn't a company recouping investment costs, this is profiteering. So they make Daraprim available. It is mentioned in the story above, here is a story about it being bought and the price jacked up:

https://www.nytimes.com/2015/09/21/business/a-huge-overnight-increase-in-a-drugs-price-raises-protests.html

Now switching to insurance. By law, insurance denials are to be looked at by doctors and signed off on. One would think that is to safeguard the consumer. In CIGNA they are signing off on denials at an incredible rate, one former employee-doctor said it takes 10 seconds to sign off on 50 denials. One doctor rejected 121,000 claims in his first 2 months. How much time is he spending looking at a file and considering?

This hit home after a buddy had a claim rejected. I've known him since high school, he was diagnosed with a degenerative lung condition and his quality of like greatly eroded. It came to the point he could no longer work though he was desperate to work until 67, so he was facing going on social security disability. Just before that point, he was sent to a new specialist. The specialist said he was misdiagnosed. his issue was in the pulmonary artery and there was a very effective treatment in a pill. Of course the pill cost maybe $1000 per pill, but it was available. This is someone who could barely sit up for 2 hours any longer. Of course his insurance denied it. He won on appeal, but it was 3 months. It seems the insurance company has an incentive to deny. The worst that happens, they save 3 months of the treatment. If they are lucky, he accepts their decision and they never pay.

So it turns out, Aetna is doing almost the same thing as CIGNA. Claims are denied in bulk without being reviewed.

https://www.cnn.com/2019/04/26/health/aetna-settlement-california-investigation/index.html

It seems coverage mandated by state law are often turned down:

Health Insurers Have Been Breaking State Laws for Years

States have passed hundreds of laws to protect people from wrongful insurance denials. Yet from emergency services to fertility preservation, insurers still say no.

www.propublica.org

Mistakes happen, we all know that. But it seems that insurers aren't particularly concerned about reducing mistakes that benefit them. And as that last article notes, the fines are often a very small percentage of their profits, so not exactly a great deterrent. If enough big bills are held back for a month or three on appeals, that can be a lot of interest gained.

 

[mcmurtry66]

First, the drug companies have a competitor, Four Thieves Vinegar Collective. They teach groups how to make their versions of the same drugs that big pharma makes. For example, there is a drug that costs $1000 per pill that cures Hep-C. Doesn't treat, cures. But it takes 84 pills. So insurance never pays for it, they pay for the much cheaper pill that treats Hep-C making it so one can live with the disease forever. Obviously, I think most would rather it be cured—the cost of the cure for the collective to make, 80 cents a pill.

‘Right to Repair for Your Body’: The Rise of DIY, Pirated Medicine

Four Thieves Vinegar Collective has made DIY medicine cheaper and more accessible to the masses.

www.404media.co

Another drug they work with is Daraprim. Now this one was $13.50 a pill until a hedge fund startup bought the rights and it went to $750. So this is different than above, this isn't a company recouping investment costs, this is profiteering. So they make Daraprim available. It is mentioned in the story above, here is a story about it being bought and the price jacked up:

https://www.nytimes.com/2015/09/21/business/a-huge-overnight-increase-in-a-drugs-price-raises-protests.html

Now switching to insurance. By law, insurance denials are to be looked at by doctors and signed off on. One would think that is to safeguard the consumer. In CIGNA they are signing off on denials at an incredible rate, one former employee-doctor said it takes 10 seconds to sign off on 50 denials. One doctor rejected 121,000 claims in his first 2 months. How much time is he spending looking at a file and considering?

This hit home after a buddy had a claim rejected. I've known him since high school, he was diagnosed with a degenerative lung condition and his quality of like greatly eroded. It came to the point he could no longer work though he was desperate to work until 67, so he was facing going on social security disability. Just before that point, he was sent to a new specialist. The specialist said he was misdiagnosed. his issue was in the pulmonary artery and there was a very effective treatment in a pill. Of course the pill cost maybe $1000 per pill, but it was available. This is someone who could barely sit up for 2 hours any longer. Of course his insurance denied it. He won on appeal, but it was 3 months. It seems the insurance company has an incentive to deny. The worst that happens, they save 3 months of the treatment. If they are lucky, he accepts their decision and they never pay.

So it turns out, Aetna is doing almost the same thing as CIGNA. Claims are denied in bulk without being reviewed.

https://www.cnn.com/2019/04/26/health/aetna-settlement-california-investigation/index.html

It seems coverage mandated by state law are often turned down:

Health Insurers Have Been Breaking State Laws for Years

States have passed hundreds of laws to protect people from wrongful insurance denials. Yet from emergency services to fertility preservation, insurers still say no.

www.propublica.org

Mistakes happen, we all know that. But it seems that insurers aren't particularly concerned about reducing mistakes that benefit them. And as that last article notes, the fines are often a very small percentage of their profits, so not exactly a great deterrent. If enough big bills are held back for a month or three on appeals, that can be a lot of interest gained.

I hate insurance companies more than Burger King commercials, more than monkeybranching, more than parking the bus, more than baseball, more than anything

 

[mcmurtry66]

First, the drug companies have a competitor, Four Thieves Vinegar Collective. They teach groups how to make their versions of the same drugs that big pharma makes. For example, there is a drug that costs $1000 per pill that cures Hep-C. Doesn't treat, cures. But it takes 84 pills. So insurance never pays for it, they pay for the much cheaper pill that treats Hep-C making it so one can live with the disease forever. Obviously, I think most would rather it be cured—the cost of the cure for the collective to make, 80 cents a pill.

‘Right to Repair for Your Body’: The Rise of DIY, Pirated Medicine

Four Thieves Vinegar Collective has made DIY medicine cheaper and more accessible to the masses.

www.404media.co

Another drug they work with is Daraprim. Now this one was $13.50 a pill until a hedge fund startup bought the rights and it went to $750. So this is different than above, this isn't a company recouping investment costs, this is profiteering. So they make Daraprim available. It is mentioned in the story above, here is a story about it being bought and the price jacked up:

https://www.nytimes.com/2015/09/21/business/a-huge-overnight-increase-in-a-drugs-price-raises-protests.html

Now switching to insurance. By law, insurance denials are to be looked at by doctors and signed off on. One would think that is to safeguard the consumer. In CIGNA they are signing off on denials at an incredible rate, one former employee-doctor said it takes 10 seconds to sign off on 50 denials. One doctor rejected 121,000 claims in his first 2 months. How much time is he spending looking at a file and considering?

This hit home after a buddy had a claim rejected. I've known him since high school, he was diagnosed with a degenerative lung condition and his quality of like greatly eroded. It came to the point he could no longer work though he was desperate to work until 67, so he was facing going on social security disability. Just before that point, he was sent to a new specialist. The specialist said he was misdiagnosed. his issue was in the pulmonary artery and there was a very effective treatment in a pill. Of course the pill cost maybe $1000 per pill, but it was available. This is someone who could barely sit up for 2 hours any longer. Of course his insurance denied it. He won on appeal, but it was 3 months. It seems the insurance company has an incentive to deny. The worst that happens, they save 3 months of the treatment. If they are lucky, he accepts their decision and they never pay.

So it turns out, Aetna is doing almost the same thing as CIGNA. Claims are denied in bulk without being reviewed.

https://www.cnn.com/2019/04/26/health/aetna-settlement-california-investigation/index.html

It seems coverage mandated by state law are often turned down:

Health Insurers Have Been Breaking State Laws for Years

States have passed hundreds of laws to protect people from wrongful insurance denials. Yet from emergency services to fertility preservation, insurers still say no.

www.propublica.org

Mistakes happen, we all know that. But it seems that insurers aren't particularly concerned about reducing mistakes that benefit them. And as that last article notes, the fines are often a very small percentage of their profits, so not exactly a great deterrent. If enough big bills are held back for a month or three on appeals, that can be a lot of interest gained.

And I will tell you another thing. Deductibles on plans today (private) are insane.

 

[Marvin the Martian]

I hate insurance companies more than Burger King commercials, more than monkeybranching, more than parking the bus, more than baseball, more than anything

Wow, that sounds like you hate them as much as a sane person hates soccer. That's something.

I think there is a misunderstanding what the insurance company is. We may pay it, or part of it, but it really doesn't work for us. You know when you pay a real estate agent, that is supposed to trigger them to work in your best interest (and it doesn't work either, hence why the lawsuit that ended the flat commission happened). Insurance companies don't seem to have any pretense that they work in our best interest. Their job is to make a profit within, or at least in the same area code of, the law.

 

[mcmurtry66]

Wow, that sounds like you hate them as much as a sane person hates soccer. That's something.

I think there is a misunderstanding what the insurance company is. We may pay it, or part of it, but it really doesn't work for us. You know when you pay a real estate agent, that is supposed to trigger them to work in your best interest (and it doesn't work either, hence why the lawsuit that ended the flat commission happened). Insurance companies don't seem to have any pretense that they work in our best interest. Their job is to make a profit within, or at least in the same area code of, the law.

The entire system is broken. And I do believe if we replaced it all with gov providers care would suffer. We wouldn’t get the best docs etc. so I wouldn’t go that far. But insurance, the cost of care, all of it needs a deep audit. I’ll spend $30k easy this year on health insurance premiums, deductibles and meds. I love when they try a new med for my daughter. Creon. Okay. $1k for the prescription. Done paid. Next month well actually now we can do it for $30. Next month we’re not covering it. We’re giving you zenpop or whatever. Okay. Next month yeah that gave her diarrhea. We want creon back. Well we need to review. Okay I’ll pay out of pocket while review is pending. Joke

 

[El Drado]

The healthcare industry just irritates me. What the healthcare/insurance charges individuals and small companies is borderline criminal. There is no other industry that can behave like this and can get away with it. When i hear people have to postpone retirement for insurance reasons, it is just sad.
The only way to get this in check is a government action. I would EASILY vote for the other political party if they had a clear path to "fixing" healthcare. There are just so many sad stories of people being financially burdened.

 

[mcmurtry66]

The healthcare industry just irritates me. What the healthcare/insurance charges individuals and small companies is borderline criminal. There is no other industry that can behave like this and can get away with it. When i hear people have to postpone retirement for insurance reasons, it is just sad.
The only way to get this in check is a government action. I would EASILY vote for the other political party if they had a clear path to "fixing" healthcare. There are just so many sad stories of people being financially burdened.

And poor people they’re fckd. Medicaid. Please. The good doctors don’t take that shit. Have your baby in the hood with the flunkies

 

[Marvin the Martian]

The entire system is broken. And I do believe if we replaced it all with gov providers care would suffer. We wouldn’t get the best docs etc. so I wouldn’t go that far. But insurance, the cost of care, all of it needs a deep audit. I’ll spend $30k easy this year on health insurance premiums, deductibles and meds. I love when they try a new med for my daughter. Creon. Okay. $1k for the prescription. Done paid. Next month well actually now we can do it for $30. Next month we’re not covering it. We’re giving you zenpop or whatever. Okay. Next month yeah that gave her diarrhea. We want creon back. Well we need to review. Okay I’ll pay out of pocket while review is pending. Joke

I get your worry about a government system, but I'm not sure. If we remove the insurance costs/profits can we keep doctors making enough to warrant better minds going there. Don't get me started on the number of overachievers that go into things like investing because that's the big money. The system needs those minds trying to cure cancer, developing new tech, etc. Not figuring out a new derivative profit machine.

 

[El Drado]

And poor people they’re fckd. Medicaid. Please. The good doctors don’t take that shit. Have your baby in the hood with the flunkies

A few years ago Bezos, Buffett, and Dimon announced they were partnering to come up with a solution for healthcare for their employees....... and..........crickets.
If those three cannot get something done...we are fvcked.

 

[BadWakeboarder]

The entire system is broken. And I do believe if we replaced it all with gov providers care would suffer. We wouldn’t get the best docs etc. so I wouldn’t go that far. But insurance, the cost of care, all of it needs a deep audit. I’ll spend $30k easy this year on health insurance premiums, deductibles and meds. I love when they try a new med for my daughter. Creon. Okay. $1k for the prescription. Done paid. Next month well actually now we can do it for $30. Next month we’re not covering it. We’re giving you zenpop or whatever. Okay. Next month yeah that gave her diarrhea. We want creon back. Well we need to review. Okay I’ll pay out of pocket while review is pending. Joke

What’s wrong with your daughter’s pancreas?

 

[mcmurtry66]

I get your worry about a government system, but I'm not sure. If we remove the insurance costs/profits can we keep doctors making enough to warrant better minds going there. Don't get me started on the number of overachievers that go into things like investing because that's the big money. The system needs those minds trying to cure cancer, developing new tech, etc. Not figuring out a new derivative profit machine.

I think k you got it. They have to be able to make the big bucks. Too hard. Too long. Too much work not to.

 

[El Drado]

I get your worry about a government system, but I'm not sure. If we remove the insurance costs/profits can we keep doctors making enough to warrant better minds going there. Don't get me started on the number of overachievers that go into things like investing because that's the big money. The system needs those minds trying to cure cancer, developing new tech, etc. Not figuring out a new derivative profit machine.

It would be fascinating to see numbers on what a government system would look like. How much it would cost people and how much would it increase the national debt?

 

[mcmurtry66]

A few years ago Bezos, Buffett, and Dimon announced they were partnering to come up with a solution for healthcare for their employees....... and..........crickets.
If those three cannot get something done...we are fvcked.

The Cuban pharmacy is interesting.

 

[mcmurtry66]

What’s wrong with your daughter’s pancreas?

She has chronic pancreatitis. It’s basically idiopathic. No triggers. Just randomly once every three months she’s in excruciating pain and we do a week at children’s

 

[BadWakeboarder]

She has chronic pancreatitis. It’s basically idiopathic. No triggers. Just randomly once every three months she’s in excruciating pain and we do a week at children’s

God that’s awful. They’re sure there are no triggers and just haven’t found them yet?

 

[Marvin the Martian]

She has chronic pancreatitis. It’s basically idiopathic. No triggers. Just randomly once every three months she’s in excruciating pain and we do a week at children’s

Sorry to hear that, idiopathic is one of the worst words in medicine.

 

[El Drado]

The Cuban pharmacy is interesting.

Very much so, and i hope it grows. That is the thing, i don't care if someone gets very fvcking rich from offering a good product at a fair price. What is insane is that we are all getting poorer for a pretty average product.
I apologize to my employees, b/c as a small business the "deluxe" insurance is not even considered reasonable. And i apologize to them saying "the company is paying for a Ferrari, but only giving you a CR-X"..............i don't get the laugh i think it deserves.

 

[mcmurtry66]

God that’s awful. They’re sure there are no triggers and just haven’t found them yet?

Nope. We go for a week. They fill her full of morphine, hydrate her, get her numbers down and send her home. Wash U hospital. Top ten pediatric gastro hospital in the nation. In nov we go to nationwide in Columbus to see a specialist.

It is awful. Tonight’s her big night. First Friday night football game with all her friends and no parents. She already had her outfit picked out. She and her friends I guess are going as baby whores. Predictable I guess. And she goes dad my stomach kind of hurts. So now it’s like fck. Is it gas or nerves or are we packing up for another week and she misses more fun. Sucks.

 

[mcmurtry66]

Sorry to hear that, idiopathic is one of the worst words in medicine.

Very frustrating word indeed

 

[hoot1]

I hate insurance companies more than Burger King commercials, more than monkeybranching, more than parking the bus, more than baseball, more than anything

Marvin brings up an interesting and extremely complicated topic. How doctors, big pharma, and insurance companies interact in our paying for our healthcare.

To all this, think about the day when medical tests and AI along with our ancestry will provide insurance companies and employers with a Medical Health Score (MHS).

The MHS will tell us what potential health problems we face in the future so that we can mitigate the consequences with our lifestyle along with diet and drugs.

The downside to MHS is some of us will find ourselves paying more for health insurance with the possibility some diseases may not be covered. Also the cost of drugs which could ameliorate the affects of some health problems may not be affordable.

On top of this, employers wishing to keep group healthcare insurance costs low will want employees with a favorable MHS score.

MM66, if you hate insurance companies now, the worst may yet to come.

 

[mcmurtry66]

Marvin brings up an interesting and extremely complicated topic. How doctors, big pharma, and insurance companies interact in our paying for our healthcare.

To all this, think about the day when medical tests and AI along with our ancestry will provide insurance companies and employers with a Medical Health Score (MHC).

The MHC will tell us what potential health problems we face in the future so that we can mitigate the consequences with our lifestyle along with diet and drugs.

The downside to MHC is some of us will find ourselves paying more for health insurance with the possibility some diseases may not be covered. Also the cost of drugs which could ameliorate the affects of some health problems may not be affordable.

On top of this, employers wishing to keep group healthcare insurance costs low will want employees with a favorable MHC score.

MM66, if you hate insurance companies now, the worst may yet to come.

And it’s not just that it’s managed care companies mso’s etc. I have a buddy who makes nearly half a mil a year at a managed care co. He’s a nobody. Makes more than doctors

 

[Univee2]

I hate insurance companies more than Burger King commercials, more than monkeybranching, more than parking the bus, more than baseball, more than anything

Seriously, baseball? We smite thee.

Agree on Burger King, although a Jardiance commercial, with the worst jingle of all time, after Cars4Kids, is even more jarring. It’s like Bohemian Rhapsody - after the first note or two I have to switch to something - anything - else.

Almost all insurance sucks, not just health insurance. Recently switched from Safeco, after a number of years, for auto, home, umbrella, after a proposed 34.7% increase. Our Morgan Stanley guy suggested we try his neighbor/friend. He put us with Cincinnati Insurance for everything, at a total amount that was/is less than we were paying with Safeco prior to the proposed jump, with slightly better coverage. Who the hell sees their insurance costs go down?

But Medicare is cool. Two knee replacements in 2023, so it was essentially BOGO, after $2,000 out-of-pocket.

 

[WhyisIUBBcursed]

And poor people they’re fckd. Medicaid. Please. The good doctors don’t take that shit. Have your baby in the hood with the flunkies

Don’t worry. We shitty docs still do😂

 

[WhyisIUBBcursed]

I actually voted for a democrat for the first time in my life in 2008 when i thought Obama truly had a shot at meaningful reform…. The affordable care act did allow more people to get insured, but how many people can actually afford these market plans now? I would go the direct care model but I still have a hint of idealism left and don’t want to leave the 15% of my patient population on Medicaid behind. I could use half the staff, see 15 patients a day instead of 30, and actually clear more $$$ if I did. I’m a dumbass for staying in the more typical American model but until I finally wave the middle finger this is where I’ll likely stay

 

[mcmurtry66]

I actually voted for a democrat for the first time in my life in 2008 when i thought Obama truly had a shot at meaningful reform…. The affordable care act did allow more people to get insured, but how many people can actually afford these market plans now? I would go the direct care model but I still have a hint of idealism left and don’t want to leave the 15% of my patient population on Medicaid behind. I could use half the staff, see 15 patients a day instead of 30, and actually clear more $$$ if I did. I’m a dumbass for staying in the more typical American model but until I finally wave the middle finger this is where I’ll likely stay

you're a good dude. i don't think most people realize that docs turn away medicaid patients. but htey certainly do. go to the good neighborhoods here and they aren't taking medicaid. obamacare was a great thing for getting coverage for those with pre-existing. monumental and lifechanging for so many. but yeah the market plans are insane. like i said in coverage, meds, and deductible i'll spend $30k on health coverage/meds this year

 

[UncleMark]

As much as we all like to bitch about health care and insurance, I've been relatively pleased with how I've been handled since I got into the clutches of IU Health. I posted recently about hitting my "donut hole" and having my copay for Trelegy jump from $47 to $171. I freaked and asked my primary to finding something else, something generic, whatever. I can afford it, but I'm not happy to pay silly money for nothing more than a proprietary delivery system for three generic drugs.

Yesterday I met with the "clinical pharmacist" that is part of the practice my PCP is in, and if all goes well it looks like I'll be going on an alternative which offers a "patient assistance program" that will make the meds free to me. I initially assumed I wouldn't qualify; while our income isn't much, we're not destitute. Turns out the cutoff is 300% of the Federal poverty line, which amounts to roughly $60K. We're well under that.

All this was done on my behalf, without me having to get shitty or loud. Well done, IU Health.

 

[UncleMark]

I actually voted for a democrat for the first time in my life in 2008 when i thought Obama truly had a shot at meaningful reform…. The affordable care act did allow more people to get insured, but how many people can actually afford these market plans now?

When the ACA first went into effect, it cut my out of pocket insurance costs by roughly 50%. It was a huge difference maker. We got to add a little beef to our beans & rice.

 

[IUfanBorden]

**** insurance companies----About cost me my life........

 

[hoot1]

When the ACA first went into effect, it cut my out of pocket insurance costs by roughly 50%. It was a huge difference maker. We got to add a little beef to our beans & rice.

Uncle, thank Heaven you got a potential lifesaving break along with having more money to spend on other necessities.

However, cannot help but wonder if others saw a bump in their insurance costs with ACA. Hopefully, most of them hardly noticed the bump as it wasn't significant given their income and wealth. Is this then an example of neo liberalism economics working effectively ?

Ask this question more to create a response than having an answer.

 

[CO. Hoosier]

First, the drug companies have a competitor, Four Thieves Vinegar Collective. They teach groups how to make their versions of the same drugs that big pharma makes. For example, there is a drug that costs $1000 per pill that cures Hep-C. Doesn't treat, cures. But it takes 84 pills. So insurance never pays for it, they pay for the much cheaper pill that treats Hep-C making it so one can live with the disease forever. Obviously, I think most would rather it be cured—the cost of the cure for the collective to make, 80 cents a pill.

‘Right to Repair for Your Body’: The Rise of DIY, Pirated Medicine

Four Thieves Vinegar Collective has made DIY medicine cheaper and more accessible to the masses.

www.404media.co

Another drug they work with is Daraprim. Now this one was $13.50 a pill until a hedge fund startup bought the rights and it went to $750. So this is different than above, this isn't a company recouping investment costs, this is profiteering. So they make Daraprim available. It is mentioned in the story above, here is a story about it being bought and the price jacked up:

https://www.nytimes.com/2015/09/21/business/a-huge-overnight-increase-in-a-drugs-price-raises-protests.html

Now switching to insurance. By law, insurance denials are to be looked at by doctors and signed off on. One would think that is to safeguard the consumer. In CIGNA they are signing off on denials at an incredible rate, one former employee-doctor said it takes 10 seconds to sign off on 50 denials. One doctor rejected 121,000 claims in his first 2 months. How much time is he spending looking at a file and considering?

This hit home after a buddy had a claim rejected. I've known him since high school, he was diagnosed with a degenerative lung condition and his quality of like greatly eroded. It came to the point he could no longer work though he was desperate to work until 67, so he was facing going on social security disability. Just before that point, he was sent to a new specialist. The specialist said he was misdiagnosed. his issue was in the pulmonary artery and there was a very effective treatment in a pill. Of course the pill cost maybe $1000 per pill, but it was available. This is someone who could barely sit up for 2 hours any longer. Of course his insurance denied it. He won on appeal, but it was 3 months. It seems the insurance company has an incentive to deny. The worst that happens, they save 3 months of the treatment. If they are lucky, he accepts their decision and they never pay.

So it turns out, Aetna is doing almost the same thing as CIGNA. Claims are denied in bulk without being reviewed.

https://www.cnn.com/2019/04/26/health/aetna-settlement-california-investigation/index.html

It seems coverage mandated by state law are often turned down:

Health Insurers Have Been Breaking State Laws for Years

States have passed hundreds of laws to protect people from wrongful insurance denials. Yet from emergency services to fertility preservation, insurers still say no.

www.propublica.org

Mistakes happen, we all know that. But it seems that insurers aren't particularly concerned about reducing mistakes that benefit them. And as that last article notes, the fines are often a very small percentage of their profits, so not exactly a great deterrent. If enough big bills are held back for a month or three on appeals, that can be a lot of interest gained.

Colorado has great statutory protections for policy holders. Unreasonable denial or delay of claims will result in paying double the claim plus attorneys fees.

Under CRS §10-3-1116(1), an insurer’s delay or denial of payment is unreasonable if the insurer delayed or denied authorizing payment of a covered benefit without a reasonable basis for that action.

This statute allows an insured party whose claim has been unreasonably delayed or denied to bring an action in a district court to recover reasonable attorney fees and court costs and two times the covered benefit.


This keeps the issue between the policy holder and company. The last thing we need is for the feds to get involved with yet another government rule making and enforcement agency.

 

[Marvin the Martian]

Colorado has great statutory protections for policy holders. Unreasonable denial or delay of claims will result in paying double the claim plus attorneys fees.

Under CRS §10-3-1116(1), an insurer’s delay or denial of payment is unreasonable if the insurer delayed or denied authorizing payment of a covered benefit without a reasonable basis for that action.

This statute allows an insured party whose claim has been unreasonably delayed or denied to bring an action in a district court to recover reasonable attorney fees and court costs and two times the covered benefit.


This keeps the issue between the policy holder and company. The last thing we need is for the feds to get involved with yet another government rule making and enforcement agency.

I wonder how often this law is used. I read an article that said your first step is to appeal, then if that is denied to ask for an external appeal. They suggest if your health is at risk, you can go straight to external appeal. Yet nationwide only .1% of denials are appealed:

Yes. One in seven claims are denied across the country, and health insurance claims. So it affects a lot of people. And yet one study found that 0.1 percent of all people who experience those denials actually took it to a step to do a formal appeal. When you're going about your day to day, maybe you're facing an illness or you're facing a chronic disease, it's hard to find the time and wherewithal to be able to figure out how to appeal these claims. And the reality is that very few people do.​

How algorithms are being used to deny health insurance claims in bulk

Federal data shows that health insurance companies denied more than 49 millions claims in 2021, but customers appealed less than 0.2 percent of them. Investigative journalists at ProPublica found that the insurance company Cigna is using an automated system to assess, and often deny, claims in...

www.google.com

 

[NPT]

She has chronic pancreatitis. It’s basically idiopathic. No triggers. Just randomly once every three months she’s in excruciating pain and we do a week at children’s

That is so sad.😥

 

[dr.jb]

I actually voted for a democrat for the first time in my life in 2008 when i thought Obama truly had a shot at meaningful reform…. The affordable care act did allow more people to get insured, but how many people can actually afford these market plans now? I would go the direct care model but I still have a hint of idealism left and don’t want to leave the 15% of my patient population on Medicaid behind. I could use half the staff, see 15 patients a day instead of 30, and actually clear more $$$ if I did. I’m a dumbass for staying in the more typical American model but until I finally wave the middle finger this is where I’ll likely stay

I took medicaid for 33 yrs. and between no shows and fighting to get paid, etc. I finally said enough

my work life got infinitely easier immediately

 

[Spartans9312]

First, the drug companies have a competitor, Four Thieves Vinegar Collective. They teach groups how to make their versions of the same drugs that big pharma makes. For example, there is a drug that costs $1000 per pill that cures Hep-C. Doesn't treat, cures. But it takes 84 pills. So insurance never pays for it, they pay for the much cheaper pill that treats Hep-C making it so one can live with the disease forever. Obviously, I think most would rather it be cured—the cost of the cure for the collective to make, 80 cents a pill.

‘Right to Repair for Your Body’: The Rise of DIY, Pirated Medicine

Four Thieves Vinegar Collective has made DIY medicine cheaper and more accessible to the masses.

www.404media.co

Another drug they work with is Daraprim. Now this one was $13.50 a pill until a hedge fund startup bought the rights and it went to $750. So this is different than above, this isn't a company recouping investment costs, this is profiteering. So they make Daraprim available. It is mentioned in the story above, here is a story about it being bought and the price jacked up:

https://www.nytimes.com/2015/09/21/business/a-huge-overnight-increase-in-a-drugs-price-raises-protests.html

Now switching to insurance. By law, insurance denials are to be looked at by doctors and signed off on. One would think that is to safeguard the consumer. In CIGNA they are signing off on denials at an incredible rate, one former employee-doctor said it takes 10 seconds to sign off on 50 denials. One doctor rejected 121,000 claims in his first 2 months. How much time is he spending looking at a file and considering?

This hit home after a buddy had a claim rejected. I've known him since high school, he was diagnosed with a degenerative lung condition and his quality of like greatly eroded. It came to the point he could no longer work though he was desperate to work until 67, so he was facing going on social security disability. Just before that point, he was sent to a new specialist. The specialist said he was misdiagnosed. his issue was in the pulmonary artery and there was a very effective treatment in a pill. Of course the pill cost maybe $1000 per pill, but it was available. This is someone who could barely sit up for 2 hours any longer. Of course his insurance denied it. He won on appeal, but it was 3 months. It seems the insurance company has an incentive to deny. The worst that happens, they save 3 months of the treatment. If they are lucky, he accepts their decision and they never pay.

So it turns out, Aetna is doing almost the same thing as CIGNA. Claims are denied in bulk without being reviewed.

https://www.cnn.com/2019/04/26/health/aetna-settlement-california-investigation/index.html

It seems coverage mandated by state law are often turned down:

Health Insurers Have Been Breaking State Laws for Years

States have passed hundreds of laws to protect people from wrongful insurance denials. Yet from emergency services to fertility preservation, insurers still say no.

www.propublica.org

Mistakes happen, we all know that. But it seems that insurers aren't particularly concerned about reducing mistakes that benefit them. And as that last article notes, the fines are often a very small percentage of their profits, so not exactly a great deterrent. If enough big bills are held back for a month or three on appeals, that can be a lot of interest gained.

From my perspective….you start with the elimination of PBMs. The cost on the medication side for the consumer will plummet. I will defer to doc and others on the major medical end

 

[Marvin the Martian]

From my perspective….you start with the elimination of PBMs. The cost on the medication side for the consumer will plummet. I will defer to doc and others on the major medical end

It seems no one, left or right, likes PBMs. Yet they flourish.

CVS owns Aetna and PBM Caremark. How can we pretend they operate on behalf of the consumer?

 

[Spartans9312]

It seems no one, left or right, likes PBMs. Yet they flourish.

CVS owns Aetna and PBM Caremark. How can we pretend they operate on behalf of the consumer?

Because they “audit” themselves….duh

They are the reason locally owned pharmacies are few and far between.

In the era of electronic claims….it still takes 2 weeks to receive payment for a covered prescription. Not to mention the shitty contracts….it makes it easier for a Walmart, CVS, Walgreens when they also own a pbm

 

[mcmurtry66]

That is so sad.😥

Fortunately when it’s not one of those weeks she’s perfect. Yesterday’s stomach cramps were just cramps so she was able to go to her first fri night lights high school football game (she’s in 8th) with her friends. And it was epic!! Everything you could ever want in a first football game. A fight!!! Mean teachers moonlighting as security. Girls crying in the bathroom. Boys!!!! Friendships destroyed!!! Soggy pretzels and orange soda!!! She gave it a 10 out of 10. Ready for the next one.

And dad did good too. Other parents finally drove so no sober fri waiting in parking lots for me!!

 

[NPT]

Fortunately when it’s not one of those weeks she’s perfect. Yesterday’s stomach cramps were just cramps so she was able to go to her first fri night lights high school football game (she’s in 8th) with her friends. And it was epic!! Everything you could ever want in a first football game. A fight!!! Mean teachers moonlighting as security. Girls crying in the bathroom. Boys!!!! Friendships destroyed!!! Soggy pretzels and orange soda!!! She gave it a 10 out of 10. Ready for the next one.

And dad did good too. Other parents finally drove so no sober fri waiting in parking lots for me!!

It's sad that she has to fight this health problem. It's not only hard on her but it's hard on mom and dad. As a parent you want to fix everything for your kid and some things you just can't fix. I told our daughter before she was married and had kids that she'd never understand how much we loved her UNTIL she had her own kids. She now has a 2 and 4 year old. The 4 year old is a hand full. They sent her to a school 2 days a week last year and when her mom picked her up the first day she (3 years old at time) got in the car she told her mom "The teacher told us to stop talking but I didn't" 🤣

 

[WhyisIUBBcursed]

Fortunately when it’s not one of those weeks she’s perfect. Yesterday’s stomach cramps were just cramps so she was able to go to her first fri night lights high school football game (she’s in 8th) with her friends. And it was epic!! Everything you could ever want in a first football game. A fight!!! Mean teachers moonlighting as security. Girls crying in the bathroom. Boys!!!! Friendships destroyed!!! Soggy pretzels and orange soda!!! She gave it a 10 out of 10. Ready for the next one.

And dad did good too. Other parents finally drove so no sober fri waiting in parking lots for me!!

No FB game in Hart County, GA because 2 dumbass high schoolers and an equally dumbass middle schooler made a shooting threat. Barrow Cty only an hour from here so people are a little paranoid right now. This truly sucks

 

[mcmurtry66]

It's sad that she has to fight this health problem. It's not only hard on her but it's hard on mom and dad. As a parent you want to fix everything for your kid and some things you just can't fix. I told our daughter before she was married and had kids that she'd never understand how much we loved her UNTIL she had her own kids. She now has a 2 and 4 year old. The 4 year old is a hand full. They sent her to a school 2 days a week last year and when her mom picked her up the first day she (3 years old at time) got in the car she told her mom "The teacher told us to stop talking but I didn't" 🤣

It is but you keep things in perspective. Her pancreas looks good so it’s really just discomfort and an intrusion on life once a quarter. Mom and I have it down to a science. Mom stays with her during the day then I come in for the night shift and crash there. Again it could be so much worse.

Literally last visit I had my minion with me too. So I said let’s go to the roof garden. We walk in and he’s as loud as a train conductor. Great big guy is sitting alone on a bench with his face in his hands. Looks up and I’m like fck I know him. You never want to see anyone at a hospital. He was the old goalkeeper for Mo State and I did some odp shit with him. Waiting for the results of his daughter’s massive brain tumor that he and his wife thought was a sinus issue. Unreal. Whole hospital full of kids with cancer and bad, bad shit. Pancreatitis we can deal with