Insurance companies deny medical necessity claims because the procedure and diagnosis code combinations don't align with what is pre-determined to be medically necessary. One of the big reasons why this happens that nobody ever talks about is because the doctors office does not code the claim correctly and it gets denied. The patient is pissed and blames the insurance company, the doctor is pissed and blames the insurance company, but in reality its the biller/coder in the back office who screwed it up.
If all insurance companies published all the code combinations covered for every procedure/diagnosis, I might buy this argument. But they don't. I've asked Blue Cross and they said they don't disclose those details. Many billing codes are open to some interpretation. So if insurance companies aren't transparent about what codes are or are not covered, why are the doctors' offices at fault when something is denied? Why isn't the default response from every insurer "code X isn't covered in combination with code Y. <some clarifying questions, explanation, and related codes>"? Why is it a black box?
All right, US insurance companies deny millions of valid claims not because of greed, but because "the doctors office does not code the claim correctly". It's just an unforeseen side effect that said insurance companies end up with billions of annual profits and patients sometime die...
Your post remains me of how Russians often react on their forums to posts regarding the corruption in Russia. There are undeniable proofs of how corrupted Putin regime is. All ministers, members of president administration, local administration, judges, generals, etc. end up owning multi-million properties both in Russia and Europe/USA, but many regular people find the stupidest excuses of how the system is fair and just, but "the doctors office does not code the claim correctly".
I’ve worked in healthcare revenue cycle management for over a decade. If you don’t accurately tell the insurance company what you’re doing and why you’re getting denied. Doesn’t matter if it’s health, auto, home, etc. There are thousands of codes, millions of combinations, and all being mostly hand coded by minimum wage workers. There are constant fuck ups most of which don’t require anyone but a computer to review to know it’s wrong. But okay cool conspiracy.
Even if we assume you're right, the way that the system is setup and the fact that there are constant fuck ups, but no effort to fix them are not accidents. Yes, there are conspiracies out there (surprise, most people are not angels) and the US health system is definitely one.
Check out the insurance companies profits. Those are directly linked to denied customer claims. Claims are not denied en-mass, by accident obviously - unless you're a complete fool.
The constant billing and coding fuckups are because the government forces providers to use them. HIPAA requires the use of the x12 standard which is woefully broken. Speech between provider and payer is completely regulated. Nobody is doing anything to address it because they are prohibited by law.
Oh and by the way: health insurance company profits are essentially capped by the government via medical loss ratios. They don’t make more money the more they deny otherwise they will be forced to send rebate checks (like what happened during Covid)
