This is an actual Aetna policy, and now other insurance companies are considering the same. It’s a shameless money grab. Literally every person on earth gets visually significant cataracts if they live long enough. There is no reason for restricting cataract surgery approval, other than greed
I've never been so angry at something more than this, these insurance companies are a disgrace to medicine and humanity. There should be more regulations asap
Thank you for posting this, Doctor. As someone who is only 40 and already manages multiple life long conditions on top of having a complex medical history...seeing things like what you are pointing out in this video, freaks me out. I already see the brutal insanity of navigating healthcare, as a long term patient, at what would be considered , an early age. So, to know what it will be like when , or should I say, make it to 80, is mind-blowing...and not in a good way. It's not that I don't want to grow old and live a long life...but with much of what health insurance companies want to do...it makes one extremely dejected and frightened with the aging process. We , as a society, in general, ARE getting older, due to advancements in medicine and science. Yet, at the same time , we have a system in place that wants to screw people over for growing old, in the first place.
@@dryb3301 In the long run? No amount of regulation can fix this. If you pass more laws to prevent abuses like this (assuming you can even get through the deliberately engineered gridlock making it impossible to make any meaningful changes while the entire biosphere we live in burns to the soon-to-be-barren ground), the companies will just bide their time while assembling the propaganda campaigns and bribes (also known as lobbying costs) necessary to undo whatever you did. The greed is just a side effect of the real problem. Markets are philosophically incapable of behaving in remotely human manners.
Some people don’t REQUIRE such surgery. With minor changes to lens you can still see and eye doctors overprescribe such surgery (4mil). Insurance companies just want to make sure they aren’t taken advantage of, after all who will perform eye surgery: eye doctor, and who will be paid for it: eye doctor. Or maybe you are afraid of oversight?
I did medical billing for YEARS. Here’s how you get a denied pre-auth approved. When you get the first denial, request a reexamination of the procedure (as protocol for most major insurers). When you get the 2nd denial it means they had an actual doctor take a look BUT they never have docs that specialize in the field your trying to get a procedure done in. For example I had an obgyn deny a cardiac surgery. By law you are allowed to request info on the medical specialty of the doc who did the appeal review. When you get it and the doc who denied is ‘out of scope’ from the procedure you’ve hit jackpot. Now here’s where they fold: resubmit third time along with a request for 3rd party arbitration (basic procedure for major carriers) and in that request you state that you want it because you doubt the ability of an obgyn to make calls on cardiac patients and you wish to question them in arbitration about their experience with cardiology. That’s it. You’ll be approved without arbitration in about 85% of cases. Yes, it’s a pain that can take awhile, but passionate admin staff can get it done along with some paperwork from the docs. I helped a lot of patients with this because their carriers made the process daunting for them or sometimes never informed them that they COULD fight a denial. Elderly patients especially have trouble with jumping thru the hoops and understanding their rights. Too many docs don’t ask their billers to pursue appeals on denials, or their staff isn’t trained in these tiny but important carrier policies. Don’t be afraid to ask your docs office for help getting a denial overturned!
How ridiculous any of that is needed at all. No doctor in Australia has to ask for permission to enact care from anyone other than the patient or their guardian.
All of these for a necessary and sometimes life changing procedure/medication? Why do you guys put up with this in America? With all the freedom you can’t fight this ridiculousness?? It makes my blood boil
@@kole1ful its because the united states is inherently selfish. the majority would not want to pay an extra small tax so that everyone could see the doctor with a universal health care system.
@@kole1ful it's unfortunately mired in politics and what people believe others ought to do when they get sick. The affordable healthcare act had been threatened so often during the past presidental term; it's maddening to think that there are millions who are against their own self-interest.
As a medical student, I one time took care of a patient admitted to the psychiatric unit for a suicide attempt. The insurance company tried to deny coverage for their treatment because they hadn't "failed outpatient management" for their condition first. I'm sorry, I'm pretty sure "ate a bottle of morphine and chased it with a fifth of bourbon" crossed that line a few miles back. Don't even get me started on how hard it is to get adequate outpatient mental healthcare covered.
Suicide attempts that are OD’s combined alcohol are absolutely no joke either. Your patient was not fucking around, jesus fucking christ. American health insurance companies genuinely have blood on their hands.
I have a very rare instance of a prior authorization actually being helpful for a mental health condition. I was diagnosed with ADHD in 2011 and got prescribed Concerta. In 2012 I switched from my parents insurance to state medical assistance bc my parents insurance didn't cover the cost of my meds. In 2016, due to some financial fuckery, I lost my MA for a few months and couldn't afford my ADHD meds. Turns out sometime between 2012 and 2016, the MA insurance decided that they'd only cover Adderall for adult ADHD but since I'd already been prescribed it my script had been grandfathered in. So when I got back on MA later in 2016, they denied my Concerta and the PA didn't go through so my PCP was like, "You wanna try Adderall?" and I was like sure why not. Turns out, Adderall works WAYYYYYYYYYYYYYYYYYY better for me! For the first time in 25 years I was like, "Is this what normal people feel like???" So yeah, if Hennepin Health/HealthPartners hadn't arbitrarily decided to not cover my meds, I'd probably still be on ineffective ADHD meds!
Totally. When I was in outpatient treatment for an ED, the hoops the therapists and the patients had to jump through just to keep us from getting booted out of the program by insurance was insane. It was like the insurance companies were standing with binoculars in the bushes looking for reasons to put a lot of vulnerable teenagers back in literal danger by taking away their support.
@@OddsandEndsandOtters I am so sorry to hear that happened. The way the US healthcare system undervalues mental healthcare in this country is a crime. We need to focus on what is best for patients and that unfortunately isn't the priority for companies that put profit first. You can't put a price on the benefit comprehensive, supportive care can have for people who need it, or how challenging dealing with the cost and roadblocks insurance puts in their way is for people who are already going through so much. I hope you are doing better today.
"Practicing medicine without a license"! THANK YOU!!! I have been saying for years that insurance companies are practicing without a license. They cover themselves by hiring old, retired doctors who haven't kept up to say whatever favors the insurance company.
It has never made any sense to me that the powers that be that get to control and dictate health insurance, have NO practical application in handling medical care in any shape , manner , or form. A MBA does not equate to MD, DO, DMD, DDS, RN, Pharm.D, etc.
Actually, many of those docs are on both sides, having active practices of their own. No old retired docs. Just not true in practice. How do I know? Insurance is my field.
It’s the same with social security disability. Patients have to jump through hoops for YEARS so someone in the Philippines who ISN’T A DOCTOR can glance at their paperwork for ten seconds and judge them as unworthy of benefits based on personal opinion alone, even if all the patient’s documents from actual doctors show disability.
@@pinkprincessinthecity1177 It has never made any sense to you because you're looking at it from the perspective of making an effective and quick healthcare system. It makes perfect sense when you look at it from the perspective of callous profit maximisation at the expense of people's health and lives.
Ugh, I just saw a rejection recently because they won't approve the surgery without "at least 12 months of unrelenting pain. at least 6 months of unrelenting pain under the constant supervision of a physicoan" and then like saying they have to try a bunch of treatments we already know will make the problem worse and more painful... like... what the fluck is wrong with people who defend insurance companies?
Not to mention the fact that people in chronic pain will have a much harder time accessing or keeping up with the supervision of a physician in the first place, so it's inherently hardest for the people who most need the surgery to jump through the hoops. Such a f*cked system
"You haven't suffered enough for us to give you a tiny drop of our billions of dollars of profit. Suffer more." that has to be, the most evil policy I've ever heard.
Try socialist medicine in Canada, where *half* the patients who need cataract surgery aren't able to get it in 3 months. Or perhaps the socialist healthcare system (i.e., NHS) in England, where the wait time is 9 months. Evil, horrible America lets you get cataract surgery in the same month, though.
For profit insurance companies act like they would they would become a high risk ICU patient, if they did they decent thing. It is essentially in their lifeblood to be evil AF.
After practicing anesthesiology for20 years I saw countless people's finances destroyed by the financial side of the medical system. I realized that not only are insurance companies are evil but they should be eliminated all together. This conservative doc is in favor of socialized medicine because of what the system we have now is evil.
I think anyone who is opposed to universal health care should be forced to work in either insurance or the medical field for a year because it'll change their minds
Rich countries have it, middle income countries have it, they all have better healthcare than the US with a socialized system, nobody goes bankrupt from cancer, I cant understand why americans refuse to fix something that causes them so much suffering.
@@dkg_gdkIt's because of the unions. Virtually all local, state and federal workers have union contracts that get them good healthcare coverage - better than most high income wage earners. Socialized medicine really does ration care to a much higher degree than we see now in America. There would be a lot of pissed off people when they are told they will have to wait for their hip replacement or that their medicine is no longer available. What socialized medicine does is level the playing field. Half of the people won't like that- especially those in power.
Frankly it only makes sense to pony up for medical costs. Taxes spent to keep people healthy - and that's a broad range of treatments and conditions - are surely better spent than on premiums, copay, and deductibles. The mental energy would be better spent, too, getting rid of pervasive insurance dependency and replacing it with public sector healthcare. Lines are already long. Costs are high. Why not fix that?
We should ensure that everyone in America has access to the highest quality healthcare without worry of financial hardship. Right now we're ensuring that insurance executives have the highest quality summer homes and yachts without worrying about financial hardship.
We need to shed light on the bad acting insurance companies so they either change or their customers switch to a different company. Government run healthcare gives no other options and the same types of cost containment measures have been used by government (and worse).
Forget about Europe . Here in India 100 million families are given free insurance coverage by the govt and it includes hip and knee replacements and cardiac bypass surgeries. Even those living in extreme poverty get medical treatment if they just pay like 2 or 3 dollars a year for their entire family and sign up for this scheme . You don't get anything fancy like a suite room in a hospital or anything but it's still better than waiting months and getting claims rejected by the insurance companies.Americans definitely deserve a lot better than what they are getting.
I have a fun one to add in there. My insurance no longer covers my _ostomy supplies._ They only cover "durable medical supplies", and since you have to change your ostomy bags and wafers very often, they're considered "non-durable" medical supplies. So now I'm forced to use Amazon to buy medical supplies that I literally _cannot live without,_ and since they're so expensive I can't afford to buy them as often as I should so now my skin is really suffering because of it. Which means I'll have to spend even _more_ money on skin care/repair products to fix that issue too - that issue that wouldn't even _be_ an issue if my insurance hadn't decided to be greedy
As a fellow ostomate, what a nightmare. I am lucky to live in BC Canada where supplies are covered after meeting an income-based deductible. But many others in Canada aren't so lucky, and some provinces don't cover them at all. What is someone supposed to do who can't afford them?? Edited to add: I also know of someone who was told the cost wasn't covered because they were "not necessary to maintain health". Ok so you won't die without an ostomy bag stuck to you, but do they seriously think there are other options? Do they want people to just resort to Ziplocs and tape? Or letting their own output run down their legs?
I'm really sorry to hear this. ): I've been unable to get surgery for my torn and dislocated jaw tendons for 6 years because it costs 100k per side, surgeons fees only (not including hospital and anesthesia). Medical Insurance says its "dental", and Dental Insurance says its "medical". So no one will cover it and I can't afford ~250k out of pocket, obviously. So I just live in nearly constant pain. Needless to say that has started a major domino effect with my health, causing a number of other serious health issues to crop up over these years. I feel your pain. All I can say is, we all need to do our research on candidates positions on healthcare and vote. ):
As a doctor in the UK, I’ve blissfully never had to deal with an insurance company for anything related to patient care. That said, I’ve dealt with two American patients who were over on holiday who discharged against medical advice to fly home because they were so convinced of the superiority of their healthcare system, despite one of them being in the hospital where the surgical procedure they needed was developed.
I absolutely LOVE the insane amount of prior auths we get for TRANSPLANT IMMUNOSUPPRESSANTS for our TRANSPLANT RECIPIENTS. Like make us jump through hoop after hoop because you think transplant patients DONT need to take their anti-rejection meds? Makes me beyond pissed.
Same here! I have lupus nephritis. I'm on dialysis. I have Optum RX via UHC. Getting Cellcept was a nightmare. It should be illegal for insurance companies to wield this power!
So true. I once worked with someone that used to work in the insurance industry. She quit her job because she can't stomach the fact that they have daily meetings where they sit and figure out ways they can deny coverage for various life saving procedures. Vile and evil is how we should describe the insurance industry. 😩
My favorite thing is how Cigna randomly decided at the beginning of the year that they didn't want patients to go wherever they wanted to for imaging procedures. They can only go to Independent imaging facilities which are cheaper, but also might have outdated equipment or equipment that is not with patient needs. What this means is that the patient might have to go across town for a standard CT scan (which as we know costs time and money) when they could just go across the street to their local hospital that is more than willing to care them. You would not believe how many people start crying when I tell them we have to cancel their appt because their insurance decided to practice medicine. Sometimes it's just imaging for a standard test and they're okay with it, but sometimes it's imaging for somebody that's really sick and really scared and doesn't know what's going on. That's the worst part of my job.
I know this is comedy. I love your content. But dad-gum this makes the bile in my belly rise and I get so angry! 10/10 acting, 10/10 portrayal of actual insurance companies. Is there an Oscars for short-form content? Because this needs a nomination. I went through a huge spectrum of emotions in a few short moments.
i mean it’s really comedy so much as it is an excuse to educate people on medical stuff and give important concerns a platform. the comedy is just to get you there
This is so true. I had C.diff from a perfect storm of factors. The Metronidazole prescribed to me kicked my butt! It did not improve my symptoms and actively aggravated them to the point that I lost a further 17 lbs in 5 days. It was brutal. My doctor (who I'd been seeing for 12 years) discontinued and prescribed Vancomycin which was denied because I hasn't completed 2 rounds of Metronidazole to show that I couldn't tolerate it. My mouth tasted like metal, I was having blinding headaches, I couldn't even keep down water and they wouldn't cover a $5 med change. My doctor called to appeal and told them if they didn't cover it, she'd admit me and they could cover an inpatient stay. All of a sudden, my $5 Vanco was covered.
To be fair, it's probably not clinically advisable to eat one's mother. I'm sorry, I couldn't resist joking about your typo :P All seriousness aside, that sucks and I'm sorry you experienced that stupid and needless trouble
@@BroadwayDuchess13 Haha relatable! And thanks for the compliment, I'll be sure to put "Once conjectured that someone likely should not eat their mother" on my med school apps, right next to "Once correctly answered an Instagram story pathophys question that the slight majority of respondents got wrong" 💪😁😆
I work for an eye clinic. One of our docs snipped at the insurance for not covering a certain eye drop. Why? Because there was a cheaper one... a cheaper one that wasn't approved by the FDA and was technically a black market drug. When the doctor asked if they were really saying he had to prescribe an illegal drug, they suddenly could apporove the original eye drop.
Working at an ophthalmology clinic, we had to be taught what exactly needs to be written down in the pt notes to get them approved for cataract surgery. Which is rather crazy, cuz if I as a technician can tell that there is cataracts, and it’s confirmed by the doctor, than we should really not have to jump through these hoops to help the patient out.
I am an ophthalmologist in a public hospital in Spain. If a patient needs and wants cataract surgery, she/he gets it within two/three months. I really don't get this "prior authorization" thing
I saw Aetna and knew this would be a good one. As an MA, if a patient's prescription plan failed to be covered and they requested the doctor to send a cheaper yet less effective solution, 9 times out of 10, you could be sure Aetna was written in big bold print on the cover letter.
He's a psychiatrist, do not dare to imply psychologists might be useful (seriously they are even more than psychiatrist for some issues but they're always ignored for some reason)
srsly when is this gonna be turned into a full-on primetime show? people eat those doctor shows up they cant miss. they'd save money too because they only have to hire one actor.
My pharmacy told me today, "Your insurance won't cover the specific type of insulin your doctor ordered. We've been trying to reach your doctor to see if they'll prescribe something else." Ha! Classic! We all had a good laugh...all joking aside, I have gestational diabetes, and I don't have to do this as a lifelong struggle, it's actually given me a horrifying insight into what regular diabetics have to go through, and it's quite sad and infuriating.
I do pharmacy prior authorizations for a women’s health clinic. Usually I can get almost anything approved by stating that the requested medication is medically necessary due to the patient being PREGNANT. They don’t fight back on that too often.
The older, generic versions of insulin work just as well as the new stuff that the Pharma companies came up with to keep making money. If they add an antacid or something useless it’s technically a “new” drug, and they can keep a patent and charge way more.
As a patient going on my 63rd surgery, currently with a PICC line in my arm (which was held up because of this very reason) this just makes me want to cry. We are human beings but our lives mean nothing to these companies. When I was 3 in had a tracheotomy, RSV and pneumonia with a temperature of 105. I needed to be airlifted from the small hospital in upstate NY to Boston Children’s. I was dying. The flight at that time cost $14,000 and they told the doctor to take me by ambulance instead. He informed them that I won’t make it to Boston in an ambulance and they still stuck to it. They only agreed when he said that his next call was going to be to channel 6 news and he will tell them they are denying a 3 year old little girl a lifesaving flight to Boston. This was 24 years ago and it’s only gotten much worse. Healthcare is no longer about healing people it’s a corporation to make money. I was just in the ER and the nurse told me one Motrin cost $50 and a bag of saline $100. I feel so sorry for the doctors that are trying to help people and have to fight this evil system as well. Thank you to all the providers who fight for us! ❤️ And thank you Dr. Glaucomflecken for shedding light on this problem!
You know what's worse, Aetna is owned by CVS so when the money for the eye drops you get prescribed afterwards go back into CVS as Aetna's preferred pharmacy. Total dominion and you as the patient get screwed.
I almost asked the doctor what it was like to need to ask the insurance company to be able to practice medicine at my kid's last allergy appointment, but I was worried I'd cause his head to explode. Still can't get our insurance to approve my kid's (very needed) allergy eye drops, but I can get nasal spray every 30 days. Cool, cool.
We are going through almost the exact situation with my son’s emergency surgery. I’m thankful the doctor’s treated my son for his injuries based on what was best for him and not based what the insurance may or may not pay for. Insurance in this country is legalized robbery. I paid my premiums, the doctor did his job, now do your job insurance companies.
This was my insurance when they straight up told me on the phone that my approval for a non formulary medication didn't expire until 2043 but that I needed a new one. The reason why? "You just need a new one" I even explicitly pointed out to several different employees how it is absurd to suddenly force me to get a new one by forcing me to take medications that my body cannot tolerate and that they had proof of that on file yet they still insisted I needed a new one.... It is absolutely unacceptable that insurance companies have to follow so few regulations that they can get away with stuff like this. How are they allowed to just constantly go back on prior approvals that they issued without any reason and without consequences. How is that not considered a breach of contract and why are more people not talking about the crap they pull? Additionally, why is it okay for insurance companies to not cover diagnostic testing at all? My doctors legally need to do them to treat me yet there is no standard stating that insurance companies need to cover those costs. For me, even after an insane deductible, they will only cover 40% of the costs. I have had more testing done than normal and never reach that deductible either because it is set way too high.
Thank you for shedding light on this extreme problem. I think that the general public is unaware of the unwillingness of insurance companies to part with their money. I believe if we can make more people aware, they will eventually rise up and demand a reformation of the insurance industry. I'm a nurse case manager and sometimes I feel like all I've done in my work day is fight to get my doctor paid, my hospital paid, my patient's bill covered, etc., and so many times, the person I'm "fighting" with on the other end of the phone is someone who's had a fraction of the experience and knowledge I have, let alone the doctor's expertise. It's beyond frustrating.
Please keep making content like this. This is an education which is rare to find. You don’t often have people who actually know what they’re talking about making content that frames complex issues simply
If they require prior authorisation for hip surgeries too, Ortho’s gonna get mad. And he has a surgical hammer. Just saying. Seriously, this infuriating. Years ago, “government death squads” were presented as a boogeyman to argue against universal healthcare. And yet it’s ok if private insurance companies get to decide who can keep their vision?
Mind you, I'm not for assisted suicide, either, voluntary or mandatory. But how long before insurance companies start offering it as an option, anyway, to sick, expensive patients in states that approve of such? I agree the method of paying for healthcare doesn't need to have anything to do with the definition of healthcare. Socialized medicine can be just as greedy as insurance; but I'd rather pay for healthcare directly instead of having a middleman in insurance.
Look, they totally have doctors reviewing your prior authorizations... you know... after they deny the authorization the first time you submit it because they weren't aware the patient had eyes (should have made that more clear in the documentation), and now you have 6 hours to schedule a peer to peer review with an MD or you forfeit your right to the peer to peer and have to go through the 30 day appeals process. 🤣 It TOOOOTALLY makes sense.
I’m a family physician. Whenever I have to do a “peer to peer” I start by getting the doctor’s name and specialty. Then I ask in which state he or she is licensed. If it is not a primary care physician with a license in my state, I refuse to go further. The calls are recorded. I politely tell the physician that he or she is not my peer. Please have someone call me back when I can speak with an actual peer. That works most of the time. If they can’t get me a primary care physician with a license in my state, not my problem.
Aetna made me fill out *three* prior auths for one of my glaucoma patients that developed an allergy to one of her meds. They delayed her access to medication for a full month...to save a grand total of $40. It's shameful. Heaven forbid we prevent irreversible vision loss.
I was dx with stage 4 renal cell carcinoma last fall. First time meeting with my oncologist he admitted me hospital because of so much back pain and had emergency spinal fusion corpectomy to remove a tumor and vertebrae that it crushed. I didn’t have pre-authorization from Aetna and I was billed the full amount of the surgery and hospital stay, totaling $375K. Fortunately, my medical team went rounds and rounds with the insurance and they finally approved and seeing that my deductible and out of pocket max was met for the year, I paid nothing. But imagine the shock and stress of receiving a bill of that amount while coping with a newly confirmed cancer diagnosis.
Insurance can be insane. When I was pregnant with my second baby, I had Hyperemesis Gravidarum (severe nausea and vomitting) and I needed IV's because I couldn't keep down enough liquid to stay hydrated (and sometimes I needed IV medications). After a few weeks I got denied from receiving further IV treatments because someone reviewing the claim decided I should be able to eat and drink and take my medications without throwing up. Fortunately I was doing well enough (past the first trimester) that I wasn't *as* sick, and I didn't get *so* dehydrated that I was disoriented or anything like I had been earlier. I thought it was nuts... as if I liked getting stuck with an IV (sometimes four or five times before it working because of dehydration) and was doing it for kicks.
You kind of proved their point, unfortunately. HG has an expected duration. I hate to defend them though. Insurance is an institution of evil. Glad things worked out in the end though.
@@cameronno6039 then again, it shows that these reviews often are unnecessary in the first place. In my country (austria), we don't have to deal with insurance companies for routine interventions like these, and it's really mind-blowing that there is a bureaucratic appartus huge enough to even maintain this.
@@cameronno6039 Only under a bare minimum standard of care. I was still pretty sick until the day I delivered my babies (HG for both, more severe the second time around), just not quite as badly. Barely tolerable levels of dehydration should not be the standard for pulling IV support. I was significantly undernourished when they stopped covering IVs, to the point that I could hardly walk around my house without my calves charlie horsing, and not having full hydration only made it that much harder. I even aspirated quite badly once trying to take medications against my body's attempt to vomit, well after they pulled IV support. My doctor should have been the one to decide if I needed IVs, not a stranger from my insurance company.
I should have explained more in my original post, so I apologize for information dumping here, but I do think my insurance was wrong. Even mild dehydration can be pretty significant. My first pregnancy I had consistent mild dehydration, which might have been what caused my low amniotic fluid, which might have led to my baby being breech with a cord in his neck, which resulted in a C-section. And mild dehydration does a real number to a mother's health. HG is health-destroying enough on its own; treating dehydration is the easiest way to make it a little less impactful, even if the dehydration isn't reaching life threatening or pregnancy threatening levels.
I had HG in both pregnancies and my OBGYN's office had to go through an utterly insane PA process to get my insurance to pay for more than 10 Zofran tablets per month.
I'm a CVS employee so I have Aetna. I'm lucky my parents still keep me under their health insurance because Aetna is horrible. You would think employees of a company who literally owns a healthcare insurance company would get better plans but our copays are outrageous
the neoliberal ideology treats employee's as an appreciating expense, rather than the empirically verified appreciating asset that they are. it wouldn't matter if the employee was the butler of god, employer's would still defacate on him, since that's how they extract surplus value, by making sure that wages are dropped by any means, prices are raised through any means, and any legislation mandating the maximum hours possible is rolled back. “Civil government, so far as it is instituted for the security of property, is in reality instituted for the defence of the rich against the poor, or of those who have some property against those who have none at all.” [Smith, Adam. The Wealth of Nations. Book V, Chapter I, Part II, 775]
I had to have cataract surgery when I was 40 (they called me the pediatric patient during surgery) and I’m thankful it didn’t have to get pre approved. I had already put the surgery off for over ten years due to eye contraption fears (thanks A Clockwork Orange)
Former nurse case manager here. The concept that physicians would actually go through the pain and torture of getting auths was so ludicrous and hysterical that tiny tears came to my eyes. (I've had cataract surgery in both eyes by the way). I also have Aetna Medicare. That also brings tiny tears to my eyes.
As a dude working in pharmacy I feel that, at least a third of the time when we get a script or even a refill request we gotta send it back to the doctor because of insurance needing PA.
Problem is you need a lot of people that don’t get sick very often to be part of it to help cover the costs for those that do get sick often. But imagine if healthcare was like part of a local tax? Add a little bit of local tax and you can go to any medical professional in your area for no extra cost? Make it a national tax and go to any doctor in the country for no extra cost.
Yes! I had to buy my 75 year old father’s new hearing aids because his insurance only covered hearing aids so cheap they could have come from a claw machine. That’s after he had to submit documentation saying he needed hearing aids for BOTH ears! 🙄🤦🏽♀️
@@Dr.E7HER that's basically how it works where I live. And in most countries outside US. We juat get taxed for medicine and that way everyone pays for everybody essentially and medicine becomes free for an 80 years old in a nursing home, 40 years old working person and an 5 years old kid.
I run into this so much from the pharmacy side of the equation. Like come on, the patient needs these medications to prevent their serious conditions from progressing further. Please just let me give them the Xarelto their doctor prescribed. For the love of god. On a more personal note, my grandmother was an Aetna medicare patient until the end of last year. I was literally on my knees begging her to switch because of policies like these and I'm so glad she listened.
You sir, are a true and rare master of this platform. So few people can make someone laugh, cry, and curse all in the same breath. This episode caused all three. Trifecta!
I SO needed to see this right now as I'm literally on hold on my office phone trying to determine why Cigna is not covering ANY of the opiate induced constipation. I just told an associate that if Cigna would not cover a medication to treat this then it's very likely they'll be covering a hospital stay and/or surgery when I have a colonitis attack or a ruptured bowel.I am very angry because I pay about $200 per paycheck for the best insurance offered by my job. I wonder how they'll react when I advise them I need ankle/foot surgery.
$200 a paycheck? That's insane. No way we pay that much in tax for everything let alone healthcare each paycheck. You and all your countrymen are being ripped a new one.
My spouse works for one of the big 3 defense contractors. The insurance benefits are expensive like yours and cover basically nothing. It's bullshit that anyone pays $2400/year for the privilege of paying lots of copays and needing prior auths for everything.
Oh now I'm confused. I thought that ppl in work got private health insurance through their jobs, not that employees have to pay extra thru their employers for private health insurance???
@@faeriegal713 You are preaching to the converted! And it seems like the BEST benefits I've had were the WORST to work with and vice versa. So I can have a great job I love and over priced insurance that makes me anxious and mad. Or I can have amazing insurance that covers everything and is affordable but I'm miserable every day at work. And I'm over 20 years away from Medicare, which I'm learning is no picnic either.
I work for customer service in a medical insurance company - it’s so unfortunately true. Even though the company I work for is non profit and we are owned by a major medical company in the state, the more I work here the more my mental health declines because I try to help people in these types of situations
I've worked in health insurance call centers, including on prior authorization teams. Alot of people think their insurance company wants them to drop dead, but of course that isn't true. Dead people don't pay premiums. Your insurance company wants you to stay alive and keep paying premiums, but never actually use healthcare. It's how they make money. The whole industry needs to be burnt to the ground and rebuilt.
Think again. They _do_ want their expensive patients dying. Why? Because they know that every expensive patient who can't be fixed up for cheap is a permanent money loser for them. Their business model is not compatible with the societal goal of promoting long and healthy lives, because as patients age it becomes exponentially more expensive to keep them at a good quality of life. In a well-designed single-payor system, this conflict of interest can be removed. In a truly nonprofit private system, it can also be removed or minimized. But not with the system we have. The system we have punishes good patient care for the chronically ill and rewards the murder of the same. From the insurance point of view, it doesn't matter if the chronically ill patient pays premiums, if every month's premium is more than offset by claims. In that situation, it's a financial loss to keep them alive and a profit center to withdraw all care. That's why the system only works _at all_ if there are strictly-enforced, powerful laws to force them to pay for needed treatments when they don't want to. Instead we've made it largely up to the insurers. A prescription for genocide.
As someone who was insured by Aetna AND processed their claims I can ONE THOUSAND PERCENT vouch for the accuracy !! I hated processing claims & preauths for Aetna patients !! Their insurance SUCKS @$$ !! 👏👏👏👏👏👏😁 #GoodOleJimothy 🤣
Everyone is dunking on Aetna, but where do patients go to find out which are the better insurance companies? I have aetna and they currently won't cover my infusion supplies unless i go to the hospital for it, want to pull me out of therapy cause im not "making enough progress" with my ptsd, my therapist wants me to get TMS but i can't bc im currently spending several days a week at the hospital for my infusion??? Like they are literally creating the problems in my treatment.
I am getting flashbacks from when I worked in a pharmacy with this one. PT: "Are my meds done?" Me: "well ma'am, this requires something called a Prior Authorization from your doctor for your insurance to be willing to pay for it. We've went ahead and contacted them and are waiti..." At least 5 times a day for the most basic things
I don't remember the details and if it was exactly prior auth-related, but I remember during my Jonathan years that we had to see a Vietnam War veteran multiple times to get coverage for something related to his exposure to Agent Orange. Super messed up. Took us about 4-6 months.
it's just so sad that all those advance medicines in the US are not enjoyed by majority of its citizens. I can't believe in a developed world, people would need to avoid calling ambulance because it causes significant financial strain.
Thank you for exposing Aetna's greed. US needs to switch to Japan's universal healthcare (since 1961), with all non-profit health insurance companies, non-profit doctors' offices and non-profit hospitals. No pre-authorizations by insurance companies. The price of every procedure, drug and hospital stay is negotiated every two years between five doctors from Japanese Medical Association and Japanese Health Ministry. That price is binding for the whole country. Rates are low, but doctors see many patients and make upper middle income. Thousands of non-profit health insurance companies, no claims denied, all billing and payment thru a centralized government agency. Emphasis on primary care. Best result in the world: oldest longevity, very low infant mortality rates. Patients pay 30% co-pay on doctors procedures up to a low maximum, so there are no medical bankruptcies. Children and poor elderly pay a lower co-pay. All fee-for-service for doctor visits, per day rates for hospital stay based on diagnosis. 2/3 of doctors graduate from public medical schools which is six years after high school at a cost of $35,000 total. Free our doctors from immoral medical school debt average of $200,000. US healthcare system needs massive overhaul. Emphasis on patients, then providers. Stop prioritizing for-profit health insurance companies, gouging pharmaceutical companies, and large hospital chains with their overpaid administrators.
Beginning in the 90’s prior authorizations became part of my job responsibilities. They are nothing but time sucking wastes. Anthem was the worst. An endless automated voice system that required input of member, birthday, ICD9, CPT, blood type and promise of first born. Was so happy when online authorizations were developed. Thanks for bringing light to this issue Dr. G.
Now I understand why they won't approve prior authorization for my dad's medicine. They don't see him as profitable enough to treat, why pay for a disabled guy to feel better? They see my dad as a money pit and decided that it's good for profit to let him suffer and slowly die. I want to sue so hard, add on pyschological damage and trauma; the amount of nights spent crying into my pillow because my dad is in pain and I can't do anything to make him happier.
And yet somehow, conservatives and libertarians tell us this is what freedom looks like. It's almost as if those are really deceptive political worldviews when it comes to how society should structure healthcare.
"But cataract is one of the most common cause of preventable blindness in the world" "Ooh Sassy. Lets wait till the cataract advances to become a morgagnian hyermature cataract to complicate into Phacoanaphylatic glaucoma and uveitis. More procedures and drugs! Ooyay!" Satan retires from his throne!
we had a situation at my first hospital where uninsured patients (who were not legal residents) would come in for dialysis, but the only way IR would get paid to place a line was if it was a "medical emergency", and they'd put in temporary lines, give two days of dialysis, pull the line, and tell the patient to come back next week for the same thing. again, these people who need life support were basically getting 60% life support through a dogs*it catheter. that doesn't happen anymore, because bcbs and fresenius decided to eat the costs of dialyzing them in outpatient clinics....and I think a surgeon agreed to place permanent accesses if patients for some menial fee, like 200 bucks. lot of evil stuff, but it's getting a little better as time goes on
it's getting a little better in some areas, but also worse in others like that new Alzheimer's drug that had the entire advisory group resign, and administration STILL APPROVED a chemical known to cause significant harm while not actually fixing the underlying condition. nothing more shows that science is incompatible with capitalism, and that capitalism is incompatable with science, than the APPROVAL of Aducanumab, when the majority of the scientific community supported it's rejection. neoliberal political economics does shorten my lifespan, and yours. time to build something else.
@@ethanstump I don't know much about the drug, just the reaction from journalists. I'd be more curious to know how doctors and patients who now have access to the drug feel about all the negative attention
Your northern neighbor here, I will never understand how brutal American Healthcare is. I once worked for an online pharmacy that catered to Americans. Learned so much about it then. With the MS meds that I need to take, I'm so happy they are totally covered for me here.
When you said "we need prior authorization for hip surgeries," I said f you (you being them). Which is rare for me. But this is one of the few moments they deserve my curse.
Having had multiple surgeries, head injury, seizures, the final insurance straw for me, was when I COBRA'd out of my previous insurance plan. My premiums went from $400 per month for BOTH my husband and I, to $1,600 PER MONTH for me ONLY and ALL of my medical issues became "preexisting" conditions wherein they were NOT covered for anywhere from 3 to 5 YEARS. Therefore I would have been paying $1,600 PER MONTH for medical insurance I would NOT be allowed to use. Insurance companies RUN the World and NEVER forget that fact for one second. They prefer people to die versus paying for the medical services they require AND are legally entitled to.
@@kole1ful nah it's fossil fuel companies, from russia to china to america to europe to australia to africa, they have the ability to poison anyone, blame the victim, sue said victim for more money than they will ever earn, and then go to the media to "right a terrible wrong". then again, the corporate model is pernicious, no matter what industry your in, someone else is dying to make the rich .03 cents more per share.
Because I've read horror stories about patients having to wait months to see a specialist and die before the appointment. A lot of Canadians come to the US and pay out of pocket for medical service. No system is perfect.
@@retired5218 You know all the horror stories about Americans not being approved for surgery and other kinds of care by their insurance until it was too late, right?
@@retired5218 I can't say I see how having a nationalized healthcare system would make that particular problem worse here. Canada has a huge doctor shortage. USA's isn't as bad. Yet. If we keep letting the healthcare system decay it probably will. Granted, moving to a nationalized healthcare system could mean that doctors don't make as much money, which could make the shortage worse. Which is why such a move should come with an overhaul of the entire system. Why make people do a four-year degree before getting another four-year degree? Why make the match as hellish as possible? Why make the working hours insane on purpose? And think of all the other benefits if we get rid of private health insurance as a necessary evil. Obviously, there's the benefit of not having to worry about going bankrupt from a medical emergency. But there are others: employers wouldn't have to pay for insurance for their employees, and employees wouldn't have to stay on a job they hate in order to keep healthcare coverage. Out-of-network no longer exists. You eliminate alot of bureaucratic billing bullshit from hospitals because there's a centralized pricing system, only keeping a few specialists on to deal with the people who have supplemental insurance.
Protip: Move to a civilized country, all of them have a health system (the US does not, the US has a bunch of corporations, some labelling themselves as "hospitals" others as "insurance agencies").
Insurance companies need more regulations. This is absolutely absurd. The only reason they get away with this is because they know the majority of the public isn't aware.
I confirm everything I learned in my business school was evil. Stupid business majors like me are ruining this world! (Only if they manage to get a job)
As a European, I scratch my head and try to understand and still don't get it. Until I remember it takes place in the USA and all the pieces fall in place.
Do worker's comp next. I have a pt that has been getting c2's like since forever. And even though he could have like 4-6 surgeries and fix his stuff they won't cover any surgeries; just his meds. He's basically an addict now. He walks with a cane and his gait is all messed up. He still needs PA's from time to time and paperwork filled out by his case manager almost every month to continue to get his meds. Paperwork back and forth for forever and a day. He could have had a perfectly normal life, got stitched up, recovered, and contributed to society afterwards but no, it's too expensive. So he's been on disability/medicare/medicaid since his accident. The issue: his "date of injury" is whatever/whatever in the year 1964. Like, are you serious?
Thank you for this. The bureaucracy and delays in allowing a patient to receive much needed and time sensitive treatments in our society is insane. Seems so inhumane.
This is everything I’ve always been saying. It’s crazy that insurance companies get to decide what treatment a patient does or does not receive based on how much of the patients’ money they get to keep. This is the reason I support a national healthcare system. Cut out the middleman and everyone saves money and gets better care.
There’s no such thing as “ stooping too low & being too much of a greedy bottom feeder “ . They don’t give a crap about grandma’s broken hip because she tripped due to her impaired vision from cataracts. It’s infuriating for everyone except the greedy insurance companies.
This reminds me of being told they were denying payment for the ambulance ride to the ER after a major injury (broken femur among many others) because it wasn't prior authorized. Fortunately they eventually stated that was an error and covered it, after much fighting.
I'm up to denial number four for a procedure that should significantly help my condition. We've jumped through all the hoops insurance said we needed, exhausted all other options outside of spinectomy, we've been pushing for this for nearly four years. My doctor is starting to get angrier than I am. Working as intended.
I work in Pharmaceutical Prior Authorizations mostly, and the way it was explained to me by an... overly candid Vice President was that Prior Authorizations exploit what's known as the Sentinel Principle. Where by if a person sees a guard or obstruction to their goals in their way, they will seek another way rather than confront the guard or obstruction. Approximately 80% of claims denied at the pharmacy level result in the patient seeking lower cost medication alternatives.
Love the skit. Prior authorization sucks. Needed it to get surgery after a Traumatic knee injury. Why do I Kneed permission for knee surgery so I can walk again...
We in PT struggle constantly to get really appropriate rehab candidates (strokes, multi trauma, amputees and the like) the life and function restoring rehab they desperately need after these events, only to be overwhelmingly denied by insurance companies. Hearing these kinds of patients sob after they've been informed that the insurance they've paid into their whole life won't approve their rehab is one of my most hated parts of my job.
As a tester for hospital medical software, specifically the referrals section, it's cool to see a system I test weekly get in a video (even if it's for the negative effects of requiring it in the first place, but hey, what I'm testing makes it occur automatically rather than manually)
@@TheMetallicaMonster You are assuming that the role of a physician at an insurance company is to do harm. That may be the job of some, but that is not mine. My job is to make sure that patients get the services they need and providers are paid for it.
@@bcsmedconsults29 soooo . . . . You don't have a set criteria dictated by the insurance company that you have to adhere to, and if the patient's medical history doesn't fall within that criteria, they're "not eligible" for the treatment that they actually need based on the opinion of the doctor that's actually laying eyes and hands on them?
@@TheMetallicaMonster No, the company does, but what you are describing is not my job there. Insurance companies consult with practicing physicians so they are compliant with State and Federal laws.
Oh my god, but WHY IS THIS SO TRUE!!!!! Prior authorizations are the absolute bane of my existence, I have been asking people without a medical license for permission to provide NECESSARY treatment for 16 years. It makes zero fucking sense
So I have a question. There are tons of medical professionals that are burnt out, depressed and overworked. This is, as far as I understand it, due to poor management and a heavy profit focus on the top level. Are there no medical unions or worker's cooperative hospitals in the US, and if not, WHY?
It is pretty much the same thing in Spain. Medical unions don't have very much strength in general because doctors don't get together. And our compensation are about 1/8 of the compensation doctors get in USA hahaha
Why? why are so many industries not unionized? here's why. a decimation of unions on the behalf of anticommunist zealots, who then gave an opportunity for business aligned fascistic mafia to scoop them up at a discount price, and then the RICO act to clean the remains of the fall guy's. en.wikipedia.org/wiki/Red_Scare there aren't any unions, because we got rid of them in the name of anticommunismistic capitalism. it is proworker, to be anticapitalist.
This is an actual Aetna policy, and now other insurance companies are considering the same. It’s a shameless money grab. Literally every person on earth gets visually significant cataracts if they live long enough. There is no reason for restricting cataract surgery approval, other than greed
I've never been so angry at something more than this, these insurance companies are a disgrace to medicine and humanity.
There should be more regulations asap
Thank you for posting this, Doctor.
As someone who is only 40 and already manages multiple life long conditions on top of having a complex medical history...seeing things like what you are pointing out in this video, freaks me out.
I already see the brutal insanity of navigating healthcare, as a long term patient, at what would be considered , an early age.
So, to know what it will be like when , or should I say, make it to 80, is mind-blowing...and not in a good way.
It's not that I don't want to grow old and live a long life...but with much of what health insurance companies want to do...it makes one extremely dejected and frightened with the aging process. We , as a society, in general, ARE getting older, due to advancements in medicine and science. Yet, at the same time , we have a system in place that wants to screw people over for growing old, in the first place.
@@dryb3301 In the long run? No amount of regulation can fix this. If you pass more laws to prevent abuses like this (assuming you can even get through the deliberately engineered gridlock making it impossible to make any meaningful changes while the entire biosphere we live in burns to the soon-to-be-barren ground), the companies will just bide their time while assembling the propaganda campaigns and bribes (also known as lobbying costs) necessary to undo whatever you did. The greed is just a side effect of the real problem. Markets are philosophically incapable of behaving in remotely human manners.
OK then go cash pay only. Duh.
Some people don’t REQUIRE such surgery. With minor changes to lens you can still see and eye doctors overprescribe such surgery (4mil). Insurance companies just want to make sure they aren’t taken advantage of, after all who will perform eye surgery: eye doctor, and who will be paid for it: eye doctor. Or maybe you are afraid of oversight?
I did medical billing for YEARS. Here’s how you get a denied pre-auth approved. When you get the first denial, request a reexamination of the procedure (as protocol for most major insurers). When you get the 2nd denial it means they had an actual doctor take a look BUT they never have docs that specialize in the field your trying to get a procedure done in. For example I had an obgyn deny a cardiac surgery. By law you are allowed to request info on the medical specialty of the doc who did the appeal review. When you get it and the doc who denied is ‘out of scope’ from the procedure you’ve hit jackpot. Now here’s where they fold: resubmit third time along with a request for 3rd party arbitration (basic procedure for major carriers) and in that request you state that you want it because you doubt the ability of an obgyn to make calls on cardiac patients and you wish to question them in arbitration about their experience with cardiology. That’s it. You’ll be approved without arbitration in about 85% of cases. Yes, it’s a pain that can take awhile, but passionate admin staff can get it done along with some paperwork from the docs. I helped a lot of patients with this because their carriers made the process daunting for them or sometimes never informed them that they COULD fight a denial. Elderly patients especially have trouble with jumping thru the hoops and understanding their rights. Too many docs don’t ask their billers to pursue appeals on denials, or their staff isn’t trained in these tiny but important carrier policies. Don’t be afraid to ask your docs office for help getting a denial overturned!
How ridiculous any of that is needed at all. No doctor in Australia has to ask for permission to enact care from anyone other than the patient or their guardian.
All of these for a necessary and sometimes life changing procedure/medication? Why do you guys put up with this in America? With all the freedom you can’t fight this ridiculousness?? It makes my blood boil
@@kole1ful its because the united states is inherently selfish. the majority would not want to pay an extra small tax so that everyone could see the doctor with a universal health care system.
this needs to be a very top comment. thank you for sharing your expertise!
@@kole1ful it's unfortunately mired in politics and what people believe others ought to do when they get sick. The affordable healthcare act had been threatened so often during the past presidental term; it's maddening to think that there are millions who are against their own self-interest.
I didn't think there was a character I could feel more pity for than Bill, but here Jimothy is
Jimothy secretly advocates for Medicare for all. He knows it will end his job but he also knows it's worth it.
There is also Tristopher
@@bdfortes Ahh,I forgot about Tristopher. What a silly name 😂
He knew what he signed up for
Yeah he's drawing a big pharma salary, my pity is limited.
As a medical student, I one time took care of a patient admitted to the psychiatric unit for a suicide attempt. The insurance company tried to deny coverage for their treatment because they hadn't "failed outpatient management" for their condition first. I'm sorry, I'm pretty sure "ate a bottle of morphine and chased it with a fifth of bourbon" crossed that line a few miles back.
Don't even get me started on how hard it is to get adequate outpatient mental healthcare covered.
Suicide attempts that are OD’s combined alcohol are absolutely no joke either. Your patient was not fucking around, jesus fucking christ.
American health insurance companies genuinely have blood on their hands.
I have a very rare instance of a prior authorization actually being helpful for a mental health condition. I was diagnosed with ADHD in 2011 and got prescribed Concerta. In 2012 I switched from my parents insurance to state medical assistance bc my parents insurance didn't cover the cost of my meds. In 2016, due to some financial fuckery, I lost my MA for a few months and couldn't afford my ADHD meds. Turns out sometime between 2012 and 2016, the MA insurance decided that they'd only cover Adderall for adult ADHD but since I'd already been prescribed it my script had been grandfathered in. So when I got back on MA later in 2016, they denied my Concerta and the PA didn't go through so my PCP was like, "You wanna try Adderall?" and I was like sure why not. Turns out, Adderall works WAYYYYYYYYYYYYYYYYYY better for me! For the first time in 25 years I was like, "Is this what normal people feel like???" So yeah, if Hennepin Health/HealthPartners hadn't arbitrarily decided to not cover my meds, I'd probably still be on ineffective ADHD meds!
Totally. When I was in outpatient treatment for an ED, the hoops the therapists and the patients had to jump through just to keep us from getting booted out of the program by insurance was insane. It was like the insurance companies were standing with binoculars in the bushes looking for reasons to put a lot of vulnerable teenagers back in literal danger by taking away their support.
@@OddsandEndsandOtters I am so sorry to hear that happened. The way the US healthcare system undervalues mental healthcare in this country is a crime. We need to focus on what is best for patients and that unfortunately isn't the priority for companies that put profit first. You can't put a price on the benefit comprehensive, supportive care can have for people who need it, or how challenging dealing with the cost and roadblocks insurance puts in their way is for people who are already going through so much. I hope you are doing better today.
@@j_skye7291 Thank you!
"Practicing medicine without a license"! THANK YOU!!! I have been saying for years that insurance companies are practicing without a license. They cover themselves by hiring old, retired doctors who haven't kept up to say whatever favors the insurance company.
It has never made any sense to me that the powers that be that get to control and dictate health insurance, have NO practical application in handling medical care in any shape , manner , or form. A MBA does not equate to MD, DO, DMD, DDS, RN, Pharm.D, etc.
Actually, many of those docs are on both sides, having active practices of their own. No old retired docs. Just not true in practice. How do I know? Insurance is my field.
For which they should be held legally responsible. Practicing medicine without a license is illegal in every state, punished with a fine and prison.
It’s the same with social security disability. Patients have to jump through hoops for YEARS so someone in the Philippines who ISN’T A DOCTOR can glance at their paperwork for ten seconds and judge them as unworthy of benefits based on personal opinion alone, even if all the patient’s documents from actual doctors show disability.
@@pinkprincessinthecity1177 It has never made any sense to you because you're looking at it from the perspective of making an effective and quick healthcare system. It makes perfect sense when you look at it from the perspective of callous profit maximisation at the expense of people's health and lives.
Ugh, I just saw a rejection recently because they won't approve the surgery without "at least 12 months of unrelenting pain. at least 6 months of unrelenting pain under the constant supervision of a physicoan" and then like saying they have to try a bunch of treatments we already know will make the problem worse and more painful... like... what the fluck is wrong with people who defend insurance companies?
Not to mention the fact that people in chronic pain will have a much harder time accessing or keeping up with the supervision of a physician in the first place, so it's inherently hardest for the people who most need the surgery to jump through the hoops. Such a f*cked system
"You haven't suffered enough for us to give you a tiny drop of our billions of dollars of profit. Suffer more." that has to be, the most evil policy I've ever heard.
“Can we, for one day, not be evil?”
Don’t think for profit insurance companies in the US are capable of that.
Try socialist medicine in Canada, where *half* the patients who need cataract surgery aren't able to get it in 3 months. Or perhaps the socialist healthcare system (i.e., NHS) in England, where the wait time is 9 months. Evil, horrible America lets you get cataract surgery in the same month, though.
All insurance companies are for profit.
@@dr.floridamanphd Actually no. There are nonprofit insurance companies (usually Medicaid managed care plans and CHIP plans).
For profit insurance companies act like they would they would become a high risk ICU patient, if they did they decent thing.
It is essentially in their lifeblood to be evil AF.
@@LeadTrumpet1 very hard finding a doctor for medicaid coverage
After practicing anesthesiology for20 years I saw countless people's finances destroyed by the financial side of the medical system. I realized that not only are insurance companies are evil but they should be eliminated all together. This conservative doc is in favor of socialized medicine because of what the system we have now is evil.
I think anyone who is opposed to universal health care should be forced to work in either insurance or the medical field for a year because it'll change their minds
Rich countries have it, middle income countries have it, they all have better healthcare than the US with a socialized system, nobody goes bankrupt from cancer, I cant understand why americans refuse to fix something that causes them so much suffering.
@@dkg_gdkIt's because of the unions. Virtually all local, state and federal workers have union contracts that get them good healthcare coverage - better than most high income wage earners. Socialized medicine really does ration care to a much higher degree than we see now in America. There would be a lot of pissed off people when they are told they will have to wait for their hip replacement or that their medicine is no longer available. What socialized medicine does is level the playing field. Half of the people won't like that- especially those in power.
Frankly it only makes sense to pony up for medical costs. Taxes spent to keep people healthy - and that's a broad range of treatments and conditions - are surely better spent than on premiums, copay, and deductibles. The mental energy would be better spent, too, getting rid of pervasive insurance dependency and replacing it with public sector healthcare.
Lines are already long. Costs are high. Why not fix that?
We should ensure that everyone in America has access to the highest quality healthcare without worry of financial hardship. Right now we're ensuring that insurance executives have the highest quality summer homes and yachts without worrying about financial hardship.
Medicare for all.
@@rocky8u32 I knocked on over 1000 doors for Bernie doing street canvassing during the primaries. We need Medicare for all.
We need to shed light on the bad acting insurance companies so they either change or their customers switch to a different company. Government run healthcare gives no other options and the same types of cost containment measures have been used by government (and worse).
You try saying that as a politician and get flamed for being a communist.
Forget about Europe . Here in India 100 million families are given free insurance coverage by the govt and it includes hip and knee replacements and cardiac bypass surgeries. Even those living in extreme poverty get medical treatment if they just pay like 2 or 3 dollars a year for their entire family and sign up for this scheme . You don't get anything fancy like a suite room in a hospital or anything but it's still better than waiting months and getting claims rejected by the insurance companies.Americans definitely deserve a lot better than what they are getting.
I have a fun one to add in there. My insurance no longer covers my _ostomy supplies._ They only cover "durable medical supplies", and since you have to change your ostomy bags and wafers very often, they're considered "non-durable" medical supplies.
So now I'm forced to use Amazon to buy medical supplies that I literally _cannot live without,_ and since they're so expensive I can't afford to buy them as often as I should so now my skin is really suffering because of it. Which means I'll have to spend even _more_ money on skin care/repair products to fix that issue too - that issue that wouldn't even _be_ an issue if my insurance hadn't decided to be greedy
As a fellow ostomate, what a nightmare. I am lucky to live in BC Canada where supplies are covered after meeting an income-based deductible. But many others in Canada aren't so lucky, and some provinces don't cover them at all. What is someone supposed to do who can't afford them??
Edited to add: I also know of someone who was told the cost wasn't covered because they were "not necessary to maintain health". Ok so you won't die without an ostomy bag stuck to you, but do they seriously think there are other options? Do they want people to just resort to Ziplocs and tape? Or letting their own output run down their legs?
I'm really sorry to hear this. ):
I've been unable to get surgery for my torn and dislocated jaw tendons for 6 years because it costs 100k per side, surgeons fees only (not including hospital and anesthesia). Medical Insurance says its "dental", and Dental Insurance says its "medical". So no one will cover it and I can't afford ~250k out of pocket, obviously.
So I just live in nearly constant pain. Needless to say that has started a major domino effect with my health, causing a number of other serious health issues to crop up over these years.
I feel your pain.
All I can say is, we all need to do our research on candidates positions on healthcare and vote. ):
As a doctor in the UK, I’ve blissfully never had to deal with an insurance company for anything related to patient care. That said, I’ve dealt with two American patients who were over on holiday who discharged against medical advice to fly home because they were so convinced of the superiority of their healthcare system, despite one of them being in the hospital where the surgical procedure they needed was developed.
you know the saying - a fool and his money are soon parted
AND it most likely would've been cheaper to have it done in the UK!
“They do it better over there”
“But I taught them the technique…”
Brainwashed by corporate America 🤦♀️
Because it is better
I absolutely LOVE the insane amount of prior auths we get for TRANSPLANT IMMUNOSUPPRESSANTS for our TRANSPLANT RECIPIENTS. Like make us jump through hoop after hoop because you think transplant patients DONT need to take their anti-rejection meds? Makes me beyond pissed.
Same here! I have lupus nephritis. I'm on dialysis. I have Optum RX via UHC. Getting Cellcept was a nightmare. It should be illegal for insurance companies to wield this power!
So true. I once worked with someone that used to work in the insurance industry. She quit her job because she can't stomach the fact that they have daily meetings where they sit and figure out ways they can deny coverage for various life saving procedures. Vile and evil is how we should describe the insurance industry. 😩
My favorite thing is how Cigna randomly decided at the beginning of the year that they didn't want patients to go wherever they wanted to for imaging procedures. They can only go to Independent imaging facilities which are cheaper, but also might have outdated equipment or equipment that is not with patient needs. What this means is that the patient might have to go across town for a standard CT scan (which as we know costs time and money) when they could just go across the street to their local hospital that is more than willing to care them.
You would not believe how many people start crying when I tell them we have to cancel their appt because their insurance decided to practice medicine. Sometimes it's just imaging for a standard test and they're okay with it, but sometimes it's imaging for somebody that's really sick and really scared and doesn't know what's going on. That's the worst part of my job.
Texaco Mike!
I know this is comedy. I love your content. But dad-gum this makes the bile in my belly rise and I get so angry! 10/10 acting, 10/10 portrayal of actual insurance companies. Is there an Oscars for short-form content? Because this needs a nomination. I went through a huge spectrum of emotions in a few short moments.
I can only laugh at the ridiculousness and cry at the fact that it’s reality.
@Dr. Glaucomflecken deserves a Webby
i mean it’s really comedy so much as it is an excuse to educate people on medical stuff and give important concerns a platform. the comedy is just to get you there
@@raphaelledesma9393 and republicans want to make it worse...
This is so true. I had C.diff from a perfect storm of factors. The Metronidazole prescribed to me kicked my butt! It did not improve my symptoms and actively aggravated them to the point that I lost a further 17 lbs in 5 days. It was brutal. My doctor (who I'd been seeing for 12 years) discontinued and prescribed Vancomycin which was denied because I hasn't completed 2 rounds of Metronidazole to show that I couldn't tolerate it. My mouth tasted like metal, I was having blinding headaches, I couldn't even keep down water and they wouldn't cover a $5 med change. My doctor called to appeal and told them if they didn't cover it, she'd admit me and they could cover an inpatient stay. All of a sudden, my $5 Vanco was covered.
To be fair, it's probably not clinically advisable to eat one's mother.
I'm sorry, I couldn't resist joking about your typo :P All seriousness aside, that sucks and I'm sorry you experienced that stupid and needless trouble
@@ItsAsparageese Ha! Agreed -- your clinical judgment is sound! (And because my need to fix typos borders on the pathological, I'm fixing it!)
...should have just gotten a fecal transplant.
@@BroadwayDuchess13 Haha relatable! And thanks for the compliment, I'll be sure to put "Once conjectured that someone likely should not eat their mother" on my med school apps, right next to "Once correctly answered an Instagram story pathophys question that the slight majority of respondents got wrong" 💪😁😆
I work for an eye clinic. One of our docs snipped at the insurance for not covering a certain eye drop. Why? Because there was a cheaper one... a cheaper one that wasn't approved by the FDA and was technically a black market drug. When the doctor asked if they were really saying he had to prescribe an illegal drug, they suddenly could apporove the original eye drop.
Working at an ophthalmology clinic, we had to be taught what exactly needs to be written down in the pt notes to get them approved for cataract surgery. Which is rather crazy, cuz if I as a technician can tell that there is cataracts, and it’s confirmed by the doctor, than we should really not have to jump through these hoops to help the patient out.
I am an ophthalmologist in a public hospital in Spain. If a patient needs and wants cataract surgery, she/he gets it within two/three months. I really don't get this "prior authorization" thing
I saw Aetna and knew this would be a good one. As an MA, if a patient's prescription plan failed to be covered and they requested the doctor to send a cheaper yet less effective solution, 9 times out of 10, you could be sure Aetna was written in big bold print on the cover letter.
The amount of moral injury Jimothy has to manage...can't wait to see how Psychology helps him!
I , for one , would love to see Jimothy , go to a session with the Therapist.
He's a psychiatrist, do not dare to imply psychologists might be useful (seriously they are even more than psychiatrist for some issues but they're always ignored for some reason)
He will probably need a prior authorization to go see a psychologist 😄
srsly when is this gonna be turned into a full-on primetime show? people eat those doctor shows up they cant miss. they'd save money too because they only have to hire one actor.
Psychology will need therapy after that
My pharmacy told me today, "Your insurance won't cover the specific type of insulin your doctor ordered. We've been trying to reach your doctor to see if they'll prescribe something else." Ha! Classic! We all had a good laugh...all joking aside, I have gestational diabetes, and I don't have to do this as a lifelong struggle, it's actually given me a horrifying insight into what regular diabetics have to go through, and it's quite sad and infuriating.
I do pharmacy prior authorizations for a women’s health clinic. Usually I can get almost anything approved by stating that the requested medication is medically necessary due to the patient being PREGNANT. They don’t fight back on that too often.
The older, generic versions of insulin work just as well as the new stuff that the Pharma companies came up with to keep making money. If they add an antacid or something useless it’s technically a “new” drug, and they can keep a patent and charge way more.
As a patient going on my 63rd surgery, currently with a PICC line in my arm (which was held up because of this very reason) this just makes me want to cry. We are human beings but our lives mean nothing to these companies. When I was 3 in had a tracheotomy, RSV and pneumonia with a temperature of 105. I needed to be airlifted from the small hospital in upstate NY to Boston Children’s. I was dying. The flight at that time cost $14,000 and they told the doctor to take me by ambulance instead. He informed them that I won’t make it to Boston in an ambulance and they still stuck to it. They only agreed when he said that his next call was going to be to channel 6 news and he will tell them they are denying a 3 year old little girl a lifesaving flight to Boston. This was 24 years ago and it’s only gotten much worse. Healthcare is no longer about healing people it’s a corporation to make money. I was just in the ER and the nurse told me one Motrin cost $50 and a bag of saline $100. I feel so sorry for the doctors that are trying to help people and have to fight this evil system as well. Thank you to all the providers who fight for us! ❤️ And thank you Dr. Glaucomflecken for shedding light on this problem!
You know what's worse, Aetna is owned by CVS so when the money for the eye drops you get prescribed afterwards go back into CVS as Aetna's preferred pharmacy. Total dominion and you as the patient get screwed.
I almost asked the doctor what it was like to need to ask the insurance company to be able to practice medicine at my kid's last allergy appointment, but I was worried I'd cause his head to explode.
Still can't get our insurance to approve my kid's (very needed) allergy eye drops, but I can get nasal spray every 30 days. Cool, cool.
We are going through almost the exact situation with my son’s emergency surgery. I’m thankful the doctor’s treated my son for his injuries based on what was best for him and not based what the insurance may or may not pay for. Insurance in this country is legalized robbery. I paid my premiums, the doctor did his job, now do your job insurance companies.
This was my insurance when they straight up told me on the phone that my approval for a non formulary medication didn't expire until 2043 but that I needed a new one. The reason why? "You just need a new one" I even explicitly pointed out to several different employees how it is absurd to suddenly force me to get a new one by forcing me to take medications that my body cannot tolerate and that they had proof of that on file yet they still insisted I needed a new one....
It is absolutely unacceptable that insurance companies have to follow so few regulations that they can get away with stuff like this. How are they allowed to just constantly go back on prior approvals that they issued without any reason and without consequences. How is that not considered a breach of contract and why are more people not talking about the crap they pull?
Additionally, why is it okay for insurance companies to not cover diagnostic testing at all? My doctors legally need to do them to treat me yet there is no standard stating that insurance companies need to cover those costs. For me, even after an insane deductible, they will only cover 40% of the costs. I have had more testing done than normal and never reach that deductible either because it is set way too high.
Thank you for shedding light on this extreme problem.
I think that the general public is unaware of the unwillingness of insurance companies to part with their money.
I believe if we can make more people aware, they will eventually rise up and demand a reformation of the insurance industry.
I'm a nurse case manager and sometimes I feel like all I've done in my work day is fight to get my doctor paid, my hospital paid, my patient's bill covered, etc., and so many times, the person I'm "fighting" with on the other end of the phone is someone who's had a fraction of the experience and knowledge I have, let alone the doctor's expertise. It's beyond frustrating.
Please keep making content like this. This is an education which is rare to find. You don’t often have people who actually know what they’re talking about making content that frames complex issues simply
and complex problems and solutions are more effectively communicated via humor
Do you really need a “be evil” mission statement when your sector is literally called “for-profit healthcare”?
If they require prior authorisation for hip surgeries too, Ortho’s gonna get mad. And he has a surgical hammer. Just saying. Seriously, this infuriating. Years ago, “government death squads” were presented as a boogeyman to argue against universal healthcare. And yet it’s ok if private insurance companies get to decide who can keep their vision?
Mind you, I'm not for assisted suicide, either, voluntary or mandatory. But how long before insurance companies start offering it as an option, anyway, to sick, expensive patients in states that approve of such?
I agree the method of paying for healthcare doesn't need to have anything to do with the definition of healthcare. Socialized medicine can be just as greedy as insurance; but I'd rather pay for healthcare directly instead of having a middleman in insurance.
Look, they totally have doctors reviewing your prior authorizations... you know... after they deny the authorization the first time you submit it because they weren't aware the patient had eyes (should have made that more clear in the documentation), and now you have 6 hours to schedule a peer to peer review with an MD or you forfeit your right to the peer to peer and have to go through the 30 day appeals process. 🤣 It TOOOOTALLY makes sense.
I’m a family physician. Whenever I have to do a “peer to peer” I start by getting the doctor’s name and specialty. Then I ask in which state he or she is licensed. If it is not a primary care physician with a license in my state, I refuse to go further. The calls are recorded. I politely tell the physician that he or she is not my peer. Please have someone call me back when I can speak with an actual peer. That works most of the time. If they can’t get me a primary care physician with a license in my state, not my problem.
Aetna made me fill out *three* prior auths for one of my glaucoma patients that developed an allergy to one of her meds. They delayed her access to medication for a full month...to save a grand total of $40. It's shameful. Heaven forbid we prevent irreversible vision loss.
I was dx with stage 4 renal cell carcinoma last fall. First time meeting with my oncologist he admitted me hospital because of so much back pain and had emergency spinal fusion corpectomy to remove a tumor and vertebrae that it crushed. I didn’t have pre-authorization from Aetna and I was billed the full amount of the surgery and hospital stay, totaling $375K. Fortunately, my medical team went rounds and rounds with the insurance and they finally approved and seeing that my deductible and out of pocket max was met for the year, I paid nothing. But imagine the shock and stress of receiving a bill of that amount while coping with a newly confirmed cancer diagnosis.
My father's medical bills amounted to over $1 million. He never paid them.
Insurance can be insane. When I was pregnant with my second baby, I had Hyperemesis Gravidarum (severe nausea and vomitting) and I needed IV's because I couldn't keep down enough liquid to stay hydrated (and sometimes I needed IV medications). After a few weeks I got denied from receiving further IV treatments because someone reviewing the claim decided I should be able to eat and drink and take my medications without throwing up. Fortunately I was doing well enough (past the first trimester) that I wasn't *as* sick, and I didn't get *so* dehydrated that I was disoriented or anything like I had been earlier.
I thought it was nuts... as if I liked getting stuck with an IV (sometimes four or five times before it working because of dehydration) and was doing it for kicks.
You kind of proved their point, unfortunately. HG has an expected duration. I hate to defend them though. Insurance is an institution of evil.
Glad things worked out in the end though.
@@cameronno6039 then again, it shows that these reviews often are unnecessary in the first place. In my country (austria), we don't have to deal with insurance companies for routine interventions like these, and it's really mind-blowing that there is a bureaucratic appartus huge enough to even maintain this.
@@cameronno6039 Only under a bare minimum standard of care. I was still pretty sick until the day I delivered my babies (HG for both, more severe the second time around), just not quite as badly. Barely tolerable levels of dehydration should not be the standard for pulling IV support. I was significantly undernourished when they stopped covering IVs, to the point that I could hardly walk around my house without my calves charlie horsing, and not having full hydration only made it that much harder. I even aspirated quite badly once trying to take medications against my body's attempt to vomit, well after they pulled IV support. My doctor should have been the one to decide if I needed IVs, not a stranger from my insurance company.
I should have explained more in my original post, so I apologize for information dumping here, but I do think my insurance was wrong. Even mild dehydration can be pretty significant. My first pregnancy I had consistent mild dehydration, which might have been what caused my low amniotic fluid, which might have led to my baby being breech with a cord in his neck, which resulted in a C-section. And mild dehydration does a real number to a mother's health. HG is health-destroying enough on its own; treating dehydration is the easiest way to make it a little less impactful, even if the dehydration isn't reaching life threatening or pregnancy threatening levels.
I had HG in both pregnancies and my OBGYN's office had to go through an utterly insane PA process to get my insurance to pay for more than 10 Zofran tablets per month.
I'm a CVS employee so I have Aetna. I'm lucky my parents still keep me under their health insurance because Aetna is horrible. You would think employees of a company who literally owns a healthcare insurance company would get better plans but our copays are outrageous
the neoliberal ideology treats employee's as an appreciating expense, rather than the empirically verified appreciating asset that they are. it wouldn't matter if the employee was the butler of god, employer's would still defacate on him, since that's how they extract surplus value, by making sure that wages are dropped by any means, prices are raised through any means, and any legislation mandating the maximum hours possible is rolled back. “Civil government, so far as it is instituted for the security of property, is in reality instituted for the defence of the rich against the poor, or of those who have some property against those who have none at all.” [Smith, Adam. The Wealth of Nations. Book V, Chapter I, Part II, 775]
I literally work FOR them and the plans you guys get are absolutely FUCKED
I had to have cataract surgery when I was 40 (they called me the pediatric patient during surgery) and I’m thankful it didn’t have to get pre approved. I had already put the surgery off for over ten years due to eye contraption fears (thanks A Clockwork Orange)
Former nurse case manager here. The concept that physicians would actually go through the pain and torture of getting auths was so ludicrous and hysterical that tiny tears came to my eyes. (I've had cataract surgery in both eyes by the way). I also have Aetna Medicare. That also brings tiny tears to my eyes.
"We only made 8 bilion in profit last year" well that won't do, better delay all those cataract surgeries
As a dude working in pharmacy I feel that, at least a third of the time when we get a script or even a refill request we gotta send it back to the doctor because of insurance needing PA.
As medical professionals we need to start our own insurance agency
👍
Y'all would be tearing each other apart for which specialties should get how much RVUs :')
Problem is you need a lot of people that don’t get sick very often to be part of it to help cover the costs for those that do get sick often.
But imagine if healthcare was like part of a local tax? Add a little bit of local tax and you can go to any medical professional in your area for no extra cost? Make it a national tax and go to any doctor in the country for no extra cost.
Yes! I had to buy my 75 year old father’s new hearing aids because his insurance only covered hearing aids so cheap they could have come from a claw machine. That’s after he had to submit documentation saying he needed hearing aids for BOTH ears! 🙄🤦🏽♀️
@@Dr.E7HER that's basically how it works where I live. And in most countries outside US. We juat get taxed for medicine and that way everyone pays for everybody essentially and medicine becomes free for an 80 years old in a nursing home, 40 years old working person and an 5 years old kid.
I run into this so much from the pharmacy side of the equation. Like come on, the patient needs these medications to prevent their serious conditions from progressing further. Please just let me give them the Xarelto their doctor prescribed. For the love of god.
On a more personal note, my grandmother was an Aetna medicare patient until the end of last year. I was literally on my knees begging her to switch because of policies like these and I'm so glad she listened.
You sir, are a true and rare master of this platform. So few people can make someone laugh, cry, and curse all in the same breath. This episode caused all three. Trifecta!
I SO needed to see this right now as I'm literally on hold on my office phone trying to determine why Cigna is not covering ANY of the opiate induced constipation. I just told an associate that if Cigna would not cover a medication to treat this then it's very likely they'll be covering a hospital stay and/or surgery when I have a colonitis attack or a ruptured bowel.I am very angry because I pay about $200 per paycheck for the best insurance offered by my job. I wonder how they'll react when I advise them I need ankle/foot surgery.
$200 a paycheck? That's insane. No way we pay that much in tax for everything let alone healthcare each paycheck. You and all your countrymen are being ripped a new one.
My spouse works for one of the big 3 defense contractors. The insurance benefits are expensive like yours and cover basically nothing. It's bullshit that anyone pays $2400/year for the privilege of paying lots of copays and needing prior auths for everything.
Oh now I'm confused. I thought that ppl in work got private health insurance through their jobs, not that employees have to pay extra thru their employers for private health insurance???
@@faeriegal713 You are preaching to the converted! And it seems like the BEST benefits I've had were the WORST to work with and vice versa. So I can have a great job I love and over priced insurance that makes me anxious and mad. Or I can have amazing insurance that covers everything and is affordable but I'm miserable every day at work. And I'm over 20 years away from Medicare, which I'm learning is no picnic either.
@@classicambo9781 ambo you don't live in the United States do you?
"The love of money is the root of all kinds of evil."
Case in point.
I work for customer service in a medical insurance company - it’s so unfortunately true. Even though the company I work for is non profit and we are owned by a major medical company in the state, the more I work here the more my mental health declines because I try to help people in these types of situations
you can try help them by giving them looph-*gunshhot*
I've worked in health insurance call centers, including on prior authorization teams. Alot of people think their insurance company wants them to drop dead, but of course that isn't true. Dead people don't pay premiums. Your insurance company wants you to stay alive and keep paying premiums, but never actually use healthcare. It's how they make money. The whole industry needs to be burnt to the ground and rebuilt.
Think again. They _do_ want their expensive patients dying. Why? Because they know that every expensive patient who can't be fixed up for cheap is a permanent money loser for them. Their business model is not compatible with the societal goal of promoting long and healthy lives, because as patients age it becomes exponentially more expensive to keep them at a good quality of life. In a well-designed single-payor system, this conflict of interest can be removed. In a truly nonprofit private system, it can also be removed or minimized. But not with the system we have. The system we have punishes good patient care for the chronically ill and rewards the murder of the same. From the insurance point of view, it doesn't matter if the chronically ill patient pays premiums, if every month's premium is more than offset by claims. In that situation, it's a financial loss to keep them alive and a profit center to withdraw all care. That's why the system only works _at all_ if there are strictly-enforced, powerful laws to force them to pay for needed treatments when they don't want to. Instead we've made it largely up to the insurers. A prescription for genocide.
As someone who was insured by Aetna AND processed their claims I can ONE THOUSAND PERCENT vouch for the accuracy !! I hated processing claims & preauths for Aetna patients !! Their insurance SUCKS @$$ !! 👏👏👏👏👏👏😁
#GoodOleJimothy 🤣
Everyone is dunking on Aetna, but where do patients go to find out which are the better insurance companies?
I have aetna and they currently won't cover my infusion supplies unless i go to the hospital for it, want to pull me out of therapy cause im not "making enough progress" with my ptsd, my therapist wants me to get TMS but i can't bc im currently spending several days a week at the hospital for my infusion??? Like they are literally creating the problems in my treatment.
I am getting flashbacks from when I worked in a pharmacy with this one. PT: "Are my meds done?" Me: "well ma'am, this requires something called a Prior Authorization from your doctor for your insurance to be willing to pay for it. We've went ahead and contacted them and are waiti..." At least 5 times a day for the most basic things
I don't remember the details and if it was exactly prior auth-related, but I remember during my Jonathan years that we had to see a Vietnam War veteran multiple times to get coverage for something related to his exposure to Agent Orange. Super messed up. Took us about 4-6 months.
Can't relate, because Europe. But still LMAO. Can't believe this practice is legal anywhere in the world.
america*
it's just so sad that all those advance medicines in the US are not enjoyed by majority of its citizens. I can't believe in a developed world, people would need to avoid calling ambulance because it causes significant financial strain.
Thank you for exposing Aetna's greed. US needs to switch to Japan's universal healthcare (since 1961), with all non-profit health insurance companies, non-profit doctors' offices and non-profit hospitals. No pre-authorizations by insurance companies. The price of every procedure, drug and hospital stay is negotiated every two years between five doctors from Japanese Medical Association and Japanese Health Ministry. That price is binding for the whole country. Rates are low, but doctors see many patients and make upper middle income. Thousands of non-profit health insurance companies, no claims denied, all billing and payment thru a centralized government agency. Emphasis on primary care. Best result in the world: oldest longevity, very low infant mortality rates. Patients pay 30% co-pay on doctors procedures up to a low maximum, so there are no medical bankruptcies. Children and poor elderly pay a lower co-pay. All fee-for-service for doctor visits, per day rates for hospital stay based on diagnosis. 2/3 of doctors graduate from public medical schools which is six years after high school at a cost of $35,000 total. Free our doctors from immoral medical school debt average of $200,000. US healthcare system needs massive overhaul. Emphasis on patients, then providers. Stop prioritizing for-profit health insurance companies, gouging pharmaceutical companies, and large hospital chains with their overpaid administrators.
Where can I sign up?
Beginning in the 90’s prior authorizations became part of my job responsibilities. They are nothing but time sucking wastes.
Anthem was the worst. An endless automated voice system that required input of member, birthday, ICD9, CPT, blood type and promise of first born. Was so happy when online authorizations were developed. Thanks for bringing light to this issue Dr. G.
Now I understand why they won't approve prior authorization for my dad's medicine. They don't see him as profitable enough to treat, why pay for a disabled guy to feel better? They see my dad as a money pit and decided that it's good for profit to let him suffer and slowly die.
I want to sue so hard, add on pyschological damage and trauma; the amount of nights spent crying into my pillow because my dad is in pain and I can't do anything to make him happier.
And yet somehow, conservatives and libertarians tell us this is what freedom looks like. It's almost as if those are really deceptive political worldviews when it comes to how society should structure healthcare.
"But cataract is one of the most common cause of preventable blindness in the world"
"Ooh Sassy. Lets wait till the cataract advances to become a morgagnian hyermature cataract to complicate into Phacoanaphylatic glaucoma and uveitis. More procedures and drugs! Ooyay!"
Satan retires from his throne!
we had a situation at my first hospital where uninsured patients (who were not legal residents) would come in for dialysis, but the only way IR would get paid to place a line was if it was a "medical emergency", and they'd put in temporary lines, give two days of dialysis, pull the line, and tell the patient to come back next week for the same thing. again, these people who need life support were basically getting 60% life support through a dogs*it catheter. that doesn't happen anymore, because bcbs and fresenius decided to eat the costs of dialyzing them in outpatient clinics....and I think a surgeon agreed to place permanent accesses if patients for some menial fee, like 200 bucks.
lot of evil stuff, but it's getting a little better as time goes on
it's getting a little better in some areas, but also worse in others like that new Alzheimer's drug that had the entire advisory group resign, and administration STILL APPROVED a chemical known to cause significant harm while not actually fixing the underlying condition. nothing more shows that science is incompatible with capitalism, and that capitalism is incompatable with science, than the APPROVAL of Aducanumab, when the majority of the scientific community supported it's rejection. neoliberal political economics does shorten my lifespan, and yours. time to build something else.
@@ethanstump I don't know much about the drug, just the reaction from journalists. I'd be more curious to know how doctors and patients who now have access to the drug feel about all the negative attention
Your northern neighbor here, I will never understand how brutal American Healthcare is. I once worked for an online pharmacy that catered to Americans. Learned so much about it then. With the MS meds that I need to take, I'm so happy they are totally covered for me here.
When you said "we need prior authorization for hip surgeries," I said f you (you being them). Which is rare for me. But this is one of the few moments they deserve my curse.
Same. Such a common surgery and yet the insurance companies are making it harder to get care.
“Can we, for one day, not be evil?” merch, please
Having had multiple surgeries, head injury, seizures, the final insurance straw for me, was when I COBRA'd out of my previous insurance plan. My premiums went from $400 per month for BOTH my husband and I, to $1,600 PER MONTH for me ONLY and ALL of my medical issues became "preexisting" conditions wherein they were NOT covered for anywhere from 3 to 5 YEARS. Therefore I would have been paying $1,600 PER MONTH for medical insurance I would NOT be allowed to use. Insurance companies RUN the World and NEVER forget that fact for one second. They prefer people to die versus paying for the medical services they require AND are legally entitled to.
Insurance companies run America not the world. Some of us have free healthcare and never pay up to $1,600 in taxes
they run the US, not the world. most of the rest of the world does not have this issue
@@kole1ful nah it's fossil fuel companies, from russia to china to america to europe to australia to africa, they have the ability to poison anyone, blame the victim, sue said victim for more money than they will ever earn, and then go to the media to "right a terrible wrong". then again, the corporate model is pernicious, no matter what industry your in, someone else is dying to make the rich .03 cents more per share.
I have yet to hear a convincing reason that we should keep the private insurance system instead of getting nationalized healthcare.
Freedom?
Because I've read horror stories about patients having to wait months to see a specialist and die before the appointment. A lot of Canadians come to the US and pay out of pocket for medical service. No system is perfect.
@@retired5218 You know all the horror stories about Americans not being approved for surgery and other kinds of care by their insurance until it was too late, right?
@@ivyhearst3554 Freedom to die because the insurance company doesn't think the life-saving treatment is necessary?
@@retired5218 I can't say I see how having a nationalized healthcare system would make that particular problem worse here. Canada has a huge doctor shortage. USA's isn't as bad. Yet. If we keep letting the healthcare system decay it probably will.
Granted, moving to a nationalized healthcare system could mean that doctors don't make as much money, which could make the shortage worse. Which is why such a move should come with an overhaul of the entire system. Why make people do a four-year degree before getting another four-year degree? Why make the match as hellish as possible? Why make the working hours insane on purpose?
And think of all the other benefits if we get rid of private health insurance as a necessary evil. Obviously, there's the benefit of not having to worry about going bankrupt from a medical emergency. But there are others: employers wouldn't have to pay for insurance for their employees, and employees wouldn't have to stay on a job they hate in order to keep healthcare coverage. Out-of-network no longer exists. You eliminate alot of bureaucratic billing bullshit from hospitals because there's a centralized pricing system, only keeping a few specialists on to deal with the people who have supplemental insurance.
Protip: Move to a civilized country, all of them have a health system (the US does not, the US has a bunch of corporations, some labelling themselves as "hospitals" others as "insurance agencies").
Spread the word !!!! Healthcare is starting to become more n more ridiculous everyday. There is serious need for some reform.
Insurance companies need more regulations. This is absolutely absurd. The only reason they get away with this is because they know the majority of the public isn't aware.
That mission statement is. Just. Perfect.
I confirm everything I learned in my business school was evil.
Stupid business majors like me are ruining this world! (Only if they manage to get a job)
As a European, I scratch my head and try to understand and still don't get it. Until I remember it takes place in the USA and all the pieces fall in place.
It becomes an endless loop next thing will be a prior authorization for headaches because Jimothy got one.
Do worker's comp next. I have a pt that has been getting c2's like since forever. And even though he could have like 4-6 surgeries and fix his stuff they won't cover any surgeries; just his meds. He's basically an addict now. He walks with a cane and his gait is all messed up. He still needs PA's from time to time and paperwork filled out by his case manager almost every month to continue to get his meds. Paperwork back and forth for forever and a day.
He could have had a perfectly normal life, got stitched up, recovered, and contributed to society afterwards but no, it's too expensive. So he's been on disability/medicare/medicaid since his accident.
The issue: his "date of injury" is whatever/whatever in the year 1964.
Like, are you serious?
Thank you for this. The bureaucracy and delays in allowing a patient to receive much needed and time sensitive treatments in our society is insane. Seems so inhumane.
This is everything I’ve always been saying. It’s crazy that insurance companies get to decide what treatment a patient does or does not receive based on how much of the patients’ money they get to keep. This is the reason I support a national healthcare system. Cut out the middleman and everyone saves money and gets better care.
There’s no such thing as “ stooping too low & being too much of a greedy bottom feeder “ . They don’t give a crap about grandma’s broken hip because she tripped due to her impaired vision from cataracts.
It’s infuriating for everyone except the greedy insurance companies.
These videos with jimothy terrify me to my very core. I am now even more terrified of medical care.
This reminds me of being told they were denying payment for the ambulance ride to the ER after a major injury (broken femur among many others) because it wasn't prior authorized. Fortunately they eventually stated that was an error and covered it, after much fighting.
"We plan to increase executive bomuses even more this year, meaning we need to do a load of bullshit to make people poor."
me as a health insurance company: you need prior authorisations! and YOU need prior authorisations! YOU there, you need prior authorisation!
I'm catching all the names in the skits .. "Jimothy", "Todrick" 🤣🤣🤣
Just wait until he introduces Thimason.
@@dr.floridamanphd 🤣
There's also Tristopher who works for Nature I believe
Your videos are bringing me so much joy right now. Thank you for helping uplift us during a really tough time!
'Be evil' you've summed it up in two words 😅 thanks for bringing to light crappy companies in such an entertainingly educational way!!
We need the Jonathan Resistance now more than ever.
This one hit too close to home 🥲
I'm up to denial number four for a procedure that should significantly help my condition. We've jumped through all the hoops insurance said we needed, exhausted all other options outside of spinectomy, we've been pushing for this for nearly four years. My doctor is starting to get angrier than I am. Working as intended.
I work in Pharmaceutical Prior Authorizations mostly, and the way it was explained to me by an... overly candid Vice President was that Prior Authorizations exploit what's known as the Sentinel Principle. Where by if a person sees a guard or obstruction to their goals in their way, they will seek another way rather than confront the guard or obstruction. Approximately 80% of claims denied at the pharmacy level result in the patient seeking lower cost medication alternatives.
Love the skit. Prior authorization sucks. Needed it to get surgery after a Traumatic knee injury. Why do I Kneed permission for knee surgery so I can walk again...
I think the insurance companies just want to see how far they can push Johnathan by also making him do prior authorizations
As someone who had to beg, I mean obtain prior authorizations for home medical equipment for many years... Spot freaking on!!!! Thanks Doc!!!
We in PT struggle constantly to get really appropriate rehab candidates (strokes, multi trauma, amputees and the like) the life and function restoring rehab they desperately need after these events, only to be overwhelmingly denied by insurance companies.
Hearing these kinds of patients sob after they've been informed that the insurance they've paid into their whole life won't approve their rehab is one of my most hated parts of my job.
As a tester for hospital medical software, specifically the referrals section, it's cool to see a system I test weekly get in a video (even if it's for the negative effects of requiring it in the first place, but hey, what I'm testing makes it occur automatically rather than manually)
I am a practicing physician and I work for an insurance company. This hits me on so many levels.
ruclips.net/video/9Deg7VrpHbM/видео.html
Um . . . Why do you work for an insurance company? I feel like that is the complete antithesis to "do no harm".
@@TheMetallicaMonster You are assuming that the role of a physician at an insurance company is to do harm. That may be the job of some, but that is not mine. My job is to make sure that patients get the services they need and providers are paid for it.
@@bcsmedconsults29 soooo . . . . You don't have a set criteria dictated by the insurance company that you have to adhere to, and if the patient's medical history doesn't fall within that criteria, they're "not eligible" for the treatment that they actually need based on the opinion of the doctor that's actually laying eyes and hands on them?
@@TheMetallicaMonster No, the company does, but what you are describing is not my job there. Insurance companies consult with practicing physicians so they are compliant with State and Federal laws.
Jimothy: I didn’t sign up for this. 😂
Oh my god, but WHY IS THIS SO TRUE!!!!! Prior authorizations are the absolute bane of my existence, I have been asking people without a medical license for permission to provide NECESSARY treatment for 16 years. It makes zero fucking sense
You should have Family Medical do a peer to peer review and absolutely destroy the peer reviewing physician.
Loved watching this video a day earlier at the ASCRS2022! 😂
Love you so much for this video!!! 🙌👏
This is soooo on point! As a former medical biller/coder, Aetna was the name of my existence!!!
Is this real-life in the USA?
So I have a question. There are tons of medical professionals that are burnt out, depressed and overworked. This is, as far as I understand it, due to poor management and a heavy profit focus on the top level.
Are there no medical unions or worker's cooperative hospitals in the US, and if not, WHY?
It is pretty much the same thing in Spain. Medical unions don't have very much strength in general because doctors don't get together. And our compensation are about 1/8 of the compensation doctors get in USA hahaha
Why? why are so many industries not unionized? here's why. a decimation of unions on the behalf of anticommunist zealots, who then gave an opportunity for business aligned fascistic mafia to scoop them up at a discount price, and then the RICO act to clean the remains of the fall guy's. en.wikipedia.org/wiki/Red_Scare
there aren't any unions, because we got rid of them in the name of anticommunismistic capitalism. it is proworker, to be anticapitalist.
Thanks for this video and the description pinned! It’s so sad what goes on with for profit health care choices made motivated by greed.
You have hit the nail on the head. Insurance People are a pain all over the world
Oh yay....my favorite topic...
this is why nobody likes businessmen, money is more important to them than people