Insurance Companies Override Clinical Decisions Doctors Cannot Appeal
Healthcare professionals and outside observers alike struggle with a lack of transparency and understanding of how the system operates. Data is incomplete, decisions are driven by external forces (like insurance companies), and those within the system lack a full view of the factors influencing patient care. This creates frustration and a desire for greater clarity.
SOURCES (60)
“And you are an expert in the medical field? You have a genuine and deep understanding of the real challenges that hospitals, the federal government, drug research, etc face? Or are you one of the masses who just regurgitates "healthcare 4 alllll" because that's a…”
“I keep seeing therapists and other behavioral health providers posting about the same things: stagnant reimbursement rates, clawbacks, audits, recoupments, credentialing problems, and appeals that go nowhere. I think we need one place to start collecting these experiences by state. If you’ve dealt with Blue Cross Blue Shield, Anthem, Elevance, Horizon, or another Blue plan, share: * Your state * Your profession * Which Blue plan * Your reimbursement rate, if you’re comfortable sharing i”
“I'm curious if the group extended health benefit plans selected for residents elsewhere are a bit more... practical? Some of it's good; the drug coverage is pretty broad, but... idk, it feels quite random in some ways. My plan would allow me to claim tons of money for a prosthetic larynx and chronic disease health coaching directed towards people 20+ years older than us, but no fertility treatment coverage. Would make a lot of sense for a group of people who don't make good money or”
“Has anyone else experienced this? It's absolutely insane. As if peer to peer wasn't ridiculous enough now they are doing away with the system entirely and putting it on the PATIENT THEMSELVES to do the appeals. Yes, let's ask sick patients with low or no medical literacy to advocate for themselves to make sure we put as many barriers to getting proper care as possible (as if peer to peer wasn't ALREADY obstructive enough) How do these insurance company execs sleep at night?”
“Looking for some advice on what to do. Sorry, this is a long one! I was scheduled for a spinal fusion on September 11th. I received a call on Monday, August 31st from the providers office that the insurance denied the claim due to there not being enough information. Providers office told me the deadline for a peer to peer was expired and they’d need to file an appeal. They also said that they have a new office system and the fax the insurance sent over got “lost in the system”. I call insurance”
Would you mind stating what State you’re in? I’m in Florida.
“Rules: I will not respond to unconstructive feedback (including calling me a bot etc.). Do not bother reading if you do not have an open mind. No political Dogma. A future plan would be necessary to increase Medicare and Medicaid payments as incentives. A separate future plan would need to repair wage rate to productivity. I fear that if we cannot have these conversations then we are stuck without any solutions. I am at least trying so please be respectful. If you do not like it tell me why and”
“My doctors office has a huge sign at the desk where you check in and also in the waiting room that says if you’re there for an annual check up, discussing new symptoms could trigger the appointment appointment to be coded differently.”
“Happened to me with my last annual Medicare visit. I was prepared though. I had called ahead regarding the need for evaluation of a rash from bites that would not heal on their own and needed a stronger strength antihistamine to help calm the reaction. Agreed that doctor would look at them on my annual visit appointment knowing it may trigger a separate visit billing in addition to the routine. Doctor evaluated by looking at the blisters and writing a prescription for a stronger steroid cream. C”
“It’s reality. Should I come to your job and demand you provide a service for free? It’s a shitty system, but it isn’t the doctor’s fault. Doctors deserve to get paid for their expertise. Blame insurance companies for making this a convoluted system to get them paid for their work. Also, this is a product of a shitty health plan. This is likely a very cheap HDHP. What is saved in premiums ends up being paid out of pocket. For example, I pay about $400/month (pre tax) for me and my wife’s PPO plan”
“99215 has a minimum threshold of 40 minutes of provider time. That's straight up medical fraud to bill a 15 minute appt as that.”
“Thank you for undervaluing all the hard work we do as PCPs. No wonder there is a primary care crisis in our country. (btw, I was with you until your last paragraph.)”
“100% this. What's going on behind the scenes is upcoding. The Physician or the clinic is billing a different service because it generates more revenue. Historically family practice doctors are at the bottom of the pile as far as medicine. They still make okay money but generally way below what other doctors make and your average family practice doctor has to see 20+ appointments a day to make ends meet at the clinic. As a consequence more and more independent family practice clinics have joi”
“I’m not sure if anyone else experiences this: I’ve worked at small/critical access hospitals and tertiary care centers and the number of transfers in to the tertiary care center is skyrocketing. I understand the lack of speciality coverage and hosptial abilities for smaller hospitals. However, immediately transferring any somewhat complicated patient has caused these hospitals not to improve or come up with creative ways to keep people at their facilities. Several problems i notice: 1) this is l”
“https://www.reddit.com/u/Patient\_Equipment728/s/RFBvANhi4G submitted by /u/Patient_Equipment728 [link] [comments]”
“30 years ago my son spent 30 days in ICU. The bill was 542,000$. I find it very hard to believe your stay was 147,000$”
“Kaiser MDs aren't aware of much If a patient lands outside of the normal trajectory, they ignore and dismiss concerns and symptoms. Ive heard of babies needing small bowel removal due to missed intussusception, hemophilia being chronically undersized on their factor to the point of having considerable joint arthropathy, and my own case of celiac disease missed for 10 years.”
“Thru either true mistakes or through no fault of your own, patients can get hurt under your watch. How do you get over it? How do you stop it from eating away at you? submitted by /u/LOR_prob [link] [comments]”
“I'm a PTA in a private clinic, but the owner recently decided to merge with Ivy Health for a private practice partnership. I'm still finding out in real time what all this means, and he doesn't have a lot of info to give us either. I know they use Raintree, which I've heard a lot of negative things about, and we'll be trained on this and expected to switch over. Has anyone gone through this? What changes are expected of the clinic and therapists? And I'm really skeptical”
“I'm aware that there are many bad physicians out there, but I'm curious what makes patients who are reasonably health-literate feel like their physician was bad even when they are receiving good care -- or whatever the most tactful way is to say, I'm not talking about people who come in with medically unreasonable requests who are less than open-minded. Essentially -- what are some reasons patients feel they weren't listened to, or that doctors didn't take their symptoms seri”
“I just realized in horror how bad this could snowball if this really becomes a thing. I was trying to explain to a patient why his tadalfil got denied from his insurance because he did not have BPH. He said he's using it for ED but also has a secondary bladder condition. He then hastily put his conditions into chat GPT asking it if would help with his condition. It replies saying yes and gave a whole slew of medical jargon explaining why. He then proudly read the entire response off as if th”
“It's an amazing and disingenuous posit that the problem here lies with the Algorithm as opposed to the consequences under which it was introduced - cost-cutting. The barriers to care for patients who are already struggling with serious mental conditions are not a new phenomenon related to automated tooling derived from best practice corpus. Rather, they are a direct result of a decline in triage staffing.Take cardiologist Dr. Lee Goldman’s chest pain decision-making algorithm, originally devised”
“If she is that sick why do you have to measure and record BP to even know it is dropping. If maintaining meds made her comfortable then isn't then stopping it more unethical because its adding to her pain. BP dropping will be part of dying, why isn't that a sign from above that she is passing. At what point would you be able to just ignore things like oxygen sats and blood pressure? Only when family agrees to remove vent? Its so unfair to her, I understand your distress for sure.”
“Yes, I agree. Listening to the patient is essential. You will be pleased to know that whenever I'm working with the local mental health trust or other professionals the need for person-centred care comes up pretty much every time. Everyone knows it's the way forward, it's just getting resources in place. In patient settings can be tough on the staff. I was speaking to one guy who'd been subjected to all kinds of abuse over the last month or so. It must take a toll on them and the”
“I'll start: Pharmacist lies to patient about having contacted doctor's office about the PA. submitted by /u/Many_Geologist6125 [link] [comments]”
“Oh this one is so sad.... our Healthcare system is so fractured and families just dont have support”
“I often remember a man in his 40s with a massive stroke who was a real shit show of a patient for weeks. He couldn’t afford his Coumadin, which doesn’t cost a lot, but knowing about his circumstances and the COL where we lived, I could see how became low-priority. I felt so bad for him and his wife, neither of whom spoke English either to add onto the hardships”
“probably 25%. probably the 15% usa people dont have actual insurance for health, i would say those are likely underemployed.”
“Well, HIPAA violations are board reportable in Ohio, so not good. No one wants a board action on their record.”
“I am currently a PA in a state that is experiencing the down coding being done by BCBS for all 99214 codes to 99213s. Our billing department asked us to go in and for the patients where our visits for 99214 extends past the time qualification of the visit to go in and add an amendment documenting exact time spent. I did this for all of my patients. The billing department then asked me to log into my supervisings EMR account and go in and add the amendment to the SPs patients as them. Am I wrong”
“100% true. You know how to get the reimbursement, you know how to rule the world.”
“Tell me your state and your percentage. We talk about pay between states so much but how much is that pay eaten up by health insurance? I am paying 5 percent of my check. Alabama. submitted by /u/frizziefrazzle [link] [comments]”
“Half the "healthcare knowledge" you need is just learning why every workflow exists to satisfy a reimbursement rule, not a patient outcome”
“KFF's 2025 analysis of insurer-reported metrics found denial rates of 18 percent in the ACA marketplace, 14 percent in Medicaid managed care, and 12 percent in Medicare Advantage. Appeals succeeded at meaningfully different rates by market: 67 percent overturned in Medicare Advantage, 47 percent in Medicaid managed care, 43 percent in the ACA marketplace. Insurers maintain publicly that prior authorization exists to limit low-value or unnecessary care. The AMA disputes that framing directly,”
“IT WON’T HURT THE PATIENTS, it will help them immediately. Apart from the days physically striking (in which hospitals are given time to transfer patients or come to the bargaining table) then ratios will be better, less burn out, etc”
“Wow. The arrogance and entitlement over there is disgusting. And people wonder why the general public hates doctors and lawyers. I feel awful for Lindsay and her children. Broken American healthcare absolutely failed them. I hope she somehow finds peace within herself.”
“So now the psychiatrist who testified for the prosecution gets national attention for not understanding what an episiotomy is... and he resigned from his job due to the backlash? Doctors didn't murder those 3 children. People have been turning on us for quite a number of years now, and this is seemingly another misinformation catalyst. Just curious if this has had any impact on your interpersonal relationships, private or professional. submitted by /u/IamEbola [link] [comme”
“My medical expenses are 1,500 a month. I can't get on Medi-cal because my specialist doesn't take Medi-cal and paying cash for her would disqualify me from getting on Medi-cal, and if I get a cheaper insurance policy my monthly expenses would get even higher so I can't even do that. I can't change to a different doctor bc there are only a dozen or so specialists that treat my condition in the country and all are in HCOL places. I save and save and save and it doesn't help bec”
“Yeah, could be non profit stuff, too. I’ve worked in NPs that had a gain share/success share program. They had metrics that the org had to meet (financial, quality, patient experience, etc.) and if those metrics were met everyone got a small bonus like that. I’m sure there were people who never read email and had no idea why a few hundred bucks turned up in their pay one day. Non-profits can’t carry over profits, they need to reinvest in the business. That means new equipment, staff bonuses, and”
“I spent almost an hour yesterday getting a prior authorization pushed through for a medication the patient has been stable on for two years, and not one minute of that was reimbursed or counted as anything. It isn't utilization review at this point, it's just free labor they've offloaded onto us because we're the ones who cave first when a patient is waiting. Every denied authorization means another portal login, another peer to peer with someone who isn't even in my specialt”
“Not my original post! I would lose my mind if there wasn’t something for the patients to shift their focus to outside of their phone and Dr Google! submitted by /u/Signal_Knowledge4934 [link] [comments]”
“Your providers are failing this patient. Violent and wanders? More sedation and medication regimen change because no nursing home will take them. Plus they should have be placed on a hold if they escaped 10 times let alone 20.”
“Cheers for this, I appreciate it. Hopefully this allows others to dodge a bullet.”
“him having consequences that are unrelated to his own actions as a professional...sounds like a lawsuit tbh”
“I have worked in both models and have seen both fail. Actually the best hospital I worked for was a for-profit hospital. They actually had an ethical framework but also had many Physicians in Leadership roles which I think made that difference. Either way the United States Healthcare System is doomed. Massive change is necessary.”
“I believe the above person's point is that health insurance should be a right, and not tied to employment.”
“it will be VERY expensive, just know that. i was in one for a week and without insurance it would have been around 30 grand. i definitely think its possible. and i think it would be fine with custody, since youre checking yourself in. i could be wrong, but i think issues only happen if you get forcefully admitted”
goodluck most hospital CEOs aren’t even licensed clinicians
“People are also quitting jobs because the health coverage is so shitty. I was working for the school district here, $19/hr to be a lunch lady. They pay for YOUR health insurance, but absolutely NOTHING towards your kids and your spouse. To put a family of 4 on shitty, high deductible coverage was $1100/mo. If you make $19/hr, barely 30 hours a week and it’s seasonal.. you’re working just for health insurance. Doesn’t make any damn sense. But even friends who are TEACHERS, that next bump up to $6”
“For tests and labs: when they don’t change the plan of care regardless of the result.”
“Can you please point out what specifically makes you believe this is AI-generated? Please remember that people have different writing styles and that some people actually do just write like this. And the repetition I'm seeing while reading this is mainly in the form of parallelism, which is a valid and commonly used element of style.”
“I run a small family medicine practice and prior authorization is honestly starting to break me. Half my day now goes to fighting insurers over meds and imaging I know my patients need, and my staff is drowning in faxes and portal logins instead of actually helping people. I got into family medicine to take care of folks, not to spend hours on hold justifying a generic blood pressure med to someone who has never met the patient. For those of you in small practices, how are you keeping up with pr”
“It’s getting embarrassing at this point submitted by /u/Special_Fox_2349 [link] [comments]”
“That’s like the time we had a patient throw a chair at the oncologist. That patient was allowed back the week later on that same docs schedule. I was irate, I don’t give a shit if you’ve got cancer, you can find somewhere else to receive treatment if you are willing to harm someone.”