Repeal or replace?

Freddy Figbottom said:
all insurance is a legalized scam.
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They use fear to convince suckers to rent a false sense of security from them on a lifetime subscription.

It is generally true that most healthy adults pay more in health insurance premiums over their lifetimes than they receive in direct medical claim payments (i.e., the benefits the insurer pays to providers on their behalf). This is a fundamental feature of how insurance works.

A significant number of insured Americans experience routine claim denials.
 
36% of U.S. adults have experienced at least one coverage denial (often multiple).

18–21% of insured adults overall say they had a claim denied in the past 12 months.

17% have been denied care recommended by their doctor.
 
Providers report initial denial rates of 11–15% across all payers in 2024–2025, up from prior years. Some of these are eventually paid after resubmission or corrections (e.g., a "coding error").

This creates massive administrative expense — hospitals spend ~$20 billion/year fighting denials.

Most common reasons (not always "fraudulent" but often frustrating):
  • Excluded service or lack of prior authorization: ~25% combined.
  • Administrative/billing errors: 18%.
  • Appeals are rare. Patients appeal <1% of denials. Many give up because the process is exhausting.
 
Denials aren't just paperwork — they delay care for ~60% of affected patients and contribute to medical debt for millions.

Providers say denials are rising deliberately as a profit tactic: payers use AI to auto-deny, knowing most won't appeal.

Denials are routine enough that 77% of revenue-cycle leaders say they're increasing, and it's a top complaint driving public fury toward the industry.

The system is built this way.
 
Diogenes said:
Denials aren't just paperwork — they delay care for ~60% of affected patients and contribute to medical debt for millions.

Providers say denials are rising deliberately as a profit tactic: payers use AI to auto-deny, knowing most won't appeal.

Denials are routine enough that 77% of revenue-cycle leaders say they're increasing, and it's a top complaint driving public fury toward the industry.

The system is built this way.
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motherfuckers.
 
Freddy Figbottom said:
yes.

denying legitimate claims shouldn't be a profit center.

I consider it fraud and customer abuse.
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Read the fine print, my fren.

In the U.S. healthcare system, the people who actually decide whether your claim gets paid (or denied) are medical claims adjudicators—sometimes called claims examiners, claims analysts, or claims processors — who work for the insurance company.

Here’s exactly who touches it and in what order:
  1. Automated system (first pass)
    Your claim hits the insurer’s computer system within hours of submission. Software instantly checks for basic errors (wrong patient ID, expired coverage, non-covered service code, etc.). About 60-70% of claims are auto-approved or auto-denied here with zero human eyes.
  2. Claims adjudicator/examiner (human decider)
    If the system flags anything or it’s a complicated claim, it lands on a real person’s desk. This is the actual human being who determines “valid = paid” or “invalid = denied.”
    • They verify:
      • Was the service medically necessary? (They compare doctor’s notes against the insurer’s medical policy)
      • Was prior authorization obtained if required?
      • Is the diagnosis code supported by the procedure code?
      • Was the provider in-network?
      • Are there duplicate charges or unbundling violations?
    • They have the authority to approve payment, pend the claim for more info, or deny it outright.
  3. Medical reviewer / nurse reviewer (for denials or high-dollar claims)
    If the adjudicator thinks it should be denied or it’s over a certain dollar threshold (often $5k–$25k depending on the insurer), it goes to an RN or MD who works for the insurer. This person decides if the treatment was medically necessary using evidence-based guidelines (Milliman Care Guidelines, InterQual, or the insurer’s internal policies).
  4. Appeals department (if you fight the denial)
    If you appeal, a different team (often including a physician advisor) re-reviews everything. This is a fresh set of eyes that can overturn the original decision.
So in short: the insurance company’s claims adjudicator is the primary person who determines if your claim is valid. They’re backed by automated rules on the front end and nurses/doctors on the back end for the tough calls.

According to the guidelines and existing law, it's not fraud to deny a claim unless it's proven in a court of law.
 
Diogenes said:
Read the fine print, my fren.

In the U.S. healthcare system, the people who actually decide whether your claim gets paid (or denied) are medical claims adjudicators—sometimes called claims examiners, claims analysts, or claims processors — who work for the insurance company.

Here’s exactly who touches it and in what order:
  1. Automated system (first pass)
    Your claim hits the insurer’s computer system within hours of submission. Software instantly checks for basic errors (wrong patient ID, expired coverage, non-covered service code, etc.). About 60-70% of claims are auto-approved or auto-denied here with zero human eyes.
  2. Claims adjudicator/examiner (human decider)
    If the system flags anything or it’s a complicated claim, it lands on a real person’s desk. This is the actual human being who determines “valid = paid” or “invalid = denied.”
    • They verify:
      • Was the service medically necessary? (They compare doctor’s notes against the insurer’s medical policy)
      • Was prior authorization obtained if required?
      • Is the diagnosis code supported by the procedure code?
      • Was the provider in-network?
      • Are there duplicate charges or unbundling violations?
    • They have the authority to approve payment, pend the claim for more info, or deny it outright.
  3. Medical reviewer / nurse reviewer (for denials or high-dollar claims)
    If the adjudicator thinks it should be denied or it’s over a certain dollar threshold (often $5k–$25k depending on the insurer), it goes to an RN or MD who works for the insurer. This person decides if the treatment was medically necessary using evidence-based guidelines (Milliman Care Guidelines, InterQual, or the insurer’s internal policies).
  4. Appeals department (if you fight the denial)
    If you appeal, a different team (often including a physician advisor) re-reviews everything. This is a fresh set of eyes that can overturn the original decision.
So in short: the insurance company’s claims adjudicator is the primary person who determines if your claim is valid. They’re backed by automated rules on the front end and nurses/doctors on the back end for the tough calls.

According to the guidelines and existing law, it's not fraud to deny a claim unless it's proven in a court of law.
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they're crooked as fuck.

:truestory:

I pity you and your black soul.
 
Diogenes said:
Denials aren't just paperwork — they delay care for ~60% of affected patients and contribute to medical debt for millions.

Providers say denials are rising deliberately as a profit tactic: payers use AI to auto-deny, knowing most won't appeal.

Denials are routine enough that 77% of revenue-cycle leaders say they're increasing, and it's a top complaint driving public fury toward the industry.

The system is built this way.
Click to expand...
Once single payer is in place, you won't have any of this to worry about. They will decide if you live or die and ration healthcare based on your remaining tax paying years. Read Ezekiel Emanual's (Rahm's brother) works.

Be careful what you wish for.
 
Diogenes said:
They're self interested, my fren. All of us are.

If they break the law, and they get charged, tried, and convicted, they are punished. Just like we'd be.



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yes.

but laws and honest business dealings are to channel self interest into pro-social behaviors.

denying legitimate claims is shitty business dealing verging on fraud.

I still pity your black and corrupt soul.
 
Freddy Figbottom said:
yes.
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I'm glad we agree.

Freddy Figbottom said:
but laws and honest business dealings are to channel self interest into pro-social behaviors.
Click to expand...

Lobbyists have to eat, too.

Freddy Figbottom said:
denying legitimate claims is shitty business dealing verging on fraud.
Click to expand...

Verging on ≠ fraud, my fren.

Freddy Figbottom said:
I still pity your black and corrupt soul.
Click to expand...

How touching. Thanks.

I hold you in high regard as well, my fren.
 
Life is Golden said:
Once single payer is in place, you won't have any of this to worry about. They will decide if you live or die and ration healthcare based on your remaining tax paying years. Read Ezekiel Emanual's (Rahm's brother) works. Be careful what you wish for.
Click to expand...

Non sequitur.
 
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