[CoachKandSportsguy]

Originally Posted by keepsake

I might as well vent here ...

The wife and I have had Devoted PPO for a few years. We decided to use the Wellness Bucks benefit and Devoted scammed us out of reimbursement. We spent nearly $550 that we wouldn't have spent if we knew Devoted was going to scam us.

The whole article is behind a paywall, but there is enough visible to get the sense that private MA is a money losing proposition without scale. That means that the only players which will remain are large, national level insurance providers. . . but large profitable means profit motive conflicts with customer service in health insurance. . . in either price or service or both.

Devoted Health’s losses in Medicare Advantage persist

[GoRedSox!]

Originally Posted by CoachKandSportsguy

The whole article is behind a paywall, but there is enough visible to get the sense that private MA is a money losing proposition without scale. That means that the only players which will remain are large, national level insurance providers. . . but large profitable means profit motive conflicts with customer service in health insurance. . . in either price or service or both.

Devoted Health’s losses in Medicare Advantage persist

I don't think that large, for-profit national health insurers are evil. But we have to accept what the American healthcare delivery system is. It is filled with profit centers at multiple points throughout the process. Big Pharma is in there as well, with all the direct-to-consumer marketing. The health insurers keep getting bigger and bigger, and competition lessens.

It is what it is. Since publicly traded companies have a fiduciary responsibility to shareholders, it's hard to argue that the patient is the first priority.

[golfing eagles]

Originally Posted by keepsake

I might as well vent here ...

The wife and I have had Devoted PPO for a few years. We decided to use the Wellness Bucks benefit and Devoted scammed us out of reimbursement. We spent nearly $550 that we wouldn't have spent if we knew Devoted was going to scam us.

They scammed you????? "They" SCAMMED you?????

Gee, I wish I had set up and insurance company----seed money, venture capital, infrastructure and employees, jumped through a zillion regulatory hoops to "scam" you out of $550.

Are you sure you didn't mean "deny us a benefit we felt we were owed" rather than "scam"?????

[CoachKandSportsguy]

Originally Posted by GoRedSox!

I don't think that large, for-profit national health insurers are evil. But we have to accept what the American healthcare delivery system is. It is filled with profit centers at multiple points throughout the process. Big Pharma is in there as well, with all the direct-to-consumer marketing. The health insurers keep getting bigger and bigger, and competition lessens.

It is what it is. Since publicly traded companies have a fiduciary responsibility to shareholders, it's hard to argue that the patient is the first priority.

What's evil is that the procedure rates / expected costs are unpublished. Like drugs at the pharmacy, the cash price might be lower than the insurance price, due to profit requirements. The cash price might also be discounted for same day pay to eliminate billing costs. Now, part of that is the complexity and uniqueness of each event, and part of is that each insurance company has contracted rates and coverages. However, that is just a math problem from the hospital's point of view. They can blend rates, they can average out procedures and normalize, and use statistics for standard deviations, etc.

The other evil part is that there are two classes of payers, the US government, and private insurers. From a hospital profitability point of view, and profitability means profits to invest in better outcomes, the US govt contracts the lowest margin / losing rates, and the private insurance has to make up the remaining difference. When payers such as UHC wants to contract rates lower than the US govt. . the hospitals can't repay both their employees and bonds and interest on their bonds. . . ie they go bankrupt. .

When UHC had a virus and caused physicians not to be able to bill and get reimbursed timely, UHC offered the physicians' offices LOANS with INTEREST . . . umm . . . that's evil. . .

monopolies are good if they are regulated with an oversite body representing the public.
oligopolies are better, as they try poaching customers from the others. .
competition is the best, but what good for the consumer is not great for companies and investment returns. . . that's the trap door of competition -> it all works great until one company reaches the ultimate corporate end goal -> MONOPOLY STATUS

Should health insurance be a utility financial model, with a limiting cap on profitability for the benefit of the population?

[GoRedSox!]

I have been out of this game for 4 years (happily retired). I did read about the data breach/ransom and that loans were made to doctors. I do not know the details around that, but many states have prompt pay laws that require electronic claims to be paid within 30 days. In NY, the interest rate was 12%. CT was 15%. NJ was 12%. These rates were high enough to motivate the insurers to pay timely. Also, all states could impose prompt pay fines on top of the interest. I think that CMS requires interest on late payment of Medicare claims by Medicare Advantage providers as well.

[collie1228]

Ten years on Careplus Medicare Advantage and I'm a big fan.

[Marathon Man]

Originally Posted by Dusty_Star

Some say that Medicare Advantage is a failed experiment. Patients get delayed & denied care, the taxpayers are paying mightily for the winners: the insurance company executives. They also say it should be discontinued or dramatically reformed.

MA was sold heavily to Congress by insurance company lobbyists on the basis that it would save money over traditional Medicare.

Is Medicare Advantage a Failed Experiment? Experts Debate - MedCity News

Such as???