Health Insurance Physicians
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- Опубліковано 18 чер 2023
- Check out the article (link below) from ProPublica that inspired this video. The info about UHC “medical directors” is particularly abhorrent. There is so much we don’t know about the inner workings of health insurance companies. Investigative journalism like this helps shed a little light.
www.propublica.org/article/un...
I’m not joking about the physician who stopped practicing in the 90s because he was scared of STDs. It’s all in this article. This person has been denying claims since 2010
www.propublica.org/article/unitedhealth-healthcare-insurance-denial-ulcerative-colitis
🎵"VD is for everybody"🎵
That's so lame lmaoo
Truth is always stranger than fiction!
Had a med-school student actually declare that they don't like blacks, wouldn't treat or accept black patients and wouldn't tell them if their HIV results came back positive.
Insurance would totally have hired them.
I have heard crazy stuff also true crime...but yeah truth here. Makes me laugh and cry for all.
As a transfusion medicine physician, I am personally a HUGE fan of blood money.
I choked on my coffee! That’s a knee slapper.😂
This is the best comment ever
I see what you did there!😂
You win 2 internets today, good sir!
This is....Ok.
Non-medical field watchers think you are kidding......he's not kidding....😢
Why say something like that? How do you know? I don't work in the medical field, but I know this is true. Rude.
how dare you undermine my lack of optimism
Yes. We know.
Funny cuase its true is all anyone is thinking
😢
I work in oncology. One of the oncologists I work with had a peer to peer where a pediatrician who had never worked in oncology in her life told the oncologist that the National Cancer Institute guidelines were actually wrong, and that the insurance company would not be paying for what standard medical practice considered to be the next appropriate drug.
Moral of the story: This video is not an exaggeration even slightly.
😔
Holy cow. This crap is why I don't trust the whole Medicare Advantage insurance model.
The couple of these I've looked up were actual examples of things that happened but I'm not sure if that is because he looks stuff up for the skits or just because the medical practice is even more screwed up than the stereotypes about it and his skit just so happened to exactly match something in real life on those couple occasions.
...kinda like how The Onion has put out satire pseudo-articles that ended up matching real world events a year or two later on a frankly depressing number of occasions...sometimes to a disturbing degree of accuracy.
Accurate. I'm an onc MSW. Was consulted yesterday because a patient's primary insurance was pushing hospice on a patient with a prognosis of multiple years with treatment.
Yeah well for something that blatant it should be easy to take them to court
I have UHC and my favorite denial so far was about my daughter. “Admission was not medically necessary because you stopped vomiting.” She spent 3 days in the hospital trying to get her condition back under control, she stopped vomiting because there was nothing left to vomit and medication to suppress her immune response…
There tried to deny my hospitalization as medically unnessary when I had had a brain hemorrhage and resulting surgery. (To be fair, after that hiccup they were actually pretty good that year, but their contract with the employer was also up for renewal and it was a big one.)
Ugh I'm sorry that happened to you. I briefly worked for a health insurance company in the underwriting department. I have second hand experience with those kinds of things happening. I was just the department lacky.... And got to overhear conversations between the underwriters marketing and actuaries that talked about this stuff.
Marketing talking about major coming claim with Underwriting and UW wanting to jack the rates sky high. Or UW Looking at group usage from the year before, jacking the rates up sky high and marketing freaking out.
The negotiations for the really large groups would go on for at least a week for the really large groups.
... And you know that the insurance company always came out making a ton of money.
Some of the conversations I overheard were breathtaking.
To be fair though, it's not just the insurance companies that are for profit... It's the WHOLE medical industry which is so gross.
@@elisabetk2595Apparently, you should have been able to perform your own brain surgery at home 😂
I had something similar happen with Anthem. I took my asthmatic some to urgent care for breathing difficulties. Two breathing treatments later and no meaningful response and they told us to go to the emergency room around the corner and they called ahead. ER docs were waiting and we were in the back immediately. Two more breathing treatments and no meaningful improvement meant admission to the children's hospital. This resulted in a 3 day stay at the children's hospital and the first 48 hours they had him in 100% oxygen and the last 24 hours were for observation after his condition improved. All claims were denied as apparently breathing isn't medically necessary.
I went to the lowest level of immediate care, urgent care, and was referred to the ER and he was admitted. If should have just been an urgent care co-pay. Nope. $16,000 bill. Insurance rates cut the bill to $8,800. I was responsible for 50% of the $8,800.
@@elisabetk2595I thought you meant a literal hiccup. I have loud powerful hiccups at least once a day and I was nodding along as if a hiccup you had caused the brian hemorrhage
I really dislike UHC.
"This claim denied as not medically necessary per Medicare's guidelines."
But, uhh, the published medical policy on Medicare's website shows it's covered for this specific condition, here's the written guideline...
"I SAID NOT MEDICALLY NECESSARY. NEXT."
If not paid for a missbilled claim(not abn, unless you have Medicaid also) the claim was to be adjusted.
@@ashleybeasley5429 I've had to go through a reconsideration....then an appeal...and then directly to our provider relations contact to get so many things (that have proof of policy showing we billed correctly) paid in the last 6 months. It's ridiculous. Clean claim shouldn't take 90+ days to get paid. 🥴
@Rabbit of Caerbannog I agree. If I is an hmo after 2 attempts call cms and clean a clock. When insurance Medicaid products do not adhere to crossover I give them 2 tries and report them to the state(pay copay on the Medicaid product.
I know you’re trying to raise awareness through comedy but every time I think about what these prices of human garbage are doing it make me want to actually through a revolution
Good
I'm not kidding, I'm an anarchist, I am right there with you when that battle happens.
Yessss, good, good, come to the red side
@@_Puppe i wrote a post above, I think we are like-minded. i’d volunteer for healthcare reform but are there even any orgs? i’m in manhattan ffs and i’ve heard nada.
this shit had to change.
@@Bajirkus the unregulated free market side?
yeah that’s working out well
I like how honest the insurance guy is.
If only real evil was like that :(
I had a professor once say, when asked about the ethics of doing research for machine vision for missiles (a field notorious for literally mass murdering children), "Oh that's simple, just don't care about the ethics. Just take the grant money and don't care."
Sometimes they are that blatantly evil!
@@thomaskilmer If the missiles can see better maybe they can miss the kids????
From the sound of this professor I think he will make them aim better at kids...
When I went into my PhD we had mandatory ethics classes wtf is going on where you are at?
@@aziouss2863 I mean, what can i say? Napalm sticks to kids
@@aziouss2863 mechatronics is a lawless wasteland, as it should be.
@@aziouss2863 unfortunately missing the children requires that the missile isn't aimed at them in the first place.
I had a denial for a patient based on an interpretation of a physician statement that a patient was Her-2 (+1) negative. When I called about it, they stated that the patient must be Her-2 negative. I told them to put me on hold and google how to read FISH results on Her-2. Magically they did, and came back with: “Good news! The notes have been re-reviewed and now we’re approving the medication!”. True story.
Hahaha Jesus Christ that's so fucking depressing man. These people are paid real money to do that shit, what the hell
Now with actual her2 low indications, shit is gonna get real fun
Wow, salute for fighting for your lucky patient and doing successful Peer to Peer Appeal and renew. But on the other end, was there a true Medical Doctor and not an outsourced to 3rd party and another language speaking robot or something AI or someone from the 3rd world medical school being paid to stamp "deny with vengeance" or "deny with passion" for as long as you can to get food on the table for your family or else...
I'm a pharmacy technician, and I utterly despise these insurance companies. Also the "we only cover this specific brand of insulin/diabetic supplies, so screw you"
See also: "I know we covered that last month, but we don't do that anymore. You will need to contact your physician so they and their staff can perform hours of free labor submitting a PA for that med we covered three days ago, or have them send in a new Rx for the med we do cover. And no, we aren't going to tell you what that is. Guessing makes it more like a game!"
@@grapatin ugggggggh yuuuuuuuup
Also: "sorry we don't cover the generic, only brand name, but feck you it's still gonna be more costly than full cash price generic"
How many prior authorizations get denied every day for a drug the patient was already on?
@@jphanks for starters, the prior authorization expires each year, so I have at least one or two a week that embark on a week/month long struggle to just renew their yearly PA. They also will get denied if the doctor even slightly changes dosage. And gods forbid they get new insurance and they have to start from scratch even if they've been on it for decades.
And this is just my single small town pharmacy- so multiply our 1/2 New-Absurd insurance rejects a day average by the 45,000 pharmacies in US....
@@AmataTai as does the "formulary", but six months after you signed up for that insurance specifically because your drug WAS ON THE FORMULARY.
As a former medical administration worker, 1 of my jobs was prior authorizations. The lengths these "health" insurance companies go through to NOT approve necessary medicines & procedures is gross. And the government accepts bribes not to change a thing.
they prefer the term lobbying over bribery
I got a pre-auth for a procedure that was declined anyway. The response I got when I called was, "Pre-Authorization is not a guarantee of payment."
@@huasohvac And the people continue to re-elect the same officials who conspire against them. Go figure. Is it ignorance or apathy?
@@wholeNwon both most likely
@@wholeNwon What choice do the people have? Every official running for office pays for that extremely expensive election campaign with money from lobbyists. They are *all* taking bribes; it's how the system works.
I had surgery last Wednesday…. I was told it would be fine and covered. However, we got a message from the insurance company FOUR DAYS after the surgery when I had just gotten home from the hospital saying they’re denying my procedure. I don’t know why they changed their minds or why they told me after the procedure was done…here starts the appeals fight
Oh Jesus Christ I wish you all the best Joshua.
Both with the appeals and recovery
That is....good luck man, I do not know what else to say, other than why would they do this? And of course, you might have already asked this question numerous times just to have some idiotic answer. So I only can say may God bless you on your appeal and recovery.
It's gonna suck the best advice I've seen over and over again is fight them, call. Every. Damn. Day. To. Bug them. They rely on ppl giving and paying out of pocket
Call your Doc and the hospital. They might be able to help you fight it.
My BIGGEST pet-peeve is when my office staff hand me a note for a “peer-to-peer” for imaging I’ve ordered and I call and wait for 15 minutes on hold only to have a nurse pick up and question me about my medical decisions. Peer-to-peer my eye.
She knows how to use a stethoscope and start lines. She’s basically a doctor 🤪
She's human too
@@PWLfr "She's human too" So are the patients. Why is the nurse more valuable and defendable than the patient that all these medical workers were hired to care for? If the patient dies, are you supposed to write "self-eliminated" as a description? Because clearly a mere nurse ain't gonna do it outside extremely understaffed conditions. Nurses are the servers, not the chefs. They are not supposed to make any decisions about patients in most countries, because that is what the MD's i.e. doctors are extensively educated for to do.
@@ihavenoson3384 I read the comment as 'Of course this nurse counts as a peer, after all, she is a human and you are a human, which clearly makes you both equally qualified to make these decisions.'
Other than that: nurses are the backbones of healthcare. They may not have the extensensive theoretical knowledge of a doctor, but they have tons of practical experience. Healthcare without doctors is bad, healthcare without nurses is pure and utter catastrophy. You need both, but you will notice a shortage of nurses a lot sooner.
@@rikwisselink-bijker You are white knighting a profession stereotype that is not even true. "practical experience" Well I have practical experience of you. Woohoo go me. You implying that docs could not do nurses jobs, which clearly indicates you have no idea what MD's training includes. There would be no "nursing experience" without docs telling the nurses what exactly to do. Even a trained monkey can follow orders and you know it.
Also, you fail to make the distinction between various kinds of nurses, making your point a generalization without any useful context. By referencing nurses as something to satisfy a shortage, you are pretty much stating that their value is to be and to be present, instead of being valuable and useful. You are so stupid in your desperate whiteknighting op that you demean what you are supposed to praise. 0/10 Gid gud.
>stopped practicing in early 90s
>"hasn't seen a patient in 20 years"
Doc, uh, I hate to break it to you, but that's *_30_* years. Don't worry, I feel that same pain every time I realize that too.
The real-life doctor that story is based on was hired in the early 2010s so it would have been nearly 20 years by that point
@@ShawFujikawa Hired by this healthcare company. He was employed in the field since the mid 90s, and hadn't seen a patient at all since shortly after the start of that decade.
I read the attached story.
You must be a Lawyer, an Accountant or someone with STEMS or sharp Math and Attention? 🤣🤣🤣🤣🤣👍
@@annamartino5681 Author of literature and computer code, both.
This story was set a decade ago. Lawsuits take time.
I'm a hospital utilization manager. It's my job to fight these assholes with our physician advisors (a new character you should do).
UHC is the worst. Medical boards need to hold insurance medical directors accountable for their denials.
As the manager of Compliance Audit, I couldn't agree with you more... Literally fighting on the exact policies that the case manager admits that the policy for which they are conducting review is not longer in effect! Better yet, they aren't even remotely familiar with our medical specialty!
Keep fighting the good fight 💪
- need the character who is a GOOD admin and not the useless CEO bro
If you know it's wrong, report it to CMS. Here is the thing; all medicare hmo's and Medicaid MCOs must adhere to the rules of Medicare and Medicaid respectively. All birthing accounts are to be paid by the insurance company. All baby Medicaid accounts are guaranteed 1st two months. These consultants make the hospitals drop accounts to the patients but if these rules were applied and more(continuity of care medicare 90 days, Medicaid mco 30-60 days so much money could be saved).. sad thing is patient accounting will not pick me up because when they read my resume their ego is afraid I will mop up or bring to light the problems.
Not denials murders.
I love you, Jimothy, but we need a hero like this!
Lol the physician advisor would be great.
“Hey doc I noticed this patient with ARDS and DIC has been under observation for 3 days, do you think that inpatient might be a little more appropriate?”
“Hey doc I noticed yesterday you said the patient was probably going to go home today, I was just wondering if you thought about throwing in the order.” “…..it’s 4:59AM.” “Yes we have moved up the goal out the door time to go along with our new discharge rooster, we call him cock-a-doodle-discharge.”
I know this was for UHC but I’m also looking at you, Aetna - thanks for making it so difficult to get the medication that keeps me alive. Oh and deciding that the appeal isn’t urgent, despite having been on this medication for years.
I mean doctors are the ones that need to mark it as urgent. If they don't then it will go based on standard appeals timeframe
@@mrgjsolorio they did mark it as urgent. Aetna denied the urgency because they (Aetna) said it wasn’t life threatening. But it was, without the medication I would have died and it’s the only medication out there for my condition.
same thing just happened to my mom this week. they suddenly stopped covering the one medication she can take for her condition so the price went from a $20 copay to $350 something :’) and no one could tell her why. I think aetna just decided they don’t want to pay for it anymore lol
@@AyaDragonheart oof I’m so sorry.
What state and product? I can get you the Formulary. Allot of doctors I tell them how to fill out the paper and they do not follow through. If you tell the medication I can tell you what the insurance is looking for
I just finished a basic course in occupational safety and health and one of the lecturers (who was also a physician) talked about "Managed Health Care" which I only just learned was what HMO, PPO, and other privatized medical insurance models were officially called. It was an extremely uncomfortable 2 hours of him struggling to justify how having our patients pay exorbitant premiums and requiring prior authorization before being given access to a physician was a good thing
"It'll prevent fraud, hospital overwhelming, and reduce costs for all insurance users"
Insurance companies are the worst. Hey Medigap instead of Medicare Advantage!!! Medicare Advantage makes money denying your claims and Medigap is required to cover any expenses approved by Medicare. Healthcare groups are required to inform you ahead of time any expenses Medicare won't cover!
Recent PharmD grad. We had a course that every Friday had to debate heated topics by groups that were then graded by our clasemates. My group had to defend PBMs ... while our group technically won the debate because our group was well prepared, we were graded lower than the other group due to the topic. (I agree with them too)
@@azalean9836If you argued the topic well, you should have received top marks.
Gotta love struggle sessions.
As a Neurosurgery RN that handles my surgeon’s peer to peers and appeals, THANK YOU FOR NAILING THIS 100% 🤣🤣our latest peer to peer: a 17 year old patient’s scoliosis surgery was denied because “her spine wasn’t badly curved”… she had a Cobb angle of 52 degrees. We asked them what “badly curved” meant and they couldn’t answer 🤦🏼♀️
Maybe you should have paid them a visit and demonstrated it for them... On their own spines.
@@mukfay I like your thinking!!!
Years ago I got divorced and bought a United Healthcare policy for my daughter, $100/month with $2000 deductible (adjusted for inflation that's $160/month and $3200 deductible). When she was 17, she was trying to open one of those plastic packages that are so difficult to open, and the scissors slipped and cut her thumb tendon. I looked up hand surgeons in the United Healthcare recommended physicians guide, and picked one close by.
I paid the $2000 deductible, and then after the surgery, they of course declined to pay $894 for anesthesia, and then they said the doctor I had chosen from THEIR GUIDE was too expensive and they were only paying 50% instead of 80%, leaving me to pay another $4500. And they only paid for 6 physical therapy visits. Then I got laid off, and delayed payment. Eventually the clinic knocked $1500 off of the bill.
In total I paid UHC around $7200 for 6 years of premiums, paid around $4000 to the hand clinic, and UHC paid about $2000 to the hand clinic. And yet they claim health insurance companies only make 5% profit.
Does it ever really happen that an insurance is more convenient than just paying out of pocket?
I don't mean extreme cases, but normally does it happen? For example what about yourself? If you had to pay out of pocket for everything would it cost more or less than what it costed you to have an insurance?
@@wisteria3032 it's straight up not possible for anyone who isn't a multi-millionaire to pay for health care in the US without insurance. The prices hospitals charge are inflated knowing that insurers will negotiate them down, and even then they're far higher than what you would pay in other countries. I cannot begin to tell you how expensive a single doctor's visit is without insurance, but i can assure you you won't be able to afford the second one. Yes, in the US it is cheaper to have health insurance, but that's because it's impossible not to have health insurance and still afford to see a doctor. Wait until you find out how much an ambulance ride costs. Point is, if you don't have health insurance, you aren't able to see a doctor in the US - period. And if you do have insurance, you still might not be able to afford care. Having to choose between getting medical care and making rent is a really common thing in the US.
@@ditch_magnet thank you for your explanation. From what I understood it seemed like people would pay for insurance and then most of the time had to cover all healthcare costs themselves. So I thought - why pay for insurance? but it makes sense if the price you pay has been negotiated down (although I wonder why it isn't possible for a single person to do the same)
I know how much an ambulance ride costs and it's disgusting. at the same time I have read and heard too many people saying they are not going to pay for everyone's health through taxes because people get spoiled that way.
I have seen americans make incredible sacrifices to help one another in any other kind of situation so it always baffled me that you can help me with everything from changing diapers to rebuild my house after a tornado but I mention health and suddenly I am a lazy bum who should get a job and pay my own insurance.
Now I am wondering if this hate for public health is caused by a misconception about how much it would cost. If I expect to pay more in taxes than I already pay for my insurance of course I'll be against it.
May I ask what some normal prices for insurance are? you mentioned around $200 a year and - if I got it right - you pay around 2000 before they start to do anything?
how much would a normal doctor visit cost?
@@wisteria3032 It was $100/month with a $2000 deductible, but that was 17 years ago. Today it would be more like $300/month with a $4000 deductible.
You've touched on a lot of issues here. I'll start with public healthcare. Most Americans are not aware that most of healthcare spending in the US is for public healthcare. We spend about $4.4 trillion total on healthcare in the US, but only about $1.2 trillion of that is through private health insurance! The rest is mostly Medicare which is pays for people 65 and older, Medicaid which pays for impoverished people, and TriCare/VA which is for military veterans.
You mentioned people thinking you're a leach if you want public healthcare. Yes! Many Americans are so bent out of shape at the very thought of paying for lazy people that they pay scammers 10 times as much or more. Back when Florida was going to require drug testing for welfare recipients, I argued with this guy and informed him that the program cost tens of millions of dollars and only saved thousands. His attitude was "I don't care, I just can't stand the idea of some druggie getting my tax money!"
Finally another insurance story I have turned out quite different for me, but illustrates the dynamic between hospitals and insurance companies. I needed back surgery in 2010, and the HR person for the small company I worked for got us the best insurance ever. The deductible was $2000, but the company paid for $1500 of that, and there were no copays! So all I really had to pay for was the MRI of my lower spine, and that met my deductible. I got a bill for $139,000, but then got a notice that insurance had paid for $15,000 of that, and that was it. Unfortunately the ACA, aka Obamacare, did away with that kind of deal. Not that I'm complaining, I used Obamacare after I got fired at 62 and had to wait three years before I could get Medicare.
@@dalegreer3095Wow, who knew, it would be nice to get a website with reference for these giant numbers. We all who work in private companies pay 15% in SS and Medicare Taxes which then go to cover these 65 and older, right? So it's essentially like paying for our older relatives?
Absolutely true. One evening I received a call from an insurance "doc" who told me that they were not going to cover a large portion of a pt.'s hospital costs incurred because of a delay in his definitive care. That delay was due to technical factors beyond my control. He was dependent on IV meds at the time. I explained the situation with great care but the insurance doc wouldn't budge. I finally said that I didn't really care what they chose to cover but asked that they inform the pt. who was a few ft. away listening to my end of the conversation. So I passed the phone to him. The doc. then said that they had made an error, had confused him with another pt. and all of his hospital care would be fully covered. He was a senior executive of one of the world's largest corporations. Never heard from that ins. co. again. I feel certain that, if that pt. had not been both wealthy and powerful, the outcome would have been very different.
Wonderful! Good awesome thinking! Beat them with the Best on Your Team Head On Nice and Strong!
I came home from work one day to find my mother in tears because she got a denial letter on the injectable being used to treat her metastatic renal cancer. The same medicine that she had been using for months. This medicine cost $5000 a month. After I was able to calm her down a little bit, I got on the phone with her insurance company. The lady I spoke with was very nice, very helpful and VERY honest. After looking at my mother’s information, she said that the agent that was working with her claim was behind on their number of denials so they had to make up for it with another random denial!!
WTF? Seriously what the fuck.
Sue and sue hard. Or at least threaten.. Even if you signed an arbitration agreement. You legally can't actually sign away your right to sue. (it's this wierd fucked up gray area that let's companies make you sign them)
You'd be amazed at how much theats like that work.
OMG
Jesus fucking christ
Oh My Lord Almighty! Wow!
Hellacious. I hope that situation turned around.
Pharmacist here - honestly, I'm a little surprised that some of these aren't worse than they actually are. Insurance companies do some really shady shit.
You know we're in deep shit when this is one of his kinder vids aimed at UHC
My wife had to fight to get her short term disability claim approved and one of the hurdles was some BS "doctor" who basically said everything in the claim was "not medically necessary" or some other nonsense. We had to hire a lawyer just to get the claim approved.
It's a sad state of affairs if even the actual health insurance companies are pulling this same crap.
They make money denying claims. This is the natural conclusion of capitalism
So now you know why the rest of the world has universal health care that usually produces much better outcomes for pts., increased longevity and better health during aging as well as lower maternal mortality and infant mortality. Health care in the USA is not what it should be at all. But the people just don 't care enough to vote for change. So, what the hell. One political party has been trying to kill Medicare and Medicaid for decades and to give it all to commercial insurance companies. They say it will "increase efficiency" when the reality is that Medicare is more efficient than any insurance co. by orders of magnitude.
The top goal of health insurance companies is not to provide a service. Their goal is to take as much of your money as possible while spending as little of it as possible on you. They are betting on your health. It's why the Obamacare act had to enact into law that insurance companies couldn't deny people based on pre-existing illnesses anymore. Their duty is to their investors not to you.
@@helter1234 Welcome to capitalism and to further evidence that "free markets" do not always produce better, cheaper products.
@@wholeNwon Yeah, my wife is from China, which despite what people believe is still capitalist, just centrally planned capitalism. But she always complains about how much more expensive everything is in America, compared to China.
Of course health insurance doesn't operate like buying or selling a car or TV, which is the type of shit that "free market" advocates are really talking about when they talk about better, cheaper products. The big health networks, the pharmaceutical companies and insurance companies hold all the cards and are becoming more and more incestuous thanks to deregulation.
As someone who worked for a clinic owned by UHG... Yeah this is spot on. If anything, its too kind to the level of incompetence and evil that ran that company.
It's either laugh or cry, because while presented in a humorous manner this exactly the sort of broken the US healthcare system is.
WOW!!! You are SO RIGHT ON with this skit!!! 😥 This truly hits home for me at the moment. I'm an RN, and I had a major open heart surgery a few weeks ago for both a valve replacement and for coronary artery bypass grafts. The plan all along had been that I would go to a nursing facility to recuperate after the hospital since my husband recently passed away. So the time came, and a bed was open. But that day my white blood cell count went up, so they kept me 2 more days at the hospital. So once again, arrangements were being made for a transfer. But suddenly the hospital was told that I no longer fit the criteria for a nursing facility, and that I was doing too well for them to pay!!!! 😯 Thankfully, some dear friends asked me to come and to stay with them awhile while I was recuperating. Praise God for that miracle!!! 🙏❤️ But there was NO EXCUSE ethically or morally for refusing the transfer!!! 😥
Actually you are much better off to be with loving kind friends who would care for you. Even just a Hug would give you more Endorfines and Happiness than a cold empty room with other stragglers and some of them even your roommates may require urgent and palative care and at this point you know it's always better to be surrounded by those who love you ❤!
Hell yeah! Shout out to my Johns Hopkins colleagues! And yes, we have the best doctors for sure who are working to stick it to Health Insurance Companies. Freaking scammers
How do I get in with patient accounting with Medicare and Medicaid, I have the goods and took blue cross to task on underpayment and Medicaid non-compliance
Yep...Hopkins doctors are the best. My cardiologist graduated from Hopkins. ❤
My last “peer-to-peer“ was with a physician who tried citing a review article to justify the denial. I asked him to compare the name of the author of the article against my name, and then tell me exactly what the authors wrote in the article.
(Hint: it was my article, and he hadn’t even read the abstract for the article properly.)
I used to think that we could salvage the current healthcare system but when things are this egregious, having “Medicare for all“/a single payer system is the one house the only options to making things right
That "What about the private practice ophthalmologist under investigation for medicare fraud ?" Sounded too specific. Is everything okay ?
😂😂😂 there was a news story a while back about a Florida ophthalmologist who went to jail for Medicare fraud
@@DGlaucomflecken his Jonathan must have been off that day
@@ciara473it’s Florida, I bet they don’t even have Jonathan’s there.
@@Jane-dr2wg They do, it's just that Jonathan was busy singlehandedly running meth production and distribution ring with steroid lab on the side
@@DenysBuryino No NO - Jonathans are busy rounding up all the Visine.
I often wish i knew the names and addresses of the people that cut off rehab coverage for my patients because they think someone being contact guard assist for up to 20 feet is enough to safely go home alone while they are also mod assist for toileting
I can never get enough of Jimothy and Bossifer.
These videos are hilarious and make me wish it was possible for me to join the medical team. I was a personal support worker before the pandemic hit and the decline I saw after it hit gave me PTSD like symptoms. It makes me nervous even typing about it. I don't know how y'all do it. Working in retirement care destroyed a part of me and I just can't go back even though its been years. Sincerely, thank you for the work you do.
You should include a piece on how insurance physicians deny tests and treatments ordered by specialties that they have no experience with (I.e. A burned out ObGyn denying MRIs ordered by the neurologist).
This! I had a pediatrician deny a cardiac procedure on a 65YO man - a procedure almost never done on children. 🙄
These are hilarious……. But the reality of it is very VERY depressing. I just got a NICI bill for my son, he was intubated for 2 days, in the NICU for 10, the healthcare workers were absolutely amazing (especially the respiratory therapists, please make sure to thank your respiratory therapists in the hospital) anyways, we just got the bill for $135,000. No, that’s not a joke. We just hope that our insurance with a 6k deductible won’t give me any issues.
This also affects/applies to a growing number of nurses who are desperate to get out of bedside nursing. The corporatization of healthcare has made caring for patients a nightmare in many cases. So they leave to get jobs with these companies, most often work from home and spend their days reviewing and denying claims at a lower, more algorithmic level than the docs to be sure, but do you want a burnt out nurse as your first interaction with your insurance company?
I am one of those nurses. We do not deny claims. We literally cannot do that. Also I am much happier working this job and happy to talk on the phone with you and see how I can help make it work within the guidelines and processes set.
Ugh. I've said it before and I"ll say it again. Healthcare insurance is a scam!
Great video, Doc. I'm glad you're not a sleazy healthcare insurance doctor! :)
Definitely is
And a lot of people in the us *enjoy* it
I feel this on a personal level. I'm a pta, but I once had an insurance "pt" tell me that a patient was ok to go home alone. The patient could not stand from his wheelchair without max assistance and had 3 stairs to enter his home. According to the insurance "pt" that would all be solved with a wheelchair cushion.
No, I'm not kidding.
You can file complaint with state. But But But was this acute ot longterm condition longterm required a screening for an aide.
@@ashleybeasley5429 this was in a long term care setting about 5 years ago, I was fresh out of school and really knew nothing about insurance. I did the best I could with what I knew before the guy ended the call. TLDR the patient did go home, as for what kind of help he had when he did I never found out.
I guess the pt was supposed to use the approved wheelchair cushion to cushion his fall😢
As a nurse working in primary care, we have to deal with UHC's consistent denials on a constant basis. The video is (sadly) spot on. Keep 'em coming Dr G and raise awareness!
sometimes these just sting, i knew exactly what article you were referencing. please continue to make them.
I felt this one in my SOUL. The number of times daily I shout something out loud while throwing my hands up in disbelief and confusion SMH at denials.. and, as a nurse , i say things like : how can it be a peer to peer if they’re not even close to the same specialty ???? Do they have a medical
Degree or was it a 6 week customer service training course ? Does Texaco Mike’s Cousin run this place ? My doctors know what they’re doing , what the HECK are yours doing ?!?! Throwing darts at responses ?!?! Sooooooooo anyway , I don’t find authorizations stressful AT ALL 🤦♀️🙄
So true!!! “Your patient isn’t symptomatic enough.” “We didn’t say you couldn’t do the procedure. We said ‘we aren’t paying for it’.”
Well, find the definition of symptomatic enough? Maybe on the Insurance Guidelines. Then ask your Patients to come back with symptoms they experience and write down in an hourly daily diary. See if this helps? It's like an old Neurologist who told someone who was a stranger it may take several visits to get to the point when insurance maybe would be willing to consider covering some of what is necessary for my struggling patients.
That last sentence is so true and probably the most frightening. When insurance and pharma aren't held accountable, the system doesn't work.
Yeah that last line was kinda chilling because it's much more true than false. Who holds them accountable for the lives their role in the system costs? Are they accountable for causing sub-optimal outcomes through sheer bureaucracy? No one does because the agencies tasked with doing so are captured bureaucrats-first themselves.
Do the insurance companies ever reach out to you about these videos?
I second this question!
Do we want them doing that? Because I don't think they'd have much of a sense of humor about their business model being speared as inherently inhumane and needlessly cruel. They're corporations, after all.
Hahahano.
Dr. G is fighting the system and the health insurance companies and their cronies in the permanent political class in DC and state capitols don't want people fighting the system.
I'm thinking along the same lines you are, I mean for instance I wonder if anybody who actually works for a health insurance company has ever seen any of these videos? How do these people, the ones actually making those decisions based on policies they agreed to enforce for their job, and then doing the paperwork for those decisions, how do they justify making a living that way? I have a hard time imagining it.
@@aylalayk6526 Apparently you wildly unfamiliar with Cluster B disorders. The are characterological in nature. Read: disorders of MORAL character.
narcissists
malignant narcissists
histrionics (i.e. the Munchausen people...now called medical fraud or medical abuse)
sociopaths
psychopaths
Sadistic Personality Disorder is no longer in the DSM, but it is in the ICD codes F.65.52 In law enforcement, they just call that sexual sadism. They are the r@pists whose victims' (yes, plural) only chance for survival is escape.
These people walk amongst us and the vast majority of them look just like you and me...only they're all capable of behaving like straight-up sociopaths, as they lack anything close to a normative moral compass.
I owe sanford just under 10,000. One MRI to make sure my slipped disc hasn't slipped further into my Spinal Column (checked because I couldn't walk for a week). One CAT scan to make sure I wasn't bleeding into my brain when I fell 8ft directly onto my head. Cement is not that soft.
Do you have insurance? If not you can ask to pay Medicare rates. Hospital Corp og America charges 26%
My CT scan of my head is $1,440 without insurance. I was having a terrible headache.
"... An appropriate amount?" "Exactly!" That attempt at hyperbole being undermined by a disturbing amount of self-awareness from the manager really says it all. Thanks, I hate it.
Me watching this man's videos while having United Healthcare: haha, I am in danger!
Want to give thumbs up but with a frown because it is speaking such truth. Keep them coming Dr G
Dear Dr G, The early nineties was thirty years ago. Signed-been waiting seven months for an MRI of my knee, which is getting worse, not better, and when it was finally scheduled, the insurance company decided three days before that they needed more information so I'm back to waiting again.
Been there in that limbo and it sucks.
Don't be waiting, go back to your doctor and surgeon and complain about how you feeling. That would be used by them for required Pre-approval for a major procedure such as MRI and they can't do this without recent clinical reevaluating you. Don't just be sitting and waiting? Go straight away to see them for your pain ASAP.
Only Dr. G can make me laugh and cry at the same time.
Thank you for sharing this article. I have ulcerative colitis and have spent years and years dealing with so much BS from health insurance companies, from prescription coverage limits to delays in care. If I hadn't lost access to my original medication (that had almost no side effects!!) thanks to a coverage limit in a student health insurance plan, I might not have needed to resort to heavier hitting medications, nor would I have spent the better part of the last decade extremely ill. My various health insurers have spent hundreds of thousands of dollars more on me than they would have if they'd covered the prescription in the first place.
As a dental provider, it is just like that. UHC isn’t the worst on our side, but some of these insurance companies make you question humanity.
How many framed cease-and-desist letters do you have on your office wall? 😂
This is about that ProPublica article about the lawsuit for the guy with UC. The insurance doctor who denied his claims (he said he only did what United told him to do) stopped practicing in the 90s because he was afraid of AIDS.
Every time you make a video about Insurance I just cheer! People need to know the depths that these companies will go to.
As someone in the global/public health field, I love that you're spotlighting this, while my heart breaks over the accuracy.
These videos are especially entertaining for people enrolled with UHC, in a state that voted down a bill that would allow Medicare to negotiate prices with drug companies, and voted down a bill to limit the length of patents for companies that charge up to $1k a month for drugs where the generic is available in other countries for less than $50 a month. A common anticoagulant older people with heart disease or DVT or just Afib has a black box warning that one can expect to have a clot develop if they stop taking it. With UHC, and other Advantage plans, one quickly reaches the “gap” in drug coverage after about 6 months into the year just because of the cost of this one drug, where Pfizer gets to keep raking in huge profits until at least 2026 or 2028. Thanks Chuck Grassley et alia.
Did you know they proposed now that majority of Heart Surgeries for AFib wouldn't be automatically covered and automatically denied by MEDICARE. Just thought you may already know this.
Is this Brillinta or Plavix? Try the other anticoagulant therapy or upgrade insurance for such people to get this covered...
@@annamartino5681 Eliquis…
@@annamartino5681 Didn’t know that, thanks -
This is why I always ask for the credentials of who decided that I don’t need my meds.
Ack. You are delightful and you horrify me on a regular basis. Thanks for your work here.
I do clerical work in a hospital. Just went through our patient pre-op list for tomorrow for cath lab. 2 of the 3 patients don't even have authorization yet. Thier procedures are in 2 days. I see this all the time.
I'm calling it now: In five years, there will be paid legal assistance to ensure coverage for what your insurance clearly states you are covered. This service will be run out of a shell company owned by Advent Health.
A formalized literal "pay an extra fee/bribe on top to actually get the thing you're already paying for" ... Yeah, this sounds like a horrifyingly accurate prediction, thanks I hate it
I am trying to get some one I trust to help do an all things health insurance and medical bills channel. I know allot. I did billing for 12 years now.
@@ashleybeasley5429 That's a great idea! I'm really into medical education and patient advocacy but insurance navigation isn't my niche so I can't be of help there, but I love your concept and I hope you make it happen, people need those kinds of resources!
This has gotten so much worse over the years. I used to be able to call up and talk to a doctor and explain the case and they would usually sort of see why I am doing what I am doing and approve what I wanted or maybe they would say "how about you try PT and if he can't do that call me back." Usually they would approve the stress test for someone with classic angina.
Today it is more like this:
Me: I think the patient has a soft tissue sarcoma and need you to approve an MRI.
Them: You need to get an x-ray.
Me: this isn't going to show up on an xray, I can feel it, it is in his muscle!
Them: It says you need to get an x-ray
Me: Can I ask what kind of doctor you are?
Them: My name is Nancy, you don't get to know my last name, I am a radiologist
Me: You know soft tissue sarcoma doesn't show up on xray, right? The radiologist who looked at the ultrasound I already did suggested an MRI.
Them: It says no to MRI, yes to Xray here.
"Fine, you get to pay for both the Xray and the MRI."
Im mostly having this problem with dental at the moment. Supposedly my insurance covers “limited” root canals. There is no explanation anywhere of what “limited” means. Even the rep I talked to had no idea. Could mean, “we will only cover one root canal per year”. Could mean, “we will only cover a root canal if it is scheduled for the third vernal equinox of the second quarter moon of the lunar new year. And only if you had prior authorization to damage the tooth in question”. I had to resort to just having the bad tooth pulled because I was in pain and no one was giving me or my oral surgeon any answers.
Spot on! Had a “insurance doctor” deny a claim stating that my overnight stay wasn’t necessary, even though my pre-existing condition said otherwise. Totally contradicted themselves.
We flight it. They ended up paying.
So sadly true. I used to get to discuss cases with a former hospitalist from UHC, and we often found a common ground and plan for a patient, suddenly last year she was gone and next doc said she had moved on to another career path, and he refused every peer to peer for about 3 months. UHC is evil.
Really, they can deny an important lifesaving Medication, like Brilinta for example after Heart Surgery, and on top of that Refuse Peer to Peer Appeal? Isn't Appeal part of the Standard CMS and part of the Standards for Medical Care? This really makes me very very sad. ❤ But as Patients we are forever greatful to all Doctors who care for us! ❤ Also, it maybe better than for Patients to see you more often for these PAs and care without existing medicines available to some but not others? How are you as a Doctor can help your Patients without Medications prescribed: advice them to walk outside and see sun every day and try calming Meditation and Breathing exercises or spending time with Loved Ones instead of say Brilinta after Heart Surgery? 😢
I'm worried for your safety. Has a "United Plumbing-care" truck been sitting outside your house?
Great documentary! I don't know how you got access to United's private meetings, but it explains a lot.
The actual best part and the most true is, “ we are United Health Care, we can do what ever we want”. 😮😢
What a diseased system.
well it's not going to get better because insurance says the treatment isn't covered...
I’m guessing that Dr. G is not a preferred provider with UHC. 😎
Recently denied for a med procedure that was done back in January. Called the dr office first and they were confused as they don't do anything without pre-approval. Which they had on file. However, nice lady on the phone noticed at the bottom of the page there was some additional legal writing basically stating that even though you are being given approval, it may still be denied at a later time. So basically, even pre-approval isn't even valid anymore. Have another procedure coming up, also with pre-approval and now I'm wondering about hat kind of surprise bill I'm going to get. Our medical system is horrific at this point. Medical Insurance carriers are worse than Telecom companies at this point.
And THIS is why a month's supply of meds is so expensive. $17 for the drug, $3,295.31 to deny, appeal, review, deny, IMR, & approve.
I heard a story once about a girl who had a heroin addiction. She'd managed two days clean at the hospital after an OD, and decided she wanted to go to a program and get help. However, her insurance would not cover it, because when they evaluated her there was no heroin in her system. So she went out, did some heroin, and came back. She was forced to do more heroin in order to combat her heroin addiction. Isn't U.S. healthcare great?
After reading the link about that ulcerative colitis case, I got to thinking, wouldn't it make sense to lower the cost for treatment so that even when the patient couldn't afford to pay for said treatment it wouldn't hit the payer near as hard when the cost would be so sky high? It just doesn't make sense for treatment on something so debilitating to cost millions of dollars a year when it's clear that MOST people wouldn't be able to afford that kind of price to begin with. I might not be the brightest on this subject so be easy with me in response to this 😂
Recently we got two pieces of mail from Aetna, both on the same day. One was an approval for the procedure my husband needed. One was a denial of the same. 🙄 Fielding this type of crap for my mom when she was in her 90s was a full time job.
I have UHC. Get any approval in writing! Save it and plan on them changing their minds after the procedure. Get it in writing!!
Ughhhh! As someone who recently received a treatment denial letter from my insurance, this is just soooon infuriating! Thank you for the chuckle! Ha!🙄🤪
You can appeal the decision always
@@ashleybeasley5429 yes, we're in the process of doing that. Thankfully my doctors are willing to fight for me❤ It's just the last thing you want to do when you're already sick and in need of treatment, you know? Thankfully, my condition isn't currently life threatening. My heart goes out to all of the severely ill people who are dealing with this insurance runaround.
Well…that explains why my levalbuterol was denied for panini-related pneumonia last month (optum’s reasoning was “it’s not approved for lung infection/pneumonia.” Meanwhile I also have POTS & barely tolerated a regular albuterol breathing treatment in my PCP’s office AND had tachycardia still 15 minutes after the treatment.) 🙃
I use levalbuterol for my asthma (and I have IST and dysautonomia too). My insurance company knows albuterol triggers tachycardia in me, but they deny it every time saying I need to try albuterol or have been hospitalized in the past 90 days for asthma or tachycardia before they'll approve the Xenopex.
My mom, a nephrologist, kept getting meds for a patient denied by insurance. The insurance doc was an OBGYN who had no clue about standard nephrology practice. My mom got them to cover the patient's medication on the THIRD attempt.
The accuracy burns. I always joke that one day I’ll loose my soul and work this job.
As a Canadian, I am just so....baffled. I can't believe you have to go through this. Thanks for making me extra grateful for our healthcare system
for now ...
@@ASid-yj1og Sadly you are right; european, canadian and others models of universal health care are being chopped up and sold by pieces, and what's even sadder is most people in those countries don't give a hoot about it.
@@MalakianM2S or care about the wait times and "medical tourism" their overlords engage in to stateside
@@ElementsRook Wait times are the product of decreasing budgets and a very well planned campaign to undermine the image of the universal health systems in front of the public at large.
Sad, but so DAMNED true? 🤬
*cries in medical assistant*
I LOVE IT when you come taking swings doc!
I know it's a parody but it hits a little to close to home for so many in the USA.
Personally I've never known issues United Healthcare cuz I've never been on them. I know Aetna can be a pain, I'm currently with Kaiser and they're being a pain, while I on my parents health insurance which was Anthem BlueCross BlueShield, they're pretty good.
Depending on the State you live in BCBS is pretty well baked into meeting minimum State standards, so they can be less terrible.
But, again, it all depends.
I second BCBS being pretty good. I didn't realize that it depended on the state.
But, BCBS companies are typically also the most expensive insurance out there. (mostly because they are pretty always PPO networks)
And they still make a stupidly huge profit. I've worked for a BCBS insurance company and seen it first hand.
My brother said pretty much the same thing a few days before he died.
This will only change when the lobbyists for the insurance companies aren’t considered better information sources than practicing physicians by lawmakers.
Ummm.. is this based on reality?? Is that really happening in us?
Absolutely!
It's not new, but it does seem to be getting worse since all the insurance companies are actually owned by 2-3 international conglomerates so it's impossible to pin down someone to talk to OR to blame.
Just came out recently that these "reviewers" have about 3 seconds to review an entire BATCH of claims (so like 50-250 people affected at once). 3 seconds per batch, max.
jfc, I wish Universal Healthcare was a remote possibility here. Yeah, it's got its problems, but since they're currently basically writing their own regulations we're already dealing with Roullette stakes.
yes, and yes. are you old enough to be using youtube unsupervised?
@@LexYeen sorry I dont know man, Im not from us. Not from Europe too if that matters
@@tscimb damn.... I have no words...
Remember, there is a doctor out there who barely got through medical school, barely passed his boards, and was easily the weakest resident in his class, and he still has MD after his name and he’s still an attending somewhere.
As (s)he should be. You go through all that and see your thoughts IF you make it. News flash, the worst doctor is still far above average intelligence. If you want the "best of the best," feel free to pay the rates for them too. They are human also, btw. Mistakes will still happen.
@@cameronno6039 nah fam I've seen some BAD doctors
@@cameronno6039the worst doctor is not above average intelligence, the worst doctor had their parents money to burn. Most physicians are very well learned and work hard on absurd schedules in a difficult field but bums exist everywhere.
@@ImmaDBZvillan bum still went to school and passed tests harder than any regular test
@@elysahatestostudy9364 Be the change then. Good luck.
Practicing hospital physician. I can verify this is 100% accurate.
I am a pulm/cc/sleep doc. I was told during a peer review by a FP that a sleep study was not needed because t 185kg 47 year old had not had a bicarbonate value done and he was young so it was ok that nocturnal saturation was ok to be in the 50’s because he was young.
This is quite possibly the most evil company.
Watching these insurance skits, I'm wondering how much different the cost between having and not having insurance. If it's not worth it, is it mandatory for people in USA to have private insurance?
I'm from Indonesia, but the goverment and the private health insurance isn't looking this bad, while of course they are not perfect. 😅
Not having insurance is WAAAAY worse. So many avenues and prescriptions and modes of care that are simply blocked without insurance. A log of drugs can also automatically cost more without it, since the Insurance company can get better deals for them through standing arrangements.
When someone owes a medicsl debt, the insurance company can take everything they owns, even just to auction it off to lower (not even erase) the bill. However, so can the doctor's office/hospital.
When you go to check in: office/hospital/clinic/walk-in, they all ask the same 3 things:
Name
Birthdate
Insurance Card
People can be so stuck that they're forced to go bankrupt on medical debt. They can even if they have insurance, but it's far more likely when they don't.
Shows like ER used to be set in "Mercy" hospitals, where anyone who couldn't pay would still be taken care of. Mercy hospitals used to be in every major city, to help everyone; but barely exist, now.
Individual hospitals might have payment programs, none are required to unless they get federal funding - and even then, they're allowed to set their own thresholds and limits (mostly).
And, unless something is Medically Necessary to keep a person alive (regardless of comfort level) they don't have to do it.
Mostly, their not gonna do anything they know they won't get paid for. Someone who doesn't have insurance better be waving around a lawyer with a loaded checkbook if they want "inclusive" service.
There's a saying: "The difference between having a house and homelessness is just one illness."
Also, insurance isn't Mandated (there was a whole decade-long saga of back-and-forth that basically boils down to: not mandatory, but dear God at least look at the offerings).
"We're United Healthcare. We can do whatever we want."
im having some uncomfortable flashbacks to that recent trailer about the Boys where homelander says this exact same thing...
I had UHC a few years back. My doctor said to choose a different insurance company, I wanted to say 'I would if I could, the company chooses the healthcare, not me.' I was even in the hospital overnight and my doctor said UHC denied the claim because I wasn't sick enough or something, like a 2 night minimum. like wtf, you would think they would be grateful I wan't there for multiple days. Jimothy, I need the bonus denial grab bag.
I... I am so glad I live in the UK, this is horrific
I work in provider billing....uhc loves denying claims...no joke they don't even like paying reimbursements to the providers/hospitals.
Edit: im in the department where i write appeals and handle denied claims and fight insurance companies to pay on the claims.
When I had my baby via csection, I found out my baby's care in the hospital wasn't covered since they didn't consider her a person until she was released from the hospital. We were there 5 days....
"At one point, court records show, United inaccurately reported to Penn State and the family that McNaughton’s doctor had agreed to lower the doses of his medication."
Insurance companies like United Healthcare have blood on their hands!