btw I would read about Kaiser Permanent and how they do things (like they have doctors on payroll instead of whatever the fuck UHG was using):
https://en.wikipedia.org/wiki/Kaiser_Permanente
They are known for a much higher standard of care and only reject 6% of claims compared to UHG's 36%.
So anyone saying a better system can't exist in the US should look at them and see what they're doing differently (I think some aspects of their operation may be non-profit but I'm not sure how they exactly work).
The thing with Kaiser is that you don’t get to make those claims…..you use their doctors who are going to be very limited in terms of what they can do.
The term you are looking for in regards to UHG or other similar medical insurance is “in network”. Meaning the insurance company does what it is supposed to do, and finds doctors that agree to negotiated rates and terms.
Now….if you have patients going to out of network doctors, or dumb doctors doing procedures that are out of what they agreed to be reasonable with the insurer, then you get rejections.
Most rejections are from risk pools of members that are already unhealthy or poor and are playing catch-up on medical issues. We call this adverse selection. In the good old days insurance companies would offset this by raising rates an / or having more healthy members. But now everyone is a fat ass, boomers live too fucking long, hospitals charge out the ass to make up for all the illegals, and yes stupid fucking trannies need their gender affirming care paid for, so someone is going to get rejections.
The insurance companies that took on the riskiest populations will deny the most claims. UHG built a massive network, marketed to the most people, or largest employers, and are now figuring out the financials of their miscalculation. So they start denying or forcing the member to absorb the cost of an increasing litany of minor things (I.e. the nuanced poor optics anesthesia thing from last week is one example, or a doctor that wants some next generation bleeding edge tech imaging to tell you that you broke your clavicle. ).
The insurance companies have their own medical directors who work with actuaries for pricing and other bean counters to determine when doctors (more accurately medical groups) are asking for shit that doesn’t make sense. Yes, you get some horror stories out of this like only paying for one foot amputation instead of two for some Jack scalfani diabetic , but it is supposed to balance out in the end.
And if you have people consulting Dr. Google who march into a specialists office seeking validation for their self diagnosis or a certain treatment, you absolutely will be told to go back to your primary and get your fucking refer all you nut bag, then the specialist can start asking the insurance company to begin a reasonable series of tests. And if you don’t like it and start bitching up a storm and not listening to the fucking doctor. You’ll get slow walked and guided back to the treatment you should get. People really get upset when their primary and Dr. Google disagree, and now they are shooting spreadsheet monkeys over it.
