@@riorio982 Really? I haven't done enough peer to peers to gauge a sense of how those people are. I imagine they are financially motivated by how many denials they give out.
The unrealistic part is that the peer to peer doctor was immediately available. One of insurance companies' new favorite tactics is to make the peer to peer call as painful and impossible to schedule as possible. I've gotten both "the doctor will call you between 7 and 7 sometime in the next 2 weeks" and "you must call within the next 15 minutes, and it'll take 12 minutes to navigate the phone tree, speak to a rep who will transfer you and be put on hold so you really have 3 minutes to drop everything and do it now now now". It's intentionally infuriating. In completely unrelated news, UHC is the 8th most valuable company in the world, with a market cap of $490 billion USD.
Yup once you somehow navigate through the Hedge maze and slay a Minator and someone named jack Torance then you must face the final boss only to get your claim denied again even if you beat em
I had an ophthalmologist who was about to dictate an order for PDT and told me “Pay no attention to what I’m about to say about your case. We’ve been using PDT for this for 20 years but to get your insurance company to approve it I have to make your case sound horrific.” She made it sound as if my head was about to go all “Scanners” and explode. I got the approval.
Its great too because yeah you most likely need that test and it really should be approved, but to get it approved the doctor is being put in the situation where they are at the least fudging details that are going into your medical record.
Glad You got the good one that is willing to risk his job for the patients but..why is it necessary. Why... I mean,I get to learn in country where a patient needing an elective surgery is more likely to take a loan and get it done privately if they want the surgery to be sometime in the next decade but still...
Yeah just ridiculous that real doctors have to feel like their scamming the system just to get a reasonable outcome from the insurance company that is basically living off sick people by making them sicker
@@margodphd Some countries like Germany have highly regulated private insurance. Or singapore makes you pay a portion of your salary into a fund, and you help pay the costs but it's reasonable costs based on income. I don't know if the US will ever have "universal healthcare" but the costs really need to come down!
I've had quite a few doctors do something similar now that you mention it. It's a shame it has to be that way but I'm grateful some of the doctors get it and are willing to play the game health insurance companies are making them play
Here is something I found in a different comment section "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."
Thank you for this tip. I would put this on my notepad, probably have a graphic artist turn it into something that looks like an inspirational quote, have it printed and framed then hang it on my station's wall in the future. If you could give me the OP's username, I will add it. Otherwise, this quote was said by "Sun Tzu Probably" 🤣
My insurance company actually denied my hip surgery, my Dr appealed it, they denied that, he requested a peer-to-peer, they granted that request, then denied it. This process took several months and was very stressful. When January rolled around, they spontaneously reversed their decision and approved the surgery. I can't prove it, but it seems to me, that since I'd already met my out of pocket cap for the year they wanted me to wait until January so I'd have to chip in more for the surgery. From a financial standpoint that makes sense to them, but damn if it didn't hurt like hell to spend a few months unnecessarily dealing with a hip socket that was so loose I would wake up with a dislocation and then have to deal with several more throughout the day. I seriously wish there were more federal restrictions on what insurance could and could not deny, like if it's medically necessary they should not be able to deny or delay it just because they don't want to pay for it.
Here in Europe, you just get the surgery done and insurance has to pay for it, there is no denying. There is no even asking them in case of a medically necessary procedure. Wtf is wrong with the US health system?!
Bear in mind a doctor is holding an epipen and the only thing stopping their life being saved is the doctor's potential personal financial harm. $700... timmy's life... $700... Better get on the phone that tesla won't buy itself! Doctors and insurance deserve each other. Except those ones that break the mould and won't charge the uninsured for emergency care. There's a few.
“What are you mad about today?” 😂😂😂 so true The peer to peer is spot on Of course, they have to pick someone who has no experience in the area of the condition in question and has not touched a pt in the last 20 yrs 😂😩 Also…utilizing archaic references and lacking basic understanding of billing. But I digress…
Exactly! I was denied payment on a treatment for a therapy that has been studied and written about recently. The doctor at the third party reviewer said I should have tried a local PT first... I had no clue who that was until I finally finagled that answer out of them ... Get this she has never seen a patient like me before Similar story with my spine doc, he said he spent an hour doing peer to peer review and they still denied despite him giving me several additional diagnosises fitting in the real of my symptoms... that should have helped but it didn't My spine surgeon told me he argued that "it's not illegal for you to cover this surgery" but no, until it's reviewed by the FDA and there's hundreds of patients in his study cohort, insurance will not approve There goes a quarter of my yearly salary on one operation
@@danielleo6855 nice...So how do they get the study patients when they don't approve the bill? Hoping only rich people have crabby spines?! Thats why I didn't get further into a medical career. I can't take that shit...I would end in a psych asyleem in no time.
@@lisastenzel5713 considering the condition I have is in women's sexual health, and it's super rare, and these Drs are the only ones actively studying and treating it in an organized and systematic way, and super one of those things people in the general public misunderstand and make fun of ... Yes there is no funding. I had to pay for my own surgery, but it's not out of reach for middle class people. And it's better to pay than die from suicide or from the exhaustion my body was undergoing from the 17 years of distress I suffered My doctors are saving my life and keep following up with me because they really do care. They don't want anyone else to die, so I'm grateful to thier commitment and their help. It's no thier fault that the system is messed up.
I’m a Kindergarten teacher with the accompanying teacher’s salary. The price tag on my refill of epi-pens made me cry because this isn’t a medication I can choose to go without. My allergies are off-the charts, and I’ve been so traumatised from my experiences with anaphylaxis that I even developed anorexia, and had to spend years recovering. I still struggle with that anxiety and trauma. And the only medication that can save my life if/when I have another reaction costs SO MUCH MONEY. And why? There’s no reason for it. It’s horrible.
Omg this is truly a nightmare! I guess a similar situation happens with people with diabetes. You are basically forced to pay to survive. Sincerely wish well for you even in those horrible circumstances
I'd modify that to some creepy cult like slogan maybe, "denial is the way of survival" but no yelling it, just stating it in a calm and almost cheery voice. Just to emphasize the insanity of it all.
I did an exchange semester of my nursing degree is the USA (from Australia). The semester before I went to go I did an ethics unit. One of the reasons I did a nursing degree was the ability to work overseas, and the USA was on my list of options to work abroad. But that one semester in the USA about 20 years ago put me right off. I could not wrap my head off being a healthcare provider with the ethics of refusing care based on insurance companies and wealth (or lack thereof), how you can justify being one of the world’s richest countries and refusing healthcare to the poorest citizens did not sit right with me. I’ve never been back to the USA (except as a stopover to get to Canada) since. I spent 2 years working abroad in Ireland instead
@@spartanB0292 an adventure. Travelling nurses also can get more pay. But most an adventure. Australia's great but seeing the world is also great and different. But sometimes in too bad of a way like re US healthcare or lack thereof.
Pediatric physical therapist here. I'd LOVE the chance for a true 'peer to peer' review. Closest yet was an M.D. who teaches at a state university, has been out of clinical practice for over a decade, and had no developmental pediatrics background.
I just want to know how this can be called peer to peer when clearly the other person on the phone is in a completely different field, and career, and hasn't even remotely been around your type of patient.
@@saysHotdogs maybe they're implying that the school isn't one with a medical school in which the faculty who teach are also practicing physicians themselves. Some people leave their fields to just teach.
Had totally had a patient at risk for severe anaphylaxis denied an Epipen within the last month so this is spot on. The only thing missing is the 5-6hour wait to actually get to the peer to peer stage and the ultimate “discussion” with the insurance company’s physician to reveal their lack of expertise in the treating area
My friend was being denied life saving treatment by insurance. Her care team was so outraged that they agreed to do it for free. Then the insurance company relented and agreed to pay, because they knew they'd look bad if she *lived* And that's the problem with for-profit medicine, right there. 😡
Your ability to simmer the whole US insurance system into these 2 min. reductions is a true art. The public needs to know this is what goes on and that it's barely satire. Thank you for raising awareness. I've done so many prior auths, and worked hard to learn the ins and outs to get as much covered as possible, and I sadly can confirm. They want to make it as difficult as possible so you will stop trying.
Really? It's that bad? Then why have I only ever had ONE issue where something wasn't covered without a long complicated trial of alternatives? Or is it a much more varied situation overall, but one only remembers the difficulties?
@@Gwentheferret Ah, Americans and their self delusion, never gets old, like an abused wife, they just want to remember the good parts abt being violated by their system
Sadly, healthcare today is about the bottom line. While I'm not sure if socialized medicine is the answer, the current system is focused on profit not just for the insurance companies but for big pharma, hospitals, physician groups and medical device companies. And because it's a third party system, payments range from 0$ to 10x or more what medicare would pay.
@@Gwentheferret Most likely it's because the doctor knows your insurance and they've been doing it long enough to know what they will and will not cover. I have medicade, doctors have to deal with this so much they already know to prescribe the cheapest medication that may not even help but make it worse until they can work their way up, or if they can't work their way up then they'll just increase it until it does something, regardless of what symptoms you have. My family has gone through that multiple times and has gotten a bunch more problems because of it
PSA for all who may need it: Auvi-Q makes epinephrine auto-injectors that give auditory instructions when opened, and if your insurance doesn't cover it, they automatically give you a coupon for a 2-pack + trainer for $25. If brand name Epi-Pen isn't in your budget, don't be afraid to ask your doctor about alternatives. Expired epinephrine isn't as effective, so it's very important that you have an unexpired dose in case of an emergency
One of my attendings had to do a peer to peer for a pareplegic patient to get a wheelchair and the insurance doctor was like "why can't the patient just use a cane?" and she's like "cause he's fucking spinal cord patient!"
I'd heard nightmares about getting insurance to approve wheelchairs. I have a spinal cord injury but I can walk a bit and I've heard it's a nightmare to get them approved unless you can't walk at all. Fortunately it got approved pretty instantly, even the fancy power assist!
£350 for a wheelchair. That entire interaction cost more than that in work hours. What a waste of existence. R will tell you it can't be done and D will tell you we promise we'll make it free and ask the insurance companies to write the legislation. 'Free healthcare for all act' by name, 'mandatory insurance that covers nothing' by nature. With how big some government entities are- how on earth there isn't a proper medical insurance regulator yet boggles the mind. Not that budget issues aren't massive in a national health service. Imagine as a patient not being the customer and they get paid the same no matter the care and it is illegal to sue them. On the other hand our private care is top class as it has to compete with 'free' (though the tax burden is HUGE) and so you get immediate service and real nice treatment for ~£100 to see a specialist and a couple grand for a surgery, depending obviously. But you're free to mix and match. All these systems have perverse incentives. It makes sense why it's hard, as you're literally selling life and death. Your customer can't negotiate. Same with lawyers.
This is hilariously true, I have a SCI and while insurance approved my actual wheelchair, they wouldn't approve a seat or a back for it. You kiiiiind of need a backrest to, yk, stay upright throughout the day and not fall over, and a seat cushion to prevent pressure sores. The funny thing? Insurance easily approved the ~7k power assist wheels. The world we live in is a weird one.
I always thought America was the land of the law suit...why aren't there more cases brought to court where patients are disabled or killed by insurance decisions ?🤷♀️
Same with the NHS trusts in the UK though. Perverse financial incentives are tough to avoid in this case. Emergency scan, ehhhh see you in 6 months, or if you drop dead before then we can assume it was a bad result. US doctors over treat and NHS under treats. NHS is only slightly cheaper. At least in the US doctors are nice to you and want to see you. In the UK you have to win a raffle at 7am to see if you are blessed enough to get a phone call from your doctor. Need to see them? 2 months okay? You get 8 minutes and not a second longer after the 2 month wait (not joking) And the tax is so high you can't afford private or insurance.
Operating room nurse here - was once in a case with a neurosurgeon that had a scheduled call for a peer-to-peer review with an insurance company for approval of an intervention for a patient. They get on the phone, discuss things for all of a minute, before he indicates that someone else needs to get a piece of information for him because he's scrubbed in for a surgical case. (This is by no means unusual, and he had stepped away from the field for the duration of the call.) The person on the other end of the line said this was "not allowed" and that he shouldn't be on the phone in this situation (again, I'll reiterate - your surgeons talk to people on the phone during surgery if they need to talk to people on the phone during surgery, this is how it is and is ENTIRELY reasonable) and she hung up on him. For a scheduled call. Yeah this shit is nefarious
I'm really glad someone is actively calling out the darkness that is the medical insurance system over there. I love your skits, and these are just the cherry on top. Thanks for what you do.
As an allergist with many food-allergic patients and who has spent tons of time and treasure on prior auths... All I can say is THANK YOU! Love your work! Keep doing what you're doing!
The presence of the second physician isn't quite realistic, but if insurance companies ever did poke their noses into the realm of medical backing for their decisions it would probably look like this. Great work as usual!
@@andyhawrylak9396 Yep, and they usually find someone with a medical degree who has never completed a residency. It's more straight up cluelessness than being held hostage.
I'm a medical student "covered" by United Healthcare.. this hit home on too many levels. Insurance decided to stop covering a med I'd been on for years. I called them about it and they suggested a cheaper alternative. B*tch this has been working for me, why should I need to go through the whole process of getting adjusted to a new medication, which may or may not work as well and have different side effects? It took a lot of trial and error to get it right, and now I have to throw it out? Not cool.
Are all us med students covered by UHC Student Resources? Bc it sucks. They won't cover generic of one of my meds. But it's not a drug where substitutes are allowed. So my doctor has to write for the name brand, which she never does bc for almost everyone else, the generic is best and she'd have to write twice bc no subs. So it's always twice for me and the office never remembers. Oh and they just don't cover during summer and are like, just ask your providers to trust that we'll cover retroactively when we start again in fall. Uhhhh my doctor's don't do IOUs with insurances.
As a Medical Insurance Specialist for a large healthcare organization, I can tell you that this is all too true. Sad, but true. (U.S., private) healthcare insurance companies have a stranglehold on America, they lobby Congress more than the department of defense. 🤦♀️🤦♀️🤦♀️
Do you ever run into problems with CMS? My understanding is that Medicare and Medicaid generally pay less than other insurance companies, with the added threat of a government lawsuit if they don’t like something.
Dante got hell all wrong. There's no lakes of fire. It's an eternity of filing insurance claims, being denied, arguing, appealing and being subjected to nonsense rules and petty conduct. Oh and waiting on hold and being transferred multiple times only to have a lazy phone rep spike the call, forcing you to start all over again.
As a PA working in allergy/asthma, I can fully attest to the accuracy of this exchange. Never mind CMS’s updated list of dx codes to support need for food allergy testing… a list that excludes angioedema, flushing, urticaria, pruritus…
I am very sure about my food allergies and have almost died from anaphylactic shock. There's no way I even want to do testing. My issue has been medical staff who don't believe I'm in anaphylaxis because my reactions don't include hives. When just minutes before that I was pale with blue lips, throat closing, about to pass out from a blood pressure drop. My EpiPen is what saved me.
My mother works for United Healthcare and has done nursing and health insurance her entire career. She's told me the inner workings of these companies and holy crap, what a scam they are. That $30,000 surgery you had? Well if your neighbor has better insurance than you do, they charge $130,000 for the EXACT same procedure. Hospitals literally make prices up on the spot based on what they think your insurance will pay. Insurance companies also make these prices up on the spot. Here's an actual example of how US medical insurance actually works: You: I need an operation done that will literally kill me if I don't get it done Doctor/Hospital: Sure that'll be $10,000 (the actual cost of this procedure is $600) Insurer: We think it's only worth $5,000 Now at this point the doctor and/or hospital can say 'K great, $5,000 is reasonable have a nice day' and let the insurance cover it. OR, and this is what they do normally, they can be jerks and say 'No the procedure costs $10,000' and then bill the patient for the remainder that the insurance didn't cover, even though the actual cost of the procedure is under $1,000. But the biggest proof that it's all a scam, these numbers are completely fabricated. Your neighbor might be getting charged $50,000 for the same procedure because they think the insurance will pay more. The neighbor on your other side might be getting charged $5,000 and the insurance will only cover $2,500. The prices don't actually exist and as long as they're getting paid more than the actual cost of the procedure, they should be happy. But they never are. They ruin people's lives over a few thousand dollars when they're already making a 6,000% profit.
This is why my dentist told me to never get dental insurance and that he will just give me better rates if I pay him directly. Some people with insurance will pay more than I paid without insurance. He gets those cases at his practice but people will insist on using the insurance because it's through their employees so they think they're somehow getting their money's worth.
How about the new Cares Act, that lets insurances decide to deny covering ANYTHING prescribed by a resident without a license. Interns, IMGs and residents training in the state they don't intend to practice in are all screwed for a while. I tried sending a patient a rescue inhaler on discharge, and the insurance wouldn't cover ALBUTEROL.
My late father had emphysema, and the VA docs would literally give him an Albuterol inhaler every visit. He rarely used one at all. He was keeping me, my husband, and asthmatic co-worker all supplied with inhalers that would have cost us $70+ dollars with decent insurance. (And yes, it was all the same med/dose, we compared the little bottles of medication)
I remember the huge price gouge hike. I worked in veterinary med and had a girl call me back after discharging her golden retriever with a paper Rx, she was screaming it was $600 bucks. I couldn’t believe they went up over $400 in a night. We changed the Rx to generic and showed her how to draw up her own. $30 for same med, minus the 🖊 pen. Sick they charge that.
Here in France an Epipen is worth 69€, which is nice. And it is reimbursed at 65% by the country, which mean you pay only 24€ out of pocket, or by the private insurance. Even better, if you don't have sufficient incomes, it's totally free !
We got about halfway there when the Epipens lost their patent protection, now 2 epipens cost about $100 USD. Insurance coverage varies, but you can see it as low as $0-20 for copay.
NZ'er here - if a Dr. said you needed an epi-pen - you got an epi-pen on a government subsidised prescription. This would cost you the Dr visit (approx $40 NZD) + the pharmacy visit (approx. $3 NZD) . Just to point out, yes you can do a lot better supposed first world country.
Ah, the peer to peer review where they get a GI doctor to approve a medication from an hematologist to which they deny because they don't know anything about blood disorders.
Apparently you're allowed to apply for 3rd party arbitration because you doubt the ability of a gi doctor to make calls on an issue with blood disorders and in the majority of cases it will be approved without going through the arbitration. I'm British so I don't know much about health insurance but I saw a video saying that once and there's a comment here with all the text from that video somewhere.
@@violetskies14 you are allowed to do so, but you have to follow the insurance company's line of policy. First you make the request, they deny it. Then you appeal the request and get their out of scope doctor to look at it. Only then can you call them out and by now several weeks have probably passed anyways so it isn't useful for patients in severe condition anyways (who coincidentally are the people who need the doctor's recommendation approved the most)
@@violetskies14 And that's the reality for most chronically sick Americans. Yet nobody ever does anything because everyone is afraid their voice will go unheard....A thousand whispers is louder than a shout but everyone is too afraid to stand alone and get the ball rolling.
I used one of your videos to tell my kids about the healthcare system and they were furious. My son (8 yo) goes “That is so dumb!” Like, yeah little buddy.
So what I understand is… the only way medicine and healing can work in the US is… hospitals get a bunch of people who constantly keep resubmitting the applications and constantly appeal
I had a PA denied because they didn’t have any of the info… which I gave to them and double checked with their pharmacy. They were like “well they’re not on any antidepressants” but has been for SEVEN years and even after that they STILL denied
I love how you got the nail on the head on these kinds of issues. If only people in government would start listening and doing something about it. On an unrelated note, would anyone like to buy ocean front property in Arizona? It will be for sale when hell freezes and all the pigs fly away.
I’ve been fighting with my insurance for about two years because they stopped covering my migraine medication. I have a minimum of 2-3 migraines a month and this medication clears it up within a few hours, which hasn’t happened with any of the covered meds I’ve tried. I got around it for awhile because I have a savings card with the manufacturer, but now the medicine has to have a pre-auth so I’m fighting tooth and nail for them to clear it
Perfectly done. This is my life. I’m constantly trying to get meds approved for patients. I’m a lot angrier about it when they don’t cooperate. But I know it’s their job to deny. Shareholders uber alles.
I am an international medical graduate and I have been looking for residency options. Honestly, I didn’t even consider US as an option and opted for Europe and UK because I cannot for the life of me handle such discriminatory medical system where I will have to deny my patients treatments and interventions because they either cannot afford it or their insurance won’t pay for it. I want to work in a system where I am paid well but not based on praying on those who may be struggling; a healthcare system that isn’t working against the people for the sake of luxury and big pharma gaining even more money.
Preying* and here in the UK you get the joys of poor people non care and private medicine. There's no incentive to care or work hard in the UK. People become doctors for the pay and as an NHS patient you aren't the customer. The NHS gets paid more the worse it performs. You get a choice of public or private but you're already poverty trapped by huge taxes to pay for the NHS. Plus our governments just borrow the money to fund it. That's totally sustainable. And they make sure the NHS only secures supplies from its friends. When you find out it costs us £10,000 for a pen because of government contracts you might re-evaluate. And my wife had to interview for an expensive treatment to judge if she was valuable enough. Also- highly question giving the government any financial incentive to shorten your lifespan. Or the ability to put you on a do not treat list.
I have Huntington's. A few years ago a guy in Canada with Huntington's was in the news telling people what their lovely healthcare system was really like. He was a single father taking care of his son too. He slipped and fell one night and made the mistake of telling his aid who came by occasionally. His aid reported the fall so he was told he could either go into a nursing home or choose assisted suicide. No other options and his current treatment was completely rescinded. He went around trying to get some news coverage for how the system up there really works but no one really cared. He chose the second option by the way. People love universal healthcare until they need treatment and find out what it's really like.
It's time to change the law. Make our health system like Japan's. All health insurance companies are nonprofit. Insurance companies may not deny a doctor's prescription. All drug, hospital procedures, and office visit prices are negotiated every two years between doctor representatives of the Japanese Medical Association and government for the entire country. No overbilling allowed. Universal healthcare, funded both privately and publicly. Best health results in the world.
Sadly, this attitude is no longer confined to insurance companies - a LOT of conversations with pharmacists have started to look like this. "Yeah, sorry I can't approve this drug, it's a dangerous nephrotoxin - did you know that?" "...um well... the patient needs his tacrolimus so that he doesn't experience kidney transplant failure..." lol I've literally had hospital pharmacists tell me they specifically took drugs off formulary so that we wouldn't be able to order them.
Yes… That’s the point of a formulary and all hospitals have them. We don’t want you to order certain medications for various reasons. FYI - whatever pharmacists you’re speaking with probably had nothing to do with the decision. Play nicely!
@@lisal6608 That's all fine and well until a patient urgently needs flagyl and you have to daisy chain consults through infectious disease all day long because they are the only ones pharmacy will allow to put the orders in... Worth saying tho, this communication breakdown issue isn't unique at all to pharmacists, it happens frequently with surgical consults, etc. Just gotta find the humor and roll with it
I worked in a pharmacy in high school and recently worked at a major health insurer. Not only is this dangerous honest in how it goes down, it has only gotten more egregious in the last 20 years. We need to better regulate insurance pre-authorizations and denials to stop useless delays and obstructions of care in medically unambiguous situations. Using unnecessary hurdles to extract profits is a form of profiteering. The people who create such hurdles portray they are mere misers, they are not. Nay, they are profiteers and pirates. That money is not made from the efficiency of collectivization or the facilitation of improved care reducing costs for all. The excess money earned on denying necessary care, delays, and hurdles is a distillation of human suffering. It is soaked in the blood, tears, vomit, and collective pain of those they made suffer unnecessarily.
The first 2 words of this video told me more about the content than the title, lol. "United Healthcare".🤣 I used to deal with them annually for ONE prior authorization on a medication until it was discontinued. I can't imagine what my Doctor went through for ALL of his patients!🤦♀️😭
This. I have lived this. Three and a half years of 6 month trials of unsuccessful lesser treatments as I lay bedridden with sever Ulcerative Colitis until we could finally make it down the list to the one my specialist knew would be right for me from the beginning. I was scheduling my surgical consult to have my entire large intestine removed when I finally began the medication... NOW I'm happy to say I'm 5 years 3 months symptom free! Would have been nice to have started with the right medication.
I work in contracting for a DME provider. And let me tell you, working with insurance companies is the bane of my existence. I swear they make their reps take an oath to be as unhelpful and unresponsive as possible.
@@violetheise4717 I'm not very sure that is the adecuate word. And I'm not saying they are good people. That's just how they work. Lets put a simple example: a car insurance. It can easily cost $1000 per year and it can "save" a $15 000 vehicle. If 100 people buy this insurance and this 100 got accidents and lost their cars that same year, the insurance company will be in bankrupt. For they to barely survive, they need that no more than 7 people lost their cars... Or to say them that they don't qualify for the insurance because it was thursday.
@@LuisXGP omg how can this "purely unethical shit" survive if it stops doing unethical shit? "Oh I'm not saying black market for organs is good, but how will they survive if they stop profiting from homicide?" Well, you know, maybe those markets shouldn't exist, just a wild idea for you. An insurance company is an unnecessary third party that does literally nothing for society but profits of the neverending thing - human's health problems.
@@mojigreen6461 no shit sherlock, couldn't realize that if you didn't re explain it to me. Blame the people that let them to be robbed, I don't even live in that s. country
I´m vetenarian in Europe. Our little Pet-insurance companies, which were founded solely for profit and are not legaly considered part of public health system or critical infrastructure (unlike human state insurance companies) are making much less fuss when it comes to covering expenses. I guess with our insurance tradition they just wont dare to refuse.
The american healthcare system, genuinely, truly scare me. I honestly don't want to visit since I'm afraid if something will happen to me I'll either be neglected medically or ruined financially.
I've heard that visitors are covered by their own nation's systems, though that might vary. Maybe some nations figure that if you come visit us, you are obviously taking your life in your hands and out of theirs.
@@letshavepie Depends in the country, for example in europe there is something called the Schengen area. Basically any country in this area will take care of your health stuff. Also EU people can get "EHIC" (european health insurance card) from their local insurance for free, which will cover you on your travel through the EU.
I was prescribed lidocaine patches for after abdominal surgery. The insurance denied it and said that they were not a approved treatment for autism spectrum disorder. Even after trying to appeal it, they still would approve. Without insurance they wanted $300 for 5 patches. I'm supposed to use 2 a day for 3 weeks. About 3 months later, they were available over the counter for about $15 for a pack of 10
As a physician, this is so truthful. Believe it or not. I have even recently had to do prior authorizations on very inexpensive generics. It has become absurd. Then again, the cost of many medications has become absurd.
ill never understand how NOT trained medical personel can decide if you can take or not that life saving medication... it baffles me beyond understanding
I moved to the US for my postdoc a few years ago. Having grown up in the UK, I knew that the healthcare system was profit-driven and dysfunctional. I had no idea just how bad it was until I was in the system. My second kid was born there, and despite being on a good insurance plan thanks to my place of employment we still had to deal with additional costs and fighting the bureaucracy of the insurer. Getting out of that system was one of the biggest factors that eventually led to us moving back to the UK.
Will, I met you yesterday after your keynote at COA. Venting here today as I just lost a P2P battle with a Pharmacist and the MD from our favorite insurance company. I fought tooth and nail for his cancer treatment and explained the whole clinical picture over 6 months, still denied. They said "don't worry you can expedite an appeal afterwards " as if that's supposed to console me. I ended the conversation by kindly advising them that I hope one day they use their positions to advocate for patients, rather than endlessly repeating the same criteria from their manuals that the non-clinicians do from their company.
I had a patient at work who lost his leg (AKA) after being ran over by TWO cars consecutively and he was denied rehab by insurance because they said he "didn't need it." This is exactly how I imagine the peer-to-peer appeal went.
Sadly so accurate. And as a nurse of 36 years experience, I can also tell you that overall the healthcare we receive as health professionals (you know - good insurance benefits which we pay out the wazoo for) is most often not there. Funny though - I do know of 1 sector of the population that has AWESOME health insurance benefits. Want to guess? Why that would be our beloved senators and other government people. You know - the people who make major decisions for the rest of us.
Don’t forget that the government has the good cushy sort of insurance! But it’s only for ‘important’ people like politicians not us meager peasants who do worthless things like paying taxes.
I have said for years that if they had to live with the same insurance we gave things would change fast. There was a ruling (I think when Obamacare passed) that Congress had to abide by the same rules we did. They got that changed really fast.
@@meg2249 some people are more equal than others. Always the case. Might as well be feudal. At least without elections we didn't waste time seeing who got bribed the most and some even felt responsibility for their holdings and people.
Don't feel sorry for the second physician working for the the insurance company. That man should get his license removed. He is selling out patients to the highest bidder.
I was that kid with a severe peanut allergy. Except I live in Canada so I got the Epipen and everything turned out fine, barely had to pay anything for it.
This is why I have said that if you truly care about people, working in the medical field will tear you apart. Because seeing how much greed has tied doctors' hands and literally makes you stand by and watch as it won't let you help, if you legit care it is heartwrenching
Last week I called to do a peer to peer and got transferred to a nurse as the peer. I assumed I’d misheard, and asked her to repeat name and credentials. She got super huffy with me and put me on hold to transfer to the actual physician. The moron physician seemed to have trouble understanding that a patient’s prior dx of carpal tunnel syndrome did NOT explain lower extremity symptoms, dysequilibrium, etc. 🤦🏻♀️ Maybe I should have just talked to the nurse wtf
As a pharmacist who has to occasionally bother doctors for things like opioid thresholds, I think it is valuable for us all to remember who the real enemy is....
I once got a pre-authorization of my expensive biological in 3 weeks. I thought a miracle happened that day, having been on this medication for 8 years over 9 insurance plans.
Surprising that he survived a month in the box without food or water. Must have been a family medicine resident. Oh well, back in the box, before they pull out the cattle prod again.
My fave is when a reviewer/nurse/doctor/medical director denies an authorization for something without reading the documentation. How hard is it to read office notes when I've idiot-proofed them by highlighting the most pertinent info??
I love your body of work. This one hit home. When I work in a pain management and physical rehabilitation practice. Had to do preauthorization for meds and implants. What is not shown is the typical 23-35 minute wait to speak with a representative.
Honestly given how short and concise your stuff is about the medical system in America I think it’s only a manner of time till a progressive politician uses it to explain to representatives
We can only hope. As a pediatric nurse who just took care of a family with a kid that requires every 4 hour cathing who came in with the kid near septic from a UTI. All because their insurance company only approves for a laughable amount of catheters a month. Meaning they had to resort to washing used urinary catheters the best they could to reuse them… That’s just pure evil corporate greed there…
The captured physician is an unscrupulous individual who was promised untold riches in exchange for his soul.
Thought about getting one of these insurance review jobs to pick up an extra day or something.. I don't mind selling my soul.
Was he not told that there are a dozen specialties in which he'd make untold riches for a mere fraction of his soul?
@@shengliang2105 some of them can be really good people that want to help, but some love being a-holes.
@@riorio982 Really? I haven't done enough peer to peers to gauge a sense of how those people are.
I imagine they are financially motivated by how many denials they give out.
He looks like a family medicine doctor who found a loophole to get work-life balance.
The unrealistic part is that the peer to peer doctor was immediately available. One of insurance companies' new favorite tactics is to make the peer to peer call as painful and impossible to schedule as possible. I've gotten both "the doctor will call you between 7 and 7 sometime in the next 2 weeks" and "you must call within the next 15 minutes, and it'll take 12 minutes to navigate the phone tree, speak to a rep who will transfer you and be put on hold so you really have 3 minutes to drop everything and do it now now now". It's intentionally infuriating. In completely unrelated news, UHC is the 8th most valuable company in the world, with a market cap of $490 billion USD.
This!
Yup once you somehow navigate through the Hedge maze and slay a Minator and someone named jack Torance then you must face the final boss only to get your claim denied again even if you beat em
So your saying that these are some of the rich we should eat first?
@@forgetfuldullahan5468 mhmm
💖🏆 God bless you.
Oh the irony of getting a pen by denying an epi pen…Great (and sadly too accurate) skit as always!
Omg I didn’t notice that! Too funny.
_it has a cap_
“It has a cap” INSULIN????!!!
🤣🤣🤣
Thank you for pointing that out! I missed it too.
(Sorry, I just realized then pun I just made, too.)
I had an ophthalmologist who was about to dictate an order for PDT and told me “Pay no attention to what I’m about to say about your case. We’ve been using PDT for this for 20 years but to get your insurance company to approve it I have to make your case sound horrific.”
She made it sound as if my head was about to go all “Scanners” and explode. I got the approval.
Its great too because yeah you most likely need that test and it really should be approved, but to get it approved the doctor is being put in the situation where they are at the least fudging details that are going into your medical record.
Glad You got the good one that is willing to risk his job for the patients but..why is it necessary. Why... I mean,I get to learn in country where a patient needing an elective surgery is more likely to take a loan and get it done privately if they want the surgery to be sometime in the next decade but still...
Yeah just ridiculous that real doctors have to feel like their scamming the system just to get a reasonable outcome from the insurance company that is basically living off sick people by making them sicker
@@margodphd Some countries like Germany have highly regulated private insurance. Or singapore makes you pay a portion of your salary into a fund, and you help pay the costs but it's reasonable costs based on income. I don't know if the US will ever have "universal healthcare" but the costs really need to come down!
I've had quite a few doctors do something similar now that you mention it. It's a shame it has to be that way but I'm grateful some of the doctors get it and are willing to play the game health insurance companies are making them play
Here is something I found in a different comment section "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."
And now that it's finally approved, we can operate on... oh? Mr Jones died of a heart attack already?
or chage your laws so companies dont kill people?
Dear god this is insane that this is what it takes
Thank you for this tip. I would put this on my notepad, probably have a graphic artist turn it into something that looks like an inspirational quote, have it printed and framed then hang it on my station's wall in the future. If you could give me the OP's username, I will add it. Otherwise, this quote was said by "Sun Tzu Probably" 🤣
This is the Bad Place. We’re in the Bad Place.
My insurance company actually denied my hip surgery, my Dr appealed it, they denied that, he requested a peer-to-peer, they granted that request, then denied it. This process took several months and was very stressful.
When January rolled around, they spontaneously reversed their decision and approved the surgery. I can't prove it, but it seems to me, that since I'd already met my out of pocket cap for the year they wanted me to wait until January so I'd have to chip in more for the surgery.
From a financial standpoint that makes sense to them, but damn if it didn't hurt like hell to spend a few months unnecessarily dealing with a hip socket that was so loose I would wake up with a dislocation and then have to deal with several more throughout the day.
I seriously wish there were more federal restrictions on what insurance could and could not deny, like if it's medically necessary they should not be able to deny or delay it just because they don't want to pay for it.
Isn't that FRAUD? to deny and wait for financial benefit? What am I hearing there nuh?
@@thenadie8 It is only fraud if normal people do it. Companies can get away with anything. You communist! /s
Here in Europe, you just get the surgery done and insurance has to pay for it, there is no denying. There is no even asking them in case of a medically necessary procedure. Wtf is wrong with the US health system?!
@@Thesakeable literally everything unfortunately
@@Thesakeable they have the money, they got to write the laws.
"Hello yes the oral antihistamine failed and the child is in ICU, I'm about to document severe head trauma though..."
"On the child?"
"On you." 💀
Bear in mind a doctor is holding an epipen and the only thing stopping their life being saved is the doctor's potential personal financial harm.
$700... timmy's life... $700...
Better get on the phone that tesla won't buy itself!
Doctors and insurance deserve each other.
Except those ones that break the mould and won't charge the uninsured for emergency care. There's a few.
“What are you mad about today?” 😂😂😂 so true
The peer to peer is spot on
Of course, they have to pick someone who has no experience in the area of the condition in question and has not touched a pt in the last 20 yrs 😂😩 Also…utilizing archaic references and lacking basic understanding of billing. But I digress…
Exactly! I was denied payment on a treatment for a therapy that has been studied and written about recently. The doctor at the third party reviewer said I should have tried a local PT first... I had no clue who that was until I finally finagled that answer out of them ... Get this she has never seen a patient like me before
Similar story with my spine doc, he said he spent an hour doing peer to peer review and they still denied despite him giving me several additional diagnosises fitting in the real of my symptoms... that should have helped but it didn't
My spine surgeon told me he argued that "it's not illegal for you to cover this surgery" but no, until it's reviewed by the FDA and there's hundreds of patients in his study cohort, insurance will not approve
There goes a quarter of my yearly salary on one operation
@@danielleo6855 nice...So how do they get the study patients when they don't approve the bill? Hoping only rich people have crabby spines?!
Thats why I didn't get further into a medical career. I can't take that shit...I would end in a psych asyleem in no time.
@@lisastenzel5713 considering the condition I have is in women's sexual health, and it's super rare, and these Drs are the only ones actively studying and treating it in an organized and systematic way, and super one of those things people in the general public misunderstand and make fun of ... Yes there is no funding. I had to pay for my own surgery, but it's not out of reach for middle class people.
And it's better to pay than die from suicide or from the exhaustion my body was undergoing from the 17 years of distress I suffered
My doctors are saving my life and keep following up with me because they really do care. They don't want anyone else to die, so I'm grateful to thier commitment and their help. It's no thier fault that the system is messed up.
I’m a Kindergarten teacher with the accompanying teacher’s salary. The price tag on my refill of epi-pens made me cry because this isn’t a medication I can choose to go without. My allergies are off-the charts, and I’ve been so traumatised from my experiences with anaphylaxis that I even developed anorexia, and had to spend years recovering. I still struggle with that anxiety and trauma. And the only medication that can save my life if/when I have another reaction costs SO MUCH MONEY. And why? There’s no reason for it. It’s horrible.
Omg this is truly a nightmare! I guess a similar situation happens with people with diabetes. You are basically forced to pay to survive. Sincerely wish well for you even in those horrible circumstances
There is a reason. Malicious greed. They simply feel as if harming hundreds of millions of people is "worth" billions.
The only reason is greed. Epinephrine is very cheap to produce. The amount in an epipen may be worth cents, or a dollar…*maybe*.
Dude you should move
Try Costplusdrugs they sell meds that are generic with no mark up
There should’ve been a voice constantly repeating “deny every medication” in the room the doc was being kept.
With a picture of United Healthcare’s CEO hanging on the wall titled ‘Our Kind and Benevolent Dear CEO’. A La North Keorea’s Cult of Personality.
I'd modify that to some creepy cult like slogan maybe, "denial is the way of survival" but no yelling it, just stating it in a calm and almost cheery voice. Just to emphasize the insanity of it all.
@@meg2249 and a TV screen that every so often plays a message from their dear CEO.
I did an exchange semester of my nursing degree is the USA (from Australia). The semester before I went to go I did an ethics unit. One of the reasons I did a nursing degree was the ability to work overseas, and the USA was on my list of options to work abroad. But that one semester in the USA about 20 years ago put me right off. I could not wrap my head off being a healthcare provider with the ethics of refusing care based on insurance companies and wealth (or lack thereof), how you can justify being one of the world’s richest countries and refusing healthcare to the poorest citizens did not sit right with me. I’ve never been back to the USA (except as a stopover to get to Canada) since. I spent 2 years working abroad in Ireland instead
Yeah, I can't blame you
That’s too bad. USA has some great places to visit. You don’t have to work there.
Just curious, why did you want to work abroad when you lived in Australia?
@@spartanB0292 an adventure. Travelling nurses also can get more pay. But most an adventure. Australia's great but seeing the world is also great and different. But sometimes in too bad of a way like re US healthcare or lack thereof.
Have you worked in Canada?
Pediatric physical therapist here. I'd LOVE the chance for a true 'peer to peer' review. Closest yet was an M.D. who teaches at a state university, has been out of clinical practice for over a decade, and had no developmental pediatrics background.
I just want to know how this can be called peer to peer when clearly the other person on the phone is in a completely different field, and career, and hasn't even remotely been around your type of patient.
@@arthurr8670 agreed. Peer to peer review should be in at least the same field of specialty.
What’s wrong with a state university?
@@saysHotdogs maybe they're implying that the school isn't one with a medical school in which the faculty who teach are also practicing physicians themselves. Some people leave their fields to just teach.
@@saysHotdogs that’s the only thing you picked out?
Had totally had a patient at risk for severe anaphylaxis denied an Epipen within the last month so this is spot on. The only thing missing is the 5-6hour wait to actually get to the peer to peer stage and the ultimate “discussion” with the insurance company’s physician to reveal their lack of expertise in the treating area
Here faster than insurance denying a claim to medication.
Impossible
My friend was being denied life saving treatment by insurance. Her care team was so outraged that they agreed to do it for free. Then the insurance company relented and agreed to pay, because they knew they'd look bad if she *lived* And that's the problem with for-profit medicine, right there. 😡
Your ability to simmer the whole US insurance system into these 2 min. reductions is a true art.
The public needs to know this is what goes on and that it's barely satire. Thank you for raising awareness.
I've done so many prior auths, and worked hard to learn the ins and outs to get as much covered as possible, and I sadly can confirm. They want to make it as difficult as possible so you will stop trying.
Really? It's that bad? Then why have I only ever had ONE issue where something wasn't covered without a long complicated trial of alternatives?
Or is it a much more varied situation overall, but one only remembers the difficulties?
@@Gwentheferret Ah, Americans and their self delusion, never gets old, like an abused wife, they just want to remember the good parts abt being violated by their system
@@Gwentheferret or you are incredibly lucky. I just read a lot of mistrust from you. Do you work for the insurance company?
Sadly, healthcare today is about the bottom line. While I'm not sure if socialized medicine is the answer, the current system is focused on profit not just for the insurance companies but for big pharma, hospitals, physician groups and medical device companies. And because it's a third party system, payments range from 0$ to 10x or more what medicare would pay.
@@Gwentheferret Most likely it's because the doctor knows your insurance and they've been doing it long enough to know what they will and will not cover. I have medicade, doctors have to deal with this so much they already know to prescribe the cheapest medication that may not even help but make it worse until they can work their way up, or if they can't work their way up then they'll just increase it until it does something, regardless of what symptoms you have. My family has gone through that multiple times and has gotten a bunch more problems because of it
PSA for all who may need it: Auvi-Q makes epinephrine auto-injectors that give auditory instructions when opened, and if your insurance doesn't cover it, they automatically give you a coupon for a 2-pack + trainer for $25. If brand name Epi-Pen isn't in your budget, don't be afraid to ask your doctor about alternatives. Expired epinephrine isn't as effective, so it's very important that you have an unexpired dose in case of an emergency
That's really cool! It sounds like how AED machines work.
Seconded! I have auvi-q myself, can confirm.
One of my attendings had to do a peer to peer for a pareplegic patient to get a wheelchair and the insurance doctor was like "why can't the patient just use a cane?" and she's like "cause he's fucking spinal cord patient!"
I'd heard nightmares about getting insurance to approve wheelchairs. I have a spinal cord injury but I can walk a bit and I've heard it's a nightmare to get them approved unless you can't walk at all. Fortunately it got approved pretty instantly, even the fancy power assist!
£350 for a wheelchair. That entire interaction cost more than that in work hours. What a waste of existence.
R will tell you it can't be done and D will tell you we promise we'll make it free and ask the insurance companies to write the legislation. 'Free healthcare for all act' by name, 'mandatory insurance that covers nothing' by nature.
With how big some government entities are- how on earth there isn't a proper medical insurance regulator yet boggles the mind.
Not that budget issues aren't massive in a national health service. Imagine as a patient not being the customer and they get paid the same no matter the care and it is illegal to sue them.
On the other hand our private care is top class as it has to compete with 'free' (though the tax burden is HUGE) and so you get immediate service and real nice treatment for ~£100 to see a specialist and a couple grand for a surgery, depending obviously. But you're free to mix and match.
All these systems have perverse incentives. It makes sense why it's hard, as you're literally selling life and death. Your customer can't negotiate.
Same with lawyers.
This is hilariously true, I have a SCI and while insurance approved my actual wheelchair, they wouldn't approve a seat or a back for it. You kiiiiind of need a backrest to, yk, stay upright throughout the day and not fall over, and a seat cushion to prevent pressure sores. The funny thing? Insurance easily approved the ~7k power assist wheels. The world we live in is a weird one.
The sad reality is the insurance company gets off lighter if the patient actually dies.
I always thought America was the land of the law suit...why aren't there more cases brought to court where patients are disabled or killed by insurance decisions ?🤷♀️
Same with the NHS trusts in the UK though. Perverse financial incentives are tough to avoid in this case.
Emergency scan, ehhhh see you in 6 months, or if you drop dead before then we can assume it was a bad result.
US doctors over treat and NHS under treats. NHS is only slightly cheaper.
At least in the US doctors are nice to you and want to see you. In the UK you have to win a raffle at 7am to see if you are blessed enough to get a phone call from your doctor. Need to see them? 2 months okay? You get 8 minutes and not a second longer after the 2 month wait (not joking)
And the tax is so high you can't afford private or insurance.
Operating room nurse here - was once in a case with a neurosurgeon that had a scheduled call for a peer-to-peer review with an insurance company for approval of an intervention for a patient. They get on the phone, discuss things for all of a minute, before he indicates that someone else needs to get a piece of information for him because he's scrubbed in for a surgical case. (This is by no means unusual, and he had stepped away from the field for the duration of the call.) The person on the other end of the line said this was "not allowed" and that he shouldn't be on the phone in this situation (again, I'll reiterate - your surgeons talk to people on the phone during surgery if they need to talk to people on the phone during surgery, this is how it is and is ENTIRELY reasonable) and she hung up on him. For a scheduled call.
Yeah this shit is nefarious
I'm really glad someone is actively calling out the darkness that is the medical insurance system over there. I love your skits, and these are just the cherry on top. Thanks for what you do.
Well, we certainly don’t want United Healtcare’s CEO to make less than the $26.5 mil he made last year for providing, you know, health care. 😒
or paying doctors adequately
Would it not be more accurate he made $26.5 million because he denied healthcare? Since that's where they profit.
The doctor being treated like a hostage is just *mwah* magnifique
The reward pen, the epipen, and the microphone pen...comedy genius 👏
The microphone is actually an alcohol marker, a blue Sharpie
As an allergist with many food-allergic patients and who has spent tons of time and treasure on prior auths... All I can say is THANK YOU! Love your work! Keep doing what you're doing!
Jonathan needs to found Jonsurance for the good of all Americans
This exact thing happened to me! They denied the pen and asked me if benadryl would be equivalent. Spot on!
The presence of the second physician isn't quite realistic, but if insurance companies ever did poke their noses into the realm of medical backing for their decisions it would probably look like this. Great work as usual!
Peer to peer reviews with insurance-company employed physicians is standard in the industry. This is a fairly accurate depiction of that process.
@@andyhawrylak9396 yeah, with the forced answers included lol.
Not sure what you’re talking about. Insurance companies have their own Doctors to approve or deny coverage.
@@andyhawrylak9396 Yep, and they usually find someone with a medical degree who has never completed a residency. It's more straight up cluelessness than being held hostage.
@@TheTravisTube and it’s usually just them reading from a script
Another enjoyable yet sad video.
I'm a medical student "covered" by United Healthcare.. this hit home on too many levels.
Insurance decided to stop covering a med I'd been on for years. I called them about it and they suggested a cheaper alternative. B*tch this has been working for me, why should I need to go through the whole process of getting adjusted to a new medication, which may or may not work as well and have different side effects? It took a lot of trial and error to get it right, and now I have to throw it out? Not cool.
Are all us med students covered by UHC Student Resources? Bc it sucks. They won't cover generic of one of my meds. But it's not a drug where substitutes are allowed. So my doctor has to write for the name brand, which she never does bc for almost everyone else, the generic is best and she'd have to write twice bc no subs. So it's always twice for me and the office never remembers. Oh and they just don't cover during summer and are like, just ask your providers to trust that we'll cover retroactively when we start again in fall.
Uhhhh my doctor's don't do IOUs with insurances.
As a Medical Insurance Specialist for a large healthcare organization, I can tell you that this is all too true. Sad, but true. (U.S., private) healthcare insurance companies have a stranglehold on America, they lobby Congress more than the department of defense. 🤦♀️🤦♀️🤦♀️
I hate that the word lobby has replaced what it truly is, bribery. Lobbying is just bribing officials.
Do you ever run into problems with CMS? My understanding is that Medicare and Medicaid generally pay less than other insurance companies, with the added threat of a government lawsuit if they don’t like something.
Medicaid sucks too. Lots of rules, don't cover needed services, reimbursement is low and late.
Dante got hell all wrong. There's no lakes of fire. It's an eternity of filing insurance claims, being denied, arguing, appealing and being subjected to nonsense rules and petty conduct. Oh and waiting on hold and being transferred multiple times only to have a lazy phone rep spike the call, forcing you to start all over again.
As a PA working in allergy/asthma, I can fully attest to the accuracy of this exchange. Never mind CMS’s updated list of dx codes to support need for food allergy testing… a list that excludes angioedema, flushing, urticaria, pruritus…
What? I'm glad I had my food allergy testing eons ago.
That's crazy about the CMS guidelines but not surprising at all. Yikes!
I am very sure about my food allergies and have almost died from anaphylactic shock. There's no way I even want to do testing. My issue has been medical staff who don't believe I'm in anaphylaxis because my reactions don't include hives. When just minutes before that I was pale with blue lips, throat closing, about to pass out from a blood pressure drop. My EpiPen is what saved me.
My mother works for United Healthcare and has done nursing and health insurance her entire career. She's told me the inner workings of these companies and holy crap, what a scam they are. That $30,000 surgery you had? Well if your neighbor has better insurance than you do, they charge $130,000 for the EXACT same procedure. Hospitals literally make prices up on the spot based on what they think your insurance will pay. Insurance companies also make these prices up on the spot. Here's an actual example of how US medical insurance actually works:
You: I need an operation done that will literally kill me if I don't get it done
Doctor/Hospital: Sure that'll be $10,000 (the actual cost of this procedure is $600)
Insurer: We think it's only worth $5,000
Now at this point the doctor and/or hospital can say 'K great, $5,000 is reasonable have a nice day' and let the insurance cover it. OR, and this is what they do normally, they can be jerks and say 'No the procedure costs $10,000' and then bill the patient for the remainder that the insurance didn't cover, even though the actual cost of the procedure is under $1,000.
But the biggest proof that it's all a scam, these numbers are completely fabricated. Your neighbor might be getting charged $50,000 for the same procedure because they think the insurance will pay more. The neighbor on your other side might be getting charged $5,000 and the insurance will only cover $2,500. The prices don't actually exist and as long as they're getting paid more than the actual cost of the procedure, they should be happy. But they never are. They ruin people's lives over a few thousand dollars when they're already making a 6,000% profit.
Im a physical therapist and have worked in the reimbursement space. This is 100% how it works.
It's as if some rich executive visited a touristy souvenir market in Turkey, and went "this is how healthcare should work"
@Pops I've heard the Protection Racket and Insurance have the same roots.
This is why my dentist told me to never get dental insurance and that he will just give me better rates if I pay him directly. Some people with insurance will pay more than I paid without insurance. He gets those cases at his practice but people will insist on using the insurance because it's through their employees so they think they're somehow getting their money's worth.
Cuba shows us all that this can just be undone with a little violence
This is why the international privatisation of healthcare and issues like the defunding of the NHS are such dire problems
"international"?
lol.
How about the new Cares Act, that lets insurances decide to deny covering ANYTHING prescribed by a resident without a license. Interns, IMGs and residents training in the state they don't intend to practice in are all screwed for a while. I tried sending a patient a rescue inhaler on discharge, and the insurance wouldn't cover ALBUTEROL.
Training for the real world
My late father had emphysema, and the VA docs would literally give him an Albuterol inhaler every visit. He rarely used one at all. He was keeping me, my husband, and asthmatic co-worker all supplied with inhalers that would have cost us $70+ dollars with decent insurance. (And yes, it was all the same med/dose, we compared the little bottles of medication)
I remember the huge price gouge hike. I worked in veterinary med and had a girl call me back after discharging her golden retriever with a paper Rx, she was screaming it was $600 bucks. I couldn’t believe they went up over $400 in a night. We changed the Rx to generic and showed her how to draw up her own. $30 for same med, minus the 🖊 pen. Sick they charge that.
Here in France an Epipen is worth 69€, which is nice.
And it is reimbursed at 65% by the country, which mean you pay only 24€ out of pocket, or by the private insurance.
Even better, if you don't have sufficient incomes, it's totally free !
😭
-🇺🇲
We got about halfway there when the Epipens lost their patent protection, now 2 epipens cost about $100 USD. Insurance coverage varies, but you can see it as low as $0-20 for copay.
So it’s not a myth! Somewhere in the world there is a hope!
CoMmUnIstT!!!!!
Si j'étais un ricain XD
NZ'er here - if a Dr. said you needed an epi-pen - you got an epi-pen on a government subsidised prescription. This would cost you the Dr visit (approx $40 NZD) + the pharmacy visit (approx. $3 NZD) . Just to point out, yes you can do a lot better supposed first world country.
Ah, the peer to peer review where they get a GI doctor to approve a medication from an hematologist to which they deny because they don't know anything about blood disorders.
Apparently you're allowed to apply for 3rd party arbitration because you doubt the ability of a gi doctor to make calls on an issue with blood disorders and in the majority of cases it will be approved without going through the arbitration. I'm British so I don't know much about health insurance but I saw a video saying that once and there's a comment here with all the text from that video somewhere.
@@violetskies14 you are allowed to do so, but you have to follow the insurance company's line of policy. First you make the request, they deny it. Then you appeal the request and get their out of scope doctor to look at it. Only then can you call them out and by now several weeks have probably passed anyways so it isn't useful for patients in severe condition anyways (who coincidentally are the people who need the doctor's recommendation approved the most)
@@princeofrain1428 God I'm chronically ill and it would suck to be American.
@@violetskies14 And that's the reality for most chronically sick Americans. Yet nobody ever does anything because everyone is afraid their voice will go unheard....A thousand whispers is louder than a shout but everyone is too afraid to stand alone and get the ball rolling.
Try to get desatinib or ponatinib approved. It safe to say they know nothing....
I genuinely feel enraged watching these.
USA you need to do something about this, asap .......
We're trying, but people equate healthcare rights to communism. I can't wait to move to New Zealand.
I used one of your videos to tell my kids about the healthcare system and they were furious. My son (8 yo) goes “That is so dumb!” Like, yeah little buddy.
So what I understand is… the only way medicine and healing can work in the US is… hospitals get a bunch of people who constantly keep resubmitting the applications and constantly appeal
A couple of days ago I had to use my epi pen for the first time and i think it saved my life, so this hit extra hard 😬
The sharpie for the headset mouthpiece I AM IN HYSTERICS😂😂😂😂 Another great sketch doc!
Love the sharpie! I love this guy!
I had a PA denied because they didn’t have any of the info… which I gave to them and double checked with their pharmacy. They were like “well they’re not on any antidepressants” but has been for SEVEN years and even after that they STILL denied
I love how you got the nail on the head on these kinds of issues. If only people in government would start listening and doing something about it. On an unrelated note, would anyone like to buy ocean front property in Arizona? It will be for sale when hell freezes and all the pigs fly away.
I’ve been fighting with my insurance for about two years because they stopped covering my migraine medication. I have a minimum of 2-3 migraines a month and this medication clears it up within a few hours, which hasn’t happened with any of the covered meds I’ve tried. I got around it for awhile because I have a savings card with the manufacturer, but now the medicine has to have a pre-auth so I’m fighting tooth and nail for them to clear it
Perfectly done. This is my life. I’m constantly trying to get meds approved for patients. I’m a lot angrier about it when they don’t cooperate. But I know it’s their job to deny. Shareholders uber alles.
I am an international medical graduate and I have been looking for residency options. Honestly, I didn’t even consider US as an option and opted for Europe and UK because I cannot for the life of me handle such discriminatory medical system where I will have to deny my patients treatments and interventions because they either cannot afford it or their insurance won’t pay for it. I want to work in a system where I am paid well but not based on praying on those who may be struggling; a healthcare system that isn’t working against the people for the sake of luxury and big pharma gaining even more money.
Every system in the world is like this. Give me an example of health care that's not focused on cost cutting?
Preying* and here in the UK you get the joys of poor people non care and private medicine. There's no incentive to care or work hard in the UK. People become doctors for the pay and as an NHS patient you aren't the customer.
The NHS gets paid more the worse it performs.
You get a choice of public or private but you're already poverty trapped by huge taxes to pay for the NHS.
Plus our governments just borrow the money to fund it. That's totally sustainable.
And they make sure the NHS only secures supplies from its friends. When you find out it costs us £10,000 for a pen because of government contracts you might re-evaluate.
And my wife had to interview for an expensive treatment to judge if she was valuable enough.
Also- highly question giving the government any financial incentive to shorten your lifespan.
Or the ability to put you on a do not treat list.
I have Huntington's. A few years ago a guy in Canada with Huntington's was in the news telling people what their lovely healthcare system was really like.
He was a single father taking care of his son too. He slipped and fell one night and made the mistake of telling his aid who came by occasionally. His aid reported the fall so he was told he could either go into a nursing home or choose assisted suicide. No other options and his current treatment was completely rescinded.
He went around trying to get some news coverage for how the system up there really works but no one really cared. He chose the second option by the way.
People love universal healthcare until they need treatment and find out what it's really like.
Maddening how real this is
It's time to change the law. Make our health system like Japan's. All health insurance companies are nonprofit. Insurance companies may not deny a doctor's prescription. All drug, hospital procedures, and office visit prices are negotiated every two years between doctor representatives of the Japanese Medical Association and government for the entire country. No overbilling allowed. Universal healthcare, funded both privately and publicly. Best health results in the world.
Sadly, this attitude is no longer confined to insurance companies - a LOT of conversations with pharmacists have started to look like this. "Yeah, sorry I can't approve this drug, it's a dangerous nephrotoxin - did you know that?" "...um well... the patient needs his tacrolimus so that he doesn't experience kidney transplant failure..." lol
I've literally had hospital pharmacists tell me they specifically took drugs off formulary so that we wouldn't be able to order them.
Yes… That’s the point of a formulary and all hospitals have them. We don’t want you to order certain medications for various reasons. FYI - whatever pharmacists you’re speaking with probably had nothing to do with the decision. Play nicely!
@@lisal6608 That's all fine and well until a patient urgently needs flagyl and you have to daisy chain consults through infectious disease all day long because they are the only ones pharmacy will allow to put the orders in...
Worth saying tho, this communication breakdown issue isn't unique at all to pharmacists, it happens frequently with surgical consults, etc. Just gotta find the humor and roll with it
I worked in a pharmacy in high school and recently worked at a major health insurer. Not only is this dangerous honest in how it goes down, it has only gotten more egregious in the last 20 years. We need to better regulate insurance pre-authorizations and denials to stop useless delays and obstructions of care in medically unambiguous situations. Using unnecessary hurdles to extract profits is a form of profiteering. The people who create such hurdles portray they are mere misers, they are not. Nay, they are profiteers and pirates. That money is not made from the efficiency of collectivization or the facilitation of improved care reducing costs for all. The excess money earned on denying necessary care, delays, and hurdles is a distillation of human suffering. It is soaked in the blood, tears, vomit, and collective pain of those they made suffer unnecessarily.
"Better regulate pre-authorizations"
Such a thing shouldn't be regulated. It shouldn't exist at all.
I don't know if laugh or cry. Good video doc.
Hugs from Argentina 🇦🇷
The first 2 words of this video told me more about the content than the title, lol. "United Healthcare".🤣 I used to deal with them annually for ONE prior authorization on a medication until it was discontinued. I can't imagine what my Doctor went through for ALL of his patients!🤦♀️😭
This. I have lived this. Three and a half years of 6 month trials of unsuccessful lesser treatments as I lay bedridden with sever Ulcerative Colitis until we could finally make it down the list to the one my specialist knew would be right for me from the beginning. I was scheduling my surgical consult to have my entire large intestine removed when I finally began the medication... NOW I'm happy to say I'm 5 years 3 months symptom free! Would have been nice to have started with the right medication.
I'm not a healthcare provider and I'm more emotionally attached to the characters of this series than anything else I've ever watched
I work in contracting for a DME provider. And let me tell you, working with insurance companies is the bane of my existence. I swear they make their reps take an oath to be as unhelpful and unresponsive as possible.
How else would do they make any money then ?
@@LuisXGP I hope this is sarcasm.
@@violetheise4717 I'm not very sure that is the adecuate word. And I'm not saying they are good people. That's just how they work.
Lets put a simple example: a car insurance. It can easily cost $1000 per year and it can "save" a $15 000 vehicle. If 100 people buy this insurance and this 100 got accidents and lost their cars that same year, the insurance company will be in bankrupt. For they to barely survive, they need that no more than 7 people lost their cars... Or to say them that they don't qualify for the insurance because it was thursday.
@@LuisXGP omg how can this "purely unethical shit" survive if it stops doing unethical shit?
"Oh I'm not saying black market for organs is good, but how will they survive if they stop profiting from homicide?"
Well, you know, maybe those markets shouldn't exist, just a wild idea for you. An insurance company is an unnecessary third party that does literally nothing for society but profits of the neverending thing - human's health problems.
@@mojigreen6461 no shit sherlock, couldn't realize that if you didn't re explain it to me. Blame the people that let them to be robbed, I don't even live in that s. country
"It has a cap!"
So do our insurance policies. Isn't America just wonderful? 😁
I´m vetenarian in Europe. Our little Pet-insurance companies, which were founded solely for profit and are not legaly considered part of public health system or critical infrastructure (unlike human state insurance companies) are making much less fuss when it comes to covering expenses. I guess with our insurance tradition they just wont dare to refuse.
I'm not American and I'm starting to understand why Mr. Incredible threw his boss through several walls now
The american healthcare system, genuinely, truly scare me. I honestly don't want to visit since I'm afraid if something will happen to me I'll either be neglected medically or ruined financially.
I've heard that visitors are covered by their own nation's systems, though that might vary. Maybe some nations figure that if you come visit us, you are obviously taking your life in your hands and out of theirs.
@@letshavepie Depends in the country, for example in europe there is something called the Schengen area. Basically any country in this area will take care of your health stuff. Also EU people can get "EHIC" (european health insurance card) from their local insurance for free, which will cover you on your travel through the EU.
Always, always get additional travel health coverage. It can save your butt financially and/or provide medical repatriation.
You can just run. Tell them to mail you the bill and ignore it. Of course you shouldn't ever visit the US again if you do that.
Come as an illegal. You get free unlimited Healthcare, free phone, free housing, free education......
"It has a cap!" Just like United Healthcare's expenses!
"It had a cap" Poor doctor
I was prescribed lidocaine patches for after abdominal surgery. The insurance denied it and said that they were not a approved treatment for autism spectrum disorder. Even after trying to appeal it, they still would approve. Without insurance they wanted $300 for 5 patches. I'm supposed to use 2 a day for 3 weeks.
About 3 months later, they were available over the counter for about $15 for a pack of 10
As a physician, this is so truthful. Believe it or not. I have even recently had to do prior authorizations on very inexpensive generics. It has become absurd. Then again, the cost of many medications has become absurd.
ill never understand how NOT trained medical personel can decide if you can take or not that life saving medication... it baffles me beyond understanding
As Doc Glauc says: If they're taking medical decisions they're practicing medicine. Without a license.
I moved to the US for my postdoc a few years ago. Having grown up in the UK, I knew that the healthcare system was profit-driven and dysfunctional. I had no idea just how bad it was until I was in the system. My second kid was born there, and despite being on a good insurance plan thanks to my place of employment we still had to deal with additional costs and fighting the bureaucracy of the insurer. Getting out of that system was one of the biggest factors that eventually led to us moving back to the UK.
Will, I met you yesterday after your keynote at COA. Venting here today as I just lost a P2P battle with a Pharmacist and the MD from our favorite insurance company. I fought tooth and nail for his cancer treatment and explained the whole clinical picture over 6 months, still denied. They said "don't worry you can expedite an appeal afterwards " as if that's supposed to console me. I ended the conversation by kindly advising them that I hope one day they use their positions to advocate for patients, rather than endlessly repeating the same criteria from their manuals that the non-clinicians do from their company.
as a former United Healthcare covered person, I approve and unfortunately lived this message
I had a patient at work who lost his leg (AKA) after being ran over by TWO cars consecutively and he was denied rehab by insurance because they said he "didn't need it." This is exactly how I imagine the peer-to-peer appeal went.
Sadly so accurate. And as a nurse of 36 years experience, I can also tell you that overall the healthcare we receive as health professionals (you know - good insurance benefits which we pay out the wazoo for) is most often not there.
Funny though - I do know of 1 sector of the population that has AWESOME health insurance benefits. Want to guess? Why that would be our beloved senators and other government people. You know - the people who make major decisions for the rest of us.
Don’t forget that the government has the good cushy sort of insurance! But it’s only for ‘important’ people like politicians not us meager peasants who do worthless things like paying taxes.
I have said for years that if they had to live with the same insurance we gave things would change fast. There was a ruling (I think when Obamacare passed) that Congress had to abide by the same rules we did. They got that changed really fast.
@@meg2249 some people are more equal than others. Always the case. Might as well be feudal. At least without elections we didn't waste time seeing who got bribed the most and some even felt responsibility for their holdings and people.
Don't feel sorry for the second physician working for the the insurance company. That man should get his license removed. He is selling out patients to the highest bidder.
💯💯💯
I was that kid with a severe peanut allergy.
Except I live in Canada so I got the Epipen and everything turned out fine, barely had to pay anything for it.
This is why I have said that if you truly care about people, working in the medical field will tear you apart. Because seeing how much greed has tied doctors' hands and literally makes you stand by and watch as it won't let you help, if you legit care it is heartwrenching
Last week I called to do a peer to peer and got transferred to a nurse as the peer. I assumed I’d misheard, and asked her to repeat name and credentials. She got super huffy with me and put me on hold to transfer to the actual physician. The moron physician seemed to have trouble understanding that a patient’s prior dx of carpal tunnel syndrome did NOT explain lower extremity symptoms, dysequilibrium, etc. 🤦🏻♀️ Maybe I should have just talked to the nurse wtf
I was expecting the physician to be locked up in some kind of dungeon… this isn’t much different from it tho 😂
Can confirm that peer to peer physicians carry with them a devastating soul level sadness that haunts you long after the case has been denied.
I also thoroughly enjoy your thought provoking vids. Keep up the great work!
As a pharmacist who has to occasionally bother doctors for things like opioid thresholds, I think it is valuable for us all to remember who the real enemy is....
I loved how you used your pen as a microphone
Excellent commentary! Thx for telling it like it be, Dr. G!
I once got a pre-authorization of my expensive biological in 3 weeks. I thought a miracle happened that day, having been on this medication for 8 years over 9 insurance plans.
Gotta love insurance company's. The same day my mother had spinal surgery they denied her pain medication.
That is horrible!
@@makmcdermott that's travelers for you.
Surprising that he survived a month in the box without food or water.
Must have been a family medicine resident.
Oh well, back in the box, before they pull out the cattle prod again.
Love how the doc isn’t wearing scrubs but the rep is 😂
Your insurance videos make me want to cry, but are so necessary for people to see.
My fave is when a reviewer/nurse/doctor/medical director denies an authorization for something without reading the documentation. How hard is it to read office notes when I've idiot-proofed them by highlighting the most pertinent info??
just curious -- does anyone from any insurance company ever respond to these?
Your videos are so funny!! The job is so stressful sometimes, it is nice to know everyone has the same issues and problems!! Thanks!
I love your body of work. This one hit home. When I work in a pain management and physical rehabilitation practice. Had to do preauthorization for meds and implants. What is not shown is the typical 23-35 minute wait to speak with a representative.
Honestly given how short and concise your stuff is about the medical system in America I think it’s only a manner of time till a progressive politician uses it to explain to representatives
We can only hope. As a pediatric nurse who just took care of a family with a kid that requires every 4 hour cathing who came in with the kid near septic from a UTI. All because their insurance company only approves for a laughable amount of catheters a month. Meaning they had to resort to washing used urinary catheters the best they could to reuse them…
That’s just pure evil corporate greed there…
Manner of time? This is not today. Decades of that. Americans don't know how to vote.
"I want to change heal"
"He's a *COMMIE!*"
"No, wait I just want to-"
*Never gets re-elected again*
Remember that this man is not joking on a deep level and make sure you take it into consideration when voting comes around.
Also remember that this is only one piece of a much larger system.
Another great video from the doctor. Thanks
You are awesome. Loving the videos.
Fun fact United healthcare had the best stock performance of any top 10 company in the stock market. They beat Apple and even Tesla.
This isn't even satire, this is just truth.
This was so beautifully done. Showing the dark side of medicine while making you laugh gives me so many different emotions 😆
You're very gifted. You can make me laugh and cry at the same time.
I am not even in the US but knowing this is actually happening makes me real angry.
Well, you've got a party in the UK trying to bring our system to you, so be aware.