I had a nurse at the hospital ask me why I had waited a week with a multi-day migraine to come in for an infusion. I told her I hadn’t waited, the insurance company had. She sighed, hunched her shoulders, and quietly said that’s why she had quit her job at an insurance company - she couldn’t handle telling people “no” when they really needed help. From her body language and voice, it was obvious she carried a lot of guilt over that. I give her credit for leaving a job over that.
Its either you learn to be stone cold and block out all the pain or you dont. Some people cant handle it while some people choose to not handle it and its actually close to being a real criminal like same process just a difference of legality since both are very rough on the conscience.
The system is working as intended: suck all the money and wealth out of the people and the government, and give it to ourselves! Slowly breaking down the entire system until everything of value on the planet belongs to us!! Then we can make massive changes that impact billions by going into a back room with 1-2 other people, shake hands, and call it law. More "efficient" that way. Ya know, people say they're afraid of Ai...that it will be given a simple directive and destroy the world trying to achieve it. But I argue that we already have this problem. The directive is, "Make as much money as possible" and now the entire world (and the 8 billion human lives on it) is being destroyed in pursuit of that goal.
I'm an senior engineer at a major medical billing company. We process a bazillion claims. It's actually worse than the video describes. I'm talking routine, automated denials on technically flawless claims, which I've personally validated. We've got the data. We know who is doing it, we know how often. I think we're the first to aggregate it. Pain is coming for these insurance dirtbags.
@maggie6152 I appreciate your support. Truthfully, you probably won't ever see it, until the reforms happen. Even now, you won't see the denials. We have a custom lockout system which we have built, where a balance never falls to a patient unless it has been fully validated. We put a lot of love into people not getting false balances. We are trying to eat all the garbage, so that the patients don't have to.
Fun story! An insurance company once told us that their third party system had information loaded incorrectly and it was our responsibility to let them know! Because we definitely knew the information was loaded incorrectly on a platform that THEY maintain 🙃
in Romania you're forced to as in they take it out of your salary, same for private pension which is separate from public pension. and while we lived in Michigan again it was taken from the salary, 12k/year and if I wanted to see a doctor, not get anything, just have them see me that I am still fine, it would cost an additional 500$ per visit. My husband had an emergency tooth infection with extraction... you can guess why he postponed it, I don't want to remember what it cost. Same for cars, it's illegal to drive without an insurance. And it never covers anything, it's just an extra car tax.
When I worked for an HR company, I would get a number of claims that were denied for the stupidest reasons and now I'm wondering if they were just auto-denied. I always walked the caller through the process of how to get it approved, or what it needed to be submitted as to be approved. (e.g., inhalers weren't covered but medicine and devices to assist breathing were - so if an inhaler was submitted as a normal medication it got denied. If it was submitted as specifically something to assist with breathing it got approved. This also happened a lot with diabetes medication, too.)
@@PhrontDoor I specifically dealt with HRAs, and I wasn't the one involved in approving or denying claims, my job was dealing with more the end of explaining how their accounts worked and making sure their info was up-to-date and correct. The result, however, was that I was VERY well-versed in what could be approved or denied, which is how I helped people where I could. Since we were a third party company, we also had no involvement in choosing what insurance company the company we were working with went with, we just helped people choose between the available insurance options. The company we worked with - let's call them Unnamed Real Company Ltd (URC for short) - was the one who made the decision on the insurance company(ies) available and the plans available. They were also the ones who set up the HRAs. Then the HR company helped their employees choose between the available plans. So I'm not sure what part of URC actually decided on what plans to use. Edit: The HRA also worked differently than the insurance. HRAs are generally set-up/"run" by the companies, while with insurance you have to deal with the insurance's policies instead.
Boss is always in such a great mood. Always so happy to see Jimothy. Turns out that joy is easy to access when the needle on your moral compass spins like a pinwheel.
@@mustang8206 Okay, then explain why, of all developed nations, we have the highest healthcare cost as a part of our GDP but the worst health outcomes?
I was denied for my insulin once... I'm a type 1 diabetic. I informed my insurance company that I will be heading to the ED for an insulin drip as my other option is a slow and painful death... they called back 5 minutes later with an approval. Every year my autoimmune inflammatory arthritis injections, which I have been on for 5 years, gets denied. In the 6 weeks it takes for the "review process" I end up with more permanent and irreversible bone damage... These denials will eventually cause me to go onto permanent disability, thanks American Healthcare!!
@@ianwells7916 it's the least I can do, an early death to increase Excellus's profit margins. Also, I work in medicine and yet somehow I still can't afford my medicine 🤷🏻♀️
@@KittenMcCoolson Sister, you and me both. COPD developed from a genetic predisposition and a history of untreated asthma, work in the medical field and the hospital system's own proprietary insurance company turns down every claim for medication since the start of the pandemic - you know, the respiratory disease that killed millions that I as a chronic sufferer of lower respiratory disease really was a risk of life altering damage from? Yeah, turns out treating the progressive and incurable condition that left me ripe for further complications wasn't medically necessary. The punchline of the joke? My single mother was a nurse, which is why my asthma went untreated.
@@Sikkeskatona Well, not in America. In many nations, healthcare is nationalized and paid for by the government. Sometimes that even means effective lifesaving and even preventative care is available!
I'm just waiting for the video where Dr Glauck explains that patients aren't allowed to sue their insurance (automatic arbitration) and even the most that insurance commissioners can do legally is say "no, actually pay for the treatment" with no penalties to the insurance company for egregiously breaking their contract to the patients.
@@goodfortunetoyou Oh, we have plenty of legislation that did exactly that. But we also have plenty of mechanism to undermine those legislation. It starts out with getting a bill to be created by the legislator in the first palce. Think of it as citizen as a whole gets 1 maybe 2 vote. But each company gets their own vote. This process alone already kills majority of the bills. Then the occasion some corporates unfavorable legislation slip pass the legislative branch crack, corporate still has a wide variety of mechanism to modify the bill through the executive branch. None of those processes are practically accessible to most citizen, however some company exec will get a direct phone line to the executive officials. Lets say the legislator and the executive official finally grew some spine and the bill get passed. Here comes the court. The outcome is either bill unmodified get pass, or more likely bill get struck down, and modification needed. In the worst case scenario, bill gets struck down and any future bill like those are automatically illegal. Where was I, oh, yea the court does not struck down the bill (which is potentially years after the initial inception of the bill at this point), the officials are up for reelection. Historically, there is a very strong correlation of money spent and chances of being elected. And company are very compelled to donate to politician that has certain ideas on the issue. Im just scratching the surface here. But lets skip a bit ahead and assume the unadulterated version of the bill gets signed into law. Whos going to enforce it? If you suspect a company has wrong doing, your best option is hire a lawyer (chances are you don't have the money to do that), or file consumer complaint to the government (they never actually get back to me), or what?
My insurance tried to deny my claim after I was hospitalized after my appendectomy had serious complications(had a tumor and internal bleeding they didn't know about) and I had to stay in the hospital for three days with a hemoglobin score of 8. They deemed it "not medically necessary".
My cardiologist did a test because my heartbeat was wonky and Cigna gave the same “not medically necessary” excuse. In that case my doctor’s office struck off the charges. First time either of those have ever happened.
"And, for an instant, she stared directly into those soft blue eyes and knew, with an instinctive mammalian certainty, that the exceedingly rich were no longer even remotely human."-- William Gibson, 'Count Zero'
I love Jimothy as a their moral compass. As a psych nurse, I can tell you I was once told by an insurance Samoans that my patient had not required enough sutures after a stated suicide attempt to warrant inpatient TX. Yes, you read that right.
Years ago I worked for a reconstructive surgeon. Once the ins clerk asked me to explain why he did emergency surgery on a Saturday instead of getting approval on Monday first for a foot, because Kai$er was refusing authorize payment. I picked up the phone and said" well he dropped the chain saw when he fell off the barrel he was standing on and it almost completely cut his foot off & it was either fix it then or finish cutting it off and throwing it in the refrigerator til your on call emergency number was answered on Monday." They authorized it & our ins clerk almost passed out.
I'm so grateful for these videos. Perhaps a long shot but I hope that they might be a piece of real change happening. Something we say all the time at my house is "health insurance is not health care"
@@BiggieChungulus Well, they will get disappeared before they can make any moves because those people needing disappearing has immense power over the legal people disappearing gestapo corp.
@@BiggieChungulus That is absolutely NOT my hope. I don't really know what the right way forward is, but radicalism will not get us where we want to go.
The thing I find the most confusing is that surely allowing preventative health care to begin with would cost less than the inevitable pay out on a major surgery
There's something to be said for that, but insurance companies don't want to pay for anything that they don't seem is medically necessary. If there's no problem yet, it's not medically necessary.
As long as the surgery happens on January 1st, the patient has to pay out-of-pocket. If they deny any and all healthcare during the months of November and December, it's basically free money, even if it eventually gets appealed.
man that's one of my favorite subjects and there's a lot of reasons for that imo but a lot of it boils down to: - preventative/public health is some commie shit (that's not a joke. the red scare has fully fucking ruined america's collective brains) - its just sooooo much more profitable for companies to develop expensive interventions rather than preventative measures, and our gvmt is lobbied to hell and back by them ( there's this whole fascinating conversation about america's hyperindividualist capitalist culture and how this bullshit kind of is the natural conclusion to that - we subconsciously associate morality with health and thus believe that we shouldn't be responsible for Bad people, we're hyperpunitive and so a lot of public health measures are rejected bc they would be seen as benefitting the "undeserving" (read: poor). but also - public health often leads to a choice between positive and negative liberties - freedom To Do [x] or freedom From [x]. so for example, do you make speed limits mandatory? if you do, there is generally a freedom From more significant injury in a crash or increased dangerous motor vehicle accidents, but you lose the freedom To travel at whatever speed you want. america will always see those negative liberties, those freedoms to do whatever you want, as more important than freedom From sickness, etc. its one of my favorite subjects i could talk about it forever ) like a big huge part of it is lobbying, of course. but the reason that so many people are accepting of it, or who even now still state that the american health care system is the best in the world despite us spending the most in the world on health care while falling 47th in the world in life expectancy, has to do with our culture's values and beliefs. i believe that both need to be (and can be!) changed. (also there's sooo much more i could say too about how the same thing is true in other aspects of america - look at the prison system for example! we run into the same issue there where intervention would ultimately be so much cheaper and be better for so many more people, but because private prisons are such a big lobbying group and because we have this overwhelming disdain for 'criminals' - not to mention like. there's a lot of racism - we're fine with having 25% of the world's prisoners.) sorry if i'm rambling or don't make sense that's my bad!
I finally got a denied claim overturned by my insurance for medical service I was billed for in MAY of this year. I had to fill out a “complaint” form for them to even start to review the denial. The kicker is that they originally denied coverage because it was a test ordered by my doctor which was considered to be “investigations” … isn’t that the doctor’s job? To investigate what’s wrong with their patient? I have already paid the bill for the test because they took so long to review the claim, I was worried my bill would be sent to collections. Makes me wonder how many millions these insurers suck out of people’s pockets who for whatever reason don’t fight the denial. Infuriating.
Bottom line, no one should be making a profit off allowing somebody to get sicker or to die of illness. And that’s the insurance companies entire game.
Pro tip: don’t need urgent medical care late in the day on a Friday of a long weekend. The auto denial happens and you’re stuck. My surgeon had to admit me overnight just so I could get a CT scan so they could prep for my life saving surgery in a few days. The CT was needed asap, but I didn’t need to be kept overnight. :(
The more I learn about Australia. The more it's just another English speaking country with a lot going for it. It's just.. Everything there also wants to kill you. So health insurance better be good
@@raycigar6356 our government competes with our insurance companies, they have no choice but to be very good. Gotta love effective socialised healthcare, it even makes businesses better at their jobs.
It's a wonder that more health insurance executives aren't found mysteriously deceased, with the cause of death being multiple copies of complex documentation being stuffed into every available orifice.
Waited 3 weeks to be seen by my doctor for an excruciating injury... left his office and felt optimistic about finally being able to get some treatment and relief and get my life back on track and start working again. Was notified 2 hours later- insurance denied everything my doctor ordered.
He's doing this for all of us because it needs doing (like the farmer who was fixing the clinic siding). I have been asking the good folks providing health care to be the ones to start fighting back because they know more, are better off financially, and are intimate to the circumstances. Will Flanary is the first one I have seen step up in an effective way. It's hard to do for them since they are so overwhelmed by the system that they can only manage to get through their days without harming any patients (if they are lucky). It's a lot to ask, but we, the people, individually are mostly powerless; the powers that be made that happen.
DR. G,, at the end of the month, PLEEEAAAASSSE send a copy of every days videos to every member of Congress, Secretary of HHS,The President, Vice President and anyone else you can think of. They so need to hear this.
Why don't you do that? You can email with an attachment. Doesn't mean that their staff will make them watch it, of course. What if all who watch these were to send them every day to all those government people all at once. Every day for thirty days a million emails with attachment would arrive in their inboxes. Hey, let's all do this! We can do this! I'll make a list of all these people and their contact information and simply send each video each of thirty days. Then I'll do the same again with all thirty attachments, maybe, at the end.
As a physician, my only hope out of this is opening in my own direct primary clinic after I get some experience out of residency... with that said I am anxiously hoping that you don't come up with a skit why that is a bad idea too! ^^'
@incapablecreditor8117 yes. Physicians can own clinics and surgery centers. But have regulations on hospitals and other ancillary care like having your own gym or physical therapy, it can be done but there are hoops to jump though making it really hard for 1 or 2 doctors to manage alone.
@@stephen4598 Can you not game the system and have the hospital run by your dog/dead person/your parents/shell corporation instead? Or hire a professional yes man to rubber stamp all medically correct decisions instead. I must be missing something because the 'no doctor' rule seems simple to get around... 🤔
I personally can't wait for you to really get into how hard it is for us providers to get in network with healthcare providers, and for them to randomly decide we're out of network, or didn't fill out a form right, and clawing back thousands of dollars. What a system...
My wife is a denials billing specialist at a children's hospital and rants at me daily about all the problems she keeps finding with the billing processes both at the hospital and the insurance companies.
Back in the badder old days, pre-existing conditions weren’t covered unless you went 6 months without treatment. Try doing that for a chronic illness! I have been living with thyroid problems since I was 9 yo, and it has been a seesaw (thanks, Hashimoto’s). I asked my doctor to test my thyroid because it had been a while. The insurance company denied the claim because they incorrectly believed that I had been treated for said pre-existing condition. I wrote them, explaining that I had not been treated with drugs, radiation, or surgery; I had merely been tested. They paid the claim.
Golden rule of denials is never, never, never accept the first insurance denial. They are relying on that last statistic. If you just submit an appeal, it will often go through with an explanation that it denied "in error" to avoid regulatory trouble. You as the patient have a right to submit that appeal and often authorize you doctor's office (or their billing company) to do so on your behalf in your intake paperwork.
I'm not sure if my soul can handle any more of the evils of insurance companies. And this is only day 12. I would rip my heart from my chest, but it's not covered. United is one of the worst, but it's not like there are any good ones.
I thought I was just loosing my mind with how badly I have been getting screwed lately. Thank you for letting me know this is an industry wide problem.
My worst denials were when Aetna cancelled my Learjet on Friday afternoon before a holiday weekend forcing me to fly across the country with hepatic encephalopathy in coach, luckily I survived. They also told me after I spent a year becoming attached to the woman who saved my life my hep transplant specialist who obviously dies one thing….when it is was time to list me my insurance made me switch hospitals 🙄
No, he's doing more than enough with these videos! Others are the ones who need to step up and push on this including each and every one of us. You should write letters to your representatives and to the local papers; you should talk to legislators.
I think it's adorable that you think talking to state and federal legislators accomplishes anything. Unless you are holding a multimillion dollar check in your left hand while offering a handshake with your right, they aren't interested in listening. They are all in the back pocket of the insurance industry, thanks to Citizens United.
@@nickdfoxy So you think it's best to just sit and do nothing, just sit and take it, let the powerful just bleed us dry? If not, what's your solution? What are you doing to fix US health care? Don't you think it's right to fight for what's right or do you just give up and give in without a fight?
@@nickdfoxy I will never, ever for the rest of my days vote for anyone who calls themselves a Republican even though as an independent voter I have voted for Republicans in the past; I vote for the person not the party and I now vote only against, not for, sad to say. And all those who call themselves Republican, leaders or citizens, are my enemy if they don't actively speak up against all those in their party who are out to destroy democracy. This has become visceral for me.
I just got done watching a RU-vid animator ask for help because of health insurance not covering a paralysis injury to his father who has paid a good amount of money over many years for healthcare insurance 🥺. This hits differently now....
I have had so so many claims denied or treatment held up its such a waste of time as they all eventually get approved as I never take no for an answer. Yes I will call you 3x a day every day to make my MRI get approved.
Sad, I remember watching so many denials on things, still have nightmares. Between you and rxcomedy I am able to make it through studying my CEs and try to get back into work again.
So: 1. US healthcare is mandatory and run by a monopoly, as you need it for different services (for some reason) 2. If you have the healthcare, then you have to pay in basically cuotas until you reach an amout where you qualify for healthcare 3. After that, if you need a procedure, it can be denied for absurd reasons or you may need to use bs methods beforehand, commanded by a non medical practitioner 4. If you get the procedure, you still pay an absurd medical bill that can include the most random things, that are expensive still. 5. Medical attention without healthcare can bankrupt you still So the answer would be to have a healthy lifestyle, to avoid having to use the healthcare, maybe avoid having a car to avoid having to pay a lot and eat nutritious food. However... 1. The US is widely known for the obesity and lack of restrain when using fats and sugar in food, which causes many comorbidities, and apparently healthy food is extremely expensive 2. Many cities in the US have transportation issues and a car is still a requirement to go to work or school (sedentarism) and owning a car requires paying the healthcare 3. Unhealthy food is still cheaper that healthier and is a preferred option when having economical issues, like paying a healthcare 4. Armed insecurity in the big cities is an issue that would force you into buying a car o needing medical attention. This is scraping the surface only. The US seems to be profiting of necesity, while creating it at the same time and people have to be lucky to be healthy/wealthy enough to get out of the loop. Having a healthy lifestyle would be an act of protest and is really the only answer apart from just leaving the country. I bet a lot of countries in africa have better nutrition than in the US
They tried this with us when my teenage son had an accident over Christmas out of state (concussion, lung contusions). We got a bill for $47,000 after they denied our claim. We DID go through the appeals process, though, and the bill was dropped to just over $4000, most of which they paid. It was an ER visit, overnight stay (less than 24 hours), MRI, xrays, and ultrasound. And this was a non-profit state university teaching hospital. Still blows me away. Did you know that if a claim is denied, the hospital bills you as if you're uninsured? You get stuck with the full inflated book rate, not the negotiated rate that insured people get (even if the insured person has to pay the full negotiated price amount because they have a high deductible). Not sure how that hospital qualifies as non-profit. The billing lady was literally there in the ER, asking how we were going to pay, while my son was trying to pee in a bottle there in the hospital bed. (They wouldn't let him out of bed because of the concussion and in case he had a neck/spine injury). Don't get me wrong, I'm grateful for emergency medicine and that we had insurance. I'm just frustrated that what we went through is par for the course. Though we had to pay a different clinic hundreds more back home to treat the concussion over the next couple of months, he wasn't badly hurt. He's a fully recovered student athlete.
"Somebody's got to go bankrupt but it won't be us" that's it that's the line that basically explains the problem with America the west and capitalism as a whole
The way he makes fun out of a bad situation certainly qualifies him to be a honorary Brazilian. He does it a video at a time... We do this ever since we're born.
Has there been any studies done into how many preventable deaths can be attributed to Heath Insurance companies in the US? Because listening to this makes them sound like the leading cause of preventable deaths and illnesses
This is the perfect example of what my over 6 months of fighting to get treatment been like. I did proper channels and eaxh time get a different "requirement " all to be denied again. I am trying to prevent my disease from getting worse, and instead, they keep me waiting (probably so they can get a bigger payout). It is a shame and pain in a butt. I should have done it years ago before the process got worse.
I just ran into Medicare and Medicaid retroactively denying claims. The OneCare Kansas program Medicade offered to help coordinate medical care is shutting down this month. also I started receiving denial of coverage letters that don’t mention what they’re denying coverage of. Are they denying a medication, a surgery, a therapy, or a procedure? I don’t know! 🤪
This is not new. In the late 1980s (age 40+) my individual policy denied every claim I made, automatically (not automated), which made me have to fight for the claim each and every time. They paid, with interest, each time many months later. Back then patients had to file their own claims; providers did not file claims. The premiums kept increasing by double digits every year as much as 19%. To keep the cost down I increased deductible and copays until I had a $650 monthly (30 years ago) policy with a $10,000 deductible and 60/40 copay; it didn't even cover drugs or pre-existing conditions as well as other things; I was quite healthy, too. I finally realized there was no reason to be having insurance so I dropped it to become a self-pay for the next 5 or 6 years; providers were very happy to give me a 10% to 25% discount to get paid immediately. It freed up so much money in my budget, but I worried about catastrophic illness.
I worked as an offshore insurance benefits and claims rep for a US health insurance company. The amount of times I had to escalate incorrectly denied claims for reprocessing is ungodly. They have these "auto-adjudication process" that just denies claims if they get flagged by the system for some mundane reasons. There were even times that I had to reason out with the corporate that there are things that do not make sense. It's infuriating how many "rules" they have in place with a lot of loopholes. I honestly thought they were just errors but I'm starting to think they're ways to prolong the processing and payment. And don't get me started with appeals! So unholy!
That's what happened to me. I was on stage 4 of the appeal process when I finally gave up. I couldn't work out what was happening because the reasons for my denials changed with each level until they looped all the way back to the first one. All because I said I'd been going to therapy for a few years, they claimed my mental health was a "pre-existing condition". Despite the fact that it had been steadily getting worse until I needed medication.
It’s the “United HELLTHCARE” that got me because UHC is THE WORST! I have appeals with denials upheld where “providers” are citing criteria that proves Medical Necessity.
Another one of those things that is actually a reasonable idea on its own, mistakes in documentation can lead to mistakes in patient healthcare. Unfortunately, it ends up lumped in with all the other ways insurance companies have learned to exploit the system and so a reasonable idea because just another weapon for them to fight off paying for anything 😢
See insurance makes sense on paper. You collectively pay into a pot of money that is used when needed. The thing is that the insurer has overheads and expenses. Also the insurer wants to make a profit, as in the reason to run a business. Thus is incentivised to charge as much as possible, while paying out as little as possible.
My child has a rare disorder and the amount of hoops insurance has is insane. Thankfully her doctors have been there fighting to get everything covered for her.
It's the idea of first being denied healthcare awesome. I like the idea of minimum wage workers getting bonuses base on how long t thry y can d delay treatment. In oz your doctor recommends treatment, you book it, you get it. I like how U.S. citizens have to get permission from a call centre worker with no medical training, permission of tthe supervisor of the a call centre. Adding week to delay treatment when days matte is awesome.
