The real question I have to ask myself, is this this really medically necessary? Do I need prior authorization for this speech? And if so, will I get denied by the algorithm? Jonathan.
The article explains how insurance companies outsource their denial or approval of claims for pre approved medical procedures. Companies like evicre that use an algorithm to sort through the requests and approve most of them, but if it sees any possible discrepancies or anything they don't like, they shunt the request for the review of a doctor. These doctors have about four minutes per review generally, and four minutes is
not a long time to get a case reviewed. To approve or deny it doctors, it requires a doctor to deny a request, so the company makes money. With every denial, the requests have to be denied again by a doctor. Some of the companies medical personnel report that they were given requests for services for service that were not in their area of expertise. A cardiologist reviewing a gastro intensinal or oncology request. This is a long but disturbing article.
Story is from pro Publica by T Christian Miller on October twenty third, twenty twenty four.
So is this medically necessary to be run by the algorithms, to be run up the dial, and to be denied by somebody who frankly doesn't have a clue. I mean, yes, they'll have some medical clue, but you're not going to have a clue if you're a p dietrist talking about you know, stomach cancer, now are you? I mean, this is the level of what we're talking about here, because these doctors who work there, they're going to have multiple specialsts.
You're going to have dermatologists, You're going to have gastro entropologists, cardiologists, pulmonologists, endocrinologists, et cetera, all doing these things that they enjoy doing and thinking of going to do my bit to help the American healthcare system. If you think you're doing a bit to help the American healthcare system, help dismantle the American healthcare system. But that's a discussion for another day. Because the American health care system is it currently is.
Constitution needs a good root and grand to rip up and start again, as I have found through my time living here. So a j do you enjoy the American medical system?
I have ample experience with the American medical system. You know, I have a whole lot of of health issues myself, and so I have actually personally had experience with this type of you know, requests because my my insurance is an HMO, so you are required to submit pretty much for outtervization for anything you want to.
Do in health organization.
Yeah, the best worst. So so I had, for example, I have a pain condition, right, it's very painful and will affect my leg. You know, I couldn't walk, I had to be unconscious sometimes in a wheelchair. And there were times where I only need a nerve block, and so my doctor would submit the request for the nerve block and they will deny it and we will look into it, and it was just such dumb things like often it will be like a small wording or like oh, you're going to use this type of.
Anesthesia and we don't, we don't cover that.
So they deny it just because they were going to use some type of anesthesia that wasn't under the specific I guess under the dial or mailing the dial that's mentioned on the article. So yeah, it's it's a mess. And I had this happened so many times and you get tired of having to appeal and having to try again and again for something.
That you know you're in your extreme pain.
You're like, I hope I can have this procedure in the next few days, but no, you have to wait weeks sometimes months.
Yes, so you remind me a friend of mine, and I'm allowed to shock. They posted this publicly on social media that they have a medical condition, they have Chrohn's disease, and they have a thirty thousand dollars drug. But that's the list price of the drug before insurance comes in. And without this drug, they will die. Straight up. They will just die because, you know, Chrome's disease in severest forms you just cannot digest and absorb nutrients from your food.
You just can't do it, so they will. They recently denied her same drugs she's been getting forever, same drugs. You'll need it. The other day she dies. No, don't need it this time. It's not medically necessary, they say, just because, and then they resubmitted. Oh no, no, no, you're going to resubmit that again in ninety days. And then they'reday, oh yeah, just have it, no rhyme, no reason, no understanding of the ins and out. No conclusion here
or anything. It's just the whim of a computer, the whim of the administrator because they have sent it from being robber stamped to denied I don't care what they say, or to go to denied by a doctor. The delay is denial. Sending it to the doctor is a form of delay denial. And you have to accept that some of these things will kill people. Like the gentleman in the article. He died because they said no through delay
and delay and delay, and he is dead now. The American healthcare system is sometimes the American death care system because it is just there to facilitate people not to get better, but to be money milked and then they die. So, Jonathan, you've got a slightly different view on this. You're a member that can access the Veterans Affairs Department if I'm accurate here, So how does it work there?
Well, the VA is a different system. It's a government system, and if you are have a service related injury or condition, it's rated. It's given a percentage disability rating. But you can go with no if you just have health issues, uh, and they're not related to your military stove. You can still use the VA, but it's it's you're gonna be charged a nominal fee for things and sometimes not so nominal uh, and you're gonna have to pay for a
lot more of your medications and things. But if you're like me and have a high enough rating, and most of it's free and you get priority for appointments in that So it's not really a perfect system because not everybody gets treated the same and not everybody gets the uh the service in the same rapidity that someone like me would get it. And but it does work fairly well. The the VA hospitals I've been at, some of them were okay, others were outstanding. I happen to live in
an area with an outstanding hospital here. They've taken care of me through a lot of serious problems and have come out more or less on top, if not completely on intact. So it's it's been a it's been a good experience for me. A lot of people don't like the weights. The appointments can be a little bit hard to get sometimes there's but they've been improving on that over the last couple of three years and things have
gotten a lot better. There's not as much of a backlog on determining if you're service connected or that, or getting your rating. But and it's not as difficult as it was when I first got mine, So it's but it's still not an easy road. But there the attitude has changed to like, let's see how we can help this guy, rather than let's pick apart whether or not we should help them, you know. So it's been very good.
I think that it can be a somewhat of a model for what could be a universal healthcare system with some tweaks and changes to it. But I'm just glad I have because it would be impossible for me to afford anything close to what I have to do now.
So the three of us come from three very different backgrounds when it comes to interact with healthcare. I come from personal which has National Health Service for a point of view, Ajau comming it from an HMO, and Nathan you comming it from the Department of Veterans Affairs. So why are so many Americans comfortable with this as their health gare system? Why are they so comfortable with this is their healthcare system?
Measure?
I don't think that you're comfortable with it necessarily. I think there is so much going on in our country and you know, in our personal lives at all times that at some points we just have to choose why do we put certain issues aside and just deal with it. We often feel that the problem can be so massive that or in the middle or fight back is just
not enough to affect any kind of change. And you know, I feel this way, you know, because of all of the health issues that I have, not just the pain I have, like like I'm therefore have, it's just with my eyes. I have had corner of transplants, have had a nerve stimulator put in, and so I have gotten good care, you know, when it is approved on time
is good. But yeah, it definitely does bring a lot of stress sometimes to the way that you have to jump through all these hooks in order to get that type of care.
So as someone who comes from your where, you know, health care is you know, considered to be you know, one of these things called a right, not you know, a luxury as it seems to be in America, or worse, an employment perk. Wooh, aren't we you pleasant in America to have a healthcare as an employment perk? This is bonkers to me, This is absolutely bonkers to me because it flips the whole system on his head because you're
not giving a toss about the patient here. And especially as these companies I ever Care or they should be sometimes called never Care.
Evil Core works to.
Slash Evil Core slash not for not ever Core decide that they're going to take on these companies contracts, and then you see who the parent company is, which is Insurance Congloberate LLC or Insurance Provider LLC.
Or anther cores case Signa, which is yeah cases.
Yeah, I was going to mention that that to me, that was like the worst part. It's like all these giant companies were all interconnected. Like you said, every Core is run by Overnothe, which is a brand of Signa, which is the you know, insurance giant. And then the next big player that does the same job as as
every Core it is called Karelian Medical Benefit Management. And guess what, there are a subsidiary of Elevants Hope, which is actually the insurance company formerly known as Anthem, so it's the same company just a different name.
And EDNA getting on the action with another company. And then do you know what makes this so egregious when it comes to ETNA. ETNA own CVS pharmacies. Ethna are the parent company of CVS Pharmacies. So your pharmacist is in the same group as the people denying you your drugs.
For a second, yeah, there are those to benefit each other.
They are in each other's pockets, in each other's pies. This is how ludicrous we have allowed the American Health Institute. And it's not a design flaw, it's an absolute design outcome.
Of all of this design attribute.
Yeah, it's a criterion to maximize because at the end of the day, the three of us are not humans as far as concern. The three of us are a price. The very article who is Dead was a price tag, and we know they're a price tag because when they try to sue them, their price tag to be sued
was too great. I find it quite weird that the doctor is being sued here when the doctor went do the healthcare and then they went no. So now the family suing the doctor who you didn't know because they're the bottom of the ladder, and.
The hospital and the doctor can be sued, but you have to sue the other people in federal court, which is a whole other animal. And they have a lot of case law that denies those kinds of things behind it. So until we can get judges with a sense of morality about it's just going to stay that way.
Good luck with that.
Good luck with that yet.
Yeah, I mean, and this company inside profiting and squatching each other's backs at the expense of the human beings on the other side waiting for you know, often life saving procedures.
The thing that bothers me the most is that all these billions and billions upon hundreds of billions of dollars that they're making could could make it affordable for universal healthcare system if all that money was just spent on everybody's health care.
You know, there is so much money they're making, but if you just got rid of all that management and profit and just put it into a system that's already there.
Yeah, but that is the whole goal for this ev core type thing that they you know, their structure to provide higher payout based on more denial, so they get a financial incentive whenever they achieve created reduction in medical spending for the hardcre you know, organizations that they're working for.
Here's question for the two of you, Government run programs are wastefully inefficient, right, so not necessarily so. How much as an overall percentage do you think Medicare spends on administration costs? What as a percentage, what do you think the number is?
Yeah, I mean I don't know. I will take a wild guest, like fifteen percent.
I don't knoween percent.
What's your number? I go twenty two two two percent?
Wow?
Is it staff by ten times that amount? Okay?
Medicare in America spends two percent of the money it receives on administration costs two percent, whereas on average, the US healthcare system spends thirteen to nineteen percent on administrative cost just on filling out paperwork, denying your requests. Computer algorithms like this government run system medicare two percent, thirteen to nineteen percent government less efficient.
Right, they're usually like all these very complicated systems like AI and you know, like doing that a whole algorithm like what they call they die.
Also, yeah, I can imagine that they spend a lot of money on that.
Well, of course they do. So people hear this, We're being overrun by the machine. How do we get the machine to stop running the healthcare system? Jonathan how do we do that?
You, I mean, make it a government agency that gives all the healthcare. You make it a single not a single payer system, but a uh you turn all these silly for profit things into a nonprofit thing or not for profit thing in the government where and that you take all those resources that those people had and you give them to this thing, and you give everybody a basic level of health care in any emergency healthcare or
complicated healthcare. They need to maintain their lives. And it shouldn't be a matter of where you are in the society, or whether you have billions or millions of dollars or you know, or whether you have hundreds of thousands of dollars to drop on it, or whether you have to sell your house, your car, your go kart, and your boat in order to pay for one month's worth of medication. You know, that's just you know, that's where it is.
And the leading cause of bankruptcy in the United States is medical.
Expousely, I've had good yeah, I've had several procedures. Then if it wasn't for the way that you know, my insurance was set up, but you know, paid the complete out of pocket, and I always get everything done towards the end of a year, like in a hurry, because that's when I know that it's going to cover everything
no matter what. But otherwise, you know, I will be paying like what thirty thousand dollars for just to get a replacement for my cochlear implant, the surgery itself with like fifty thousand dollars, Like, there's no way, you know, people can afford something like that.
It's it's ludicrous, It's absolutely ludicrous.