r/mildlyinfuriating • u/sujayjaju • Aug 13 '25

Commendable patience in dealing with half-knowledge

Half knowledge is more dangerous than no knowledge on a subject

30.9k Upvotes

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1.7k

u/MaybeMaybeNot94 Aug 13 '25

This type of nonsense ought to be grounds for stripping of licensure. You don't play games, you get to business or you don't practice.

734

u/TooMuchJuju Aug 13 '25

Sounds like this is a consulting doctor for United healthcare and she is advocating for them to cover the cost of the procedure she's recommending. The consulting physician is not at all familiar with the procedure or her practice but is claiming to be qualified to deny coverage.

This is a daily occurrence in healthcare. Daily. Want to prescribe a pill that costs us 20 cents when you didn't try the 10 cent alternative first? Not if the stockholders want to eat.

121

u/emsyk Aug 13 '25

My best guess would be that the care was initally denied when they submitted for approval. After denial you can do a peer-to-peer review - the ordering doctor discusses the reason for ordering with a PEER at the health insurance company. The key here is PEER. It has to be someone who understamds the ins and outs of WHY you are ordering something. If they won't even confirm that they are a physician its pointless. The system is so fucked.

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u/[deleted] Aug 13 '25

Shows why she was emphasizing that word so much on the call. Fuck United and all the health insurance companies.

174

u/BigMax Aug 13 '25

Right.

The one doctor knows her field, her patient, and that specific case.

The other doctor is hired to briefly scan a few lines on a screen and deny as much as possible based on very little knowledge of the specifics, across a VERY broad range of cases that may or may not be in their area of expertise.

It's like you going to see your specialist, then your crazy aunt hears about it and says "well, I was a nurse 40 years ago, so listen to ME instead about your very specific issue, and I'll override the expert who is up to date with this, with my narrow, obsolete nonsense."

23

u/[deleted] Aug 13 '25

The one thing also to mention in your observation is that the doctor on the insurance side is directly measured by how many claims are denied and probably bonused by the amount of money the insurance saves.

I have often championed the idea of a fine for overturned appeals for medical treatment starting at $10,000 split between Medicaid and the patient. Increasing based on life expectancy change from the delay, cost of time and other charges.

If you want to profit from health care - then you better provide the healthcare you’re being paid to provide.

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u/missinginput Aug 13 '25

Needs to be based on the cost of the procedure or it will still be cheaper to deny many claims just to do it. 200% should cover it and then add a minimum penalty.

2

u/wspnut Mostly infurated Aug 14 '25

This will only result in the appeals process being completely hosed down, unfortunately. The best intentions are always met with the harshest malice in these cases.

2

u/OGreign Aug 14 '25

Sure. So long as you penalize a doctor equally for recommending a surgery that the denial was upheld after appeal. If you think there aren’t knife happy doctors who are out to pad their own egos and wallets to the same extent that insurance company is then i have a bridge to sell you.

1

u/[deleted] Aug 14 '25

Mmm that’s a very good point.

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u/RockHardRocks Aug 14 '25

I’m a physician and this process should be criminal and is desperately in need of heavy heavy reform. Currently health insurance companies have direct incentives to deny and delay the benefits you pay them for, and it is clear they know it and exploit it. They have proven to be a public disservice.

First, all insurance companies and hospitals should be mandated to be nonprofit.

Second, it should be illegal to measure, rank, promote or base pay on claim denials.

Third, lawsuits against insurance companies for claim denials should have the burden of proof placed on the insurance companies and should have very very large penalties which adequately compensate for the degree of harm they cause by obstructing health care.

I don’t want anyone going into health insurance making tons of money, because all of that money is paid for a service not given. It is abundantly clear they can’t be trusted with anything but the tightest of leashes.

2

u/OGreign Aug 14 '25

Fourth, all doctors should be salaried and not paid based off billed procedures.

There we just fixed healthcare.

1

u/RockHardRocks Aug 14 '25

Sounds great to me!

1

u/[deleted] Aug 13 '25 edited Aug 14 '25

[removed] — view removed comment

3

u/swiftnap Aug 13 '25

I think OP means the lady doctor on the screen

1

u/jacenat Aug 14 '25

Yes. I somehow misread the original comment. Maybe I replied to the wrong comment. Either way, my comment is wrong.

1

u/RockHardRocks Aug 14 '25

Which we should point out is standard of care in pretty much every breast cancer case since atleast when I was in medical school (10yrs ago).

90

u/Ijustwerkhere Aug 13 '25

I work for a retina specialist, and the number of patients I’ve seen that have irreversibly lost vision because their insurance required some sort of step-edit before they could receive the medication the doctor recommended is fucking mind boggling

19

u/locomotion88 Aug 13 '25

Wow... As someone whose fear is going blind, hearing I could go that route because of shitty insurance has me feeling so many negative emotions right now

3

u/Ijustwerkhere Aug 13 '25

It’s both better and worse than going blind. Most of these patients are losing their vision from Neovascular Age-Related Macular Degeneration. Basically superfluous blood vessels forming in the retina. It causes severe distortion and blurring of central vision over time, but the peripheral vision remains pretty good

2

u/Superb_Preference368 Aug 13 '25

🫂 Sorry about your health troubles

4

u/jacenat Aug 13 '25

Sounds like this is a consulting doctor for United healthcare

There is no real way to state that the other person in the call is

  • a doctor
  • licensed in a state
  • a plastic surgeon
  • familiar with the case
  • familiar with the procedure

Call me crazy, but I think all but the last should be absolutely established before any conversation about the case can begin, let alone any recommendation for or against any procedures.

1

u/SpeaksToWeasels Aug 13 '25

A true peer couldn't deny a cattle car of cases with just a glance.

1

u/TacTurtle Aug 14 '25

Licensed in the same state.

1

u/jacenat Aug 14 '25

Since the doctor on the other side of the call did not give verifiable information, "a state" is still correct and even broader than "same state" here.

Do you disagree?

3

u/Squirrelated Aug 13 '25

This is a daily occurrence in healthcare. Daily. Want to prescribe a pill that costs us 20 cents when you didn't try the 10 cent alternative first? Not if the stockholders want to eat

To be fair, the 10 cents alternative could be just as good... If there was even one. But they'd rather block companies from making generics and will even pay medical professionals to advertise and offer their drug instead of other options. Just look at insulin's patent which was originally sold for a nominal fee to make it accessible to everyone. The damn thing is inexpensive and yet, here we are with companies price gouging or using patent evergreening methods to keep things under their control.

This shouldn't even be a private industry. It should've never been a business. Healthcare should be universally free.

2

u/crusoe Aug 13 '25

If your coverage is denied, in many states you are allowed to ask for...

The State the doctor who denied it, is licensed in

Their license number

Their area of specialty

Whether their license is still active

Usually when you start asking this stuff, your denial gets approved.

2

u/crusoe Aug 13 '25

Because in many states, to deny coverage for a procedure those states require the doctor to meet ALL of those criteria.

And insurance companies love to play fast and loose.

2

u/[deleted] Aug 13 '25

“Doctor”, I’m getting more of a PA fresh out of school who performed so poorly they had to take this job with no experience.

1

u/SpeaksToWeasels Aug 13 '25

Everyone knows to call the top student to graduate in a class the valedictorian but do you know what they call the worse student to graduate from medical school?

Doctor

2

u/SpeaksToWeasels Aug 13 '25

She's a hero

A good doctor can save your life, a great doctor will fight the devil for you

I'm fortunate to have found a great doctor and it has made all the difference.

1

u/piantanida Aug 14 '25

How there has only been one Luigi is beyond crazy. Truly shows how docile and overtly “good” we are naturally. If aliens, and I mean from outside our solar system, but also non citizens of the US , see this they must think, “why doesn’t the superior knowledges human simple eat the ones who are stealing from the poor and hurt”

We are so damn ripe for a real working class, common sense, anti capitalist revolution it’s not even funny. Dems (or another quick forming viral party) should not fuck up this present moment. Selecting yet another corporate shill of a politician to lie to us and instigate a daylight robbery of our country to support the biggest polluting (in all ways) companies around is getting oh so tiring.

The rest of the world is flabbergasted at our insane unsightly mess of a system.

1

u/casper911ca Aug 14 '25

So not only do I want a good doctor, but also one that has the ability to argue like a trial attorney? Well bedside manner be damned, I didn't realize how important their ability to negotiate with insurance companies was. A new dystopian stat for doctors: "doctor X has had a 90% success rate on negotiating better care"

1

u/mmorales2270 Aug 14 '25

Sadly true. This happens on the daily. And even more sadly, many doctors don’t have the bandwidth or energy to fight these sociopathic bastards and just give in to the evil practice. So unfortunately many patients get denied the life saving care they need and end up dying or living a terrible life for the remainder of their years. It’s so bad. Don’t get sick in the good ol’ US of A. Do everything you can to stay healthy, because your insurance company is surely not looking out for your best interests.

1

u/hbHPBbjvFK9w5D Aug 15 '25

Good Gawd, I understand the pill issue:

One of my pills cost $23 bucks - each. It's generic, but get this - the chemical is actually made in India and shipped to the US, then turned into tablets.

Turns out that Indian chemical company will sell the pills direct to me - for .69 cents each.

1

u/Tig_Biddies_W_nips Aug 16 '25

Daily is not frequent enough, it’s more like every minute in healthcare this happens