How often do health insurers say no to patients? (2023)

You are on a high deductible plan. With those plans you pay the first $X and after that a percentage of costs (coinsurance) up to $Y.

Sometimes certain things are covered before you hit your deductible other times not.

Yes, but you'll often find that in a high-deductible plan the insurance company gets a "discount" of your $1k med down to $200, which they brag about in your EOB… but the medication's cash price for uninsured people would be $20.

You're out of pocket $180 more than you should be, and paying the $20 cash price out of pocket means your deductible doesn't budge.

What if the medicine costs 100$ to produce, should uninsured have to pay that rather than a subsidized 20$?

What if the medicine costs $0.01 to produce and both are getting hosed?

It's straightforward fraud. Both the providers and insurers goal is to mislead people into thinking the "adjustment" represents a payment from the insurance company.

The pattern is even more flagrant when done with post-facto billed services, since the price hasn't even been assented to. The whole medical industry has essentially normalized many different types of fraud against patients, and yet the industry is so entrenched that state/county AGs don't bother going after them.

Unless you are comparing a generic to a name brand in a situation where the insurance company forces the name brand that shouldn't be the case.

For better or worse in your hypothetical the uninsured price legally has to be $1,000 for medicine. They can write off part of that but no one would write off 99.8% as the insurance company would sue their pants off.

As long as it is a legitimate discount (which it legally always is) they aren't lying perse.

After all the discount getting inflated by charging non-insured people ludicrous prices is the real issue but not one you can meaningfully complain about as an insured.

And unfortunately if you ask for pricing they will give you the inflated pricing meaning it isn't necessarily deceptive there.

The problem is that it's framed as a payment from the insurance company, so people think the insurance is helping with the bill. What has actually happened is the insurer and pharmacy are cooperating to create sham prices/paperwork and confuse the market.

It's even more glaring for post-facto bills from providers, because those prices are being presented on a cost-reimbursement basis (not contractual). The provider is essentially saying "You owe us $500 because that is what it cost to provide your care". But it obviously could not have cost $500 to provide the service, because they're happy to accept $150 in total.

Providing a discount to insurance companies is not fundamentally bad or nefarious.

Medicare/Medicaid tend to pay less than private insurance, however lots of places accept it because that gives them access to a bunch of potential clients.

Leveraging your user base to get a discount from a provider is normal and expected.

The problem is when insurance companies demand a particular discount and providers given them that discount by raising their prices.

Certainly a 70% discount is a sign of a bad price (assuming it isn't part of a cost normalization scheme where some services get deep discounts and others are paid with little or no discount aka "I get 70% off dangerous surgeries but I will pay 110% of simple ones")

However if instead the normal price was $200 and they accepted $150 to get access to the network that is normal.

It feels like you're just skipping the core of my points and repeating the justification that has allowed the situation to get this bad. The fake prices and 50-100% discounts are indeed symptoms of a pathological behavior that indicates it's not about true good-faith "discounts".

One straightforward healthcare reform that could be done tomorrow would be to mandate that providers must charge the same price no matter who is paying, rather than the current behavior of operating pricing cartels in league with the insurance companies. This would work even if the government kept giving itself a pass by excepting Medicare.

> that shouldn't be the case

Oh, I agree. But it is.

> For better or worse in your hypothetical the uninsured price legally has to be $1,000 for medicine.

No, it doesn't.

https://www.nbcnews.com/health/health-news/cost-weight-loss-...

"In March, Novo Nordisk cut the price of all doses of Wegovy by 23% for people paying in cash, dropping it from $650 to $499 per month for uninsured patients or those without coverage. (The list price of $1,349 stayed the same.)"

"It follows a similar move from Eli Lilly, which reduced Zepbound’s starter dose to $349 and higher doses to $499 through its self-pay program, Lilly Direct. The discounted doses require patients to manually draw the medication from a vial with a syringe, adding an extra step compared to the prefilled injector pens."

There are entire businesses and apps built around figuring out which is cheaper, paying out of pocket or going through insurance. https://www.healthcaredive.com/news/goodrx-benefits-check-pr...

And if a provider keeps charging the same amount only now they actually get it because the law requires that insurance companies pay in certain instances?

My point is just that providers raising their prices to give insurance companies a bigger discount is a problem but getting a discount isn't itself flawed.

You keep outright ignoring my point, and then simply asserting that you don't see a problem. A bill from the provider shows a fake cost that they're demanding you reimburse them, and also a fake payment from the insurance company. Those are lies to make you think you are getting a benefit that you are not actually getting. That's called fraud.

Ah yes $500 vs $1,349 is exactly the same as $20 vs $1,000