1) know who to appeal to outside the company. This is the nuclear option. It's usually listed in fine print on every paper denial.

2) "My (partner) works in insurance. He does shit like this for a living. Please don't make me have to (goto 1)".

3) Feel free to cite the law where relevant, on paper, certified mail. The response is invariably "this is wrong, you misunderstand the law, but we will make an exception and (follow the fucking law this once.)"

I was in health insurance, management level, before I went into medicine.

The number one rule is don't pay anything until it is resolved. The second you've made payment, nobody else cares to make any effort.

This is not something I'd recommend. Any lapse in payment will be used to suspend your policy in the future in the event you get flagged as a high-expense patient, backdated to the period you didn't pay your premiums on time.

Pay on time, keep documentation you paid on time. Hell, turn on autopay and keep documentation on -that-.

Don't ever think you can hold your premiums hostage. You'll only be screwing yourself.

Edit: if you're referring to clinic bills, be sure you're in active communication with the practice manager so you don't get sent to collections. If it's a hospital, you'll be sent to collections anyway - they automate that process, once you're sufficiently late.

I wonder if they meant that you shouldn't pay providers until things are sorted out. I agree that you need to pay your premiums, but doctors and hospitals will just send you to collections. Still not a great option, but it does keep the money in your pocket until things are sorted out. (Of course, I wouldn't do this unless I was very sure I was right, also, so that any collections issues would be an insurer/provider error.)

It is (also) their problem. If they're in the network, they've agreed to certain terms as well.

I'm not saying skip out on your bills. I'm saying that the provider and insurance need to figure the bill out. I'm not floating a provider in my network so that I can fill out a ton more paperwork to get reimbursed eventually.

And yes, they do make errors in major ways. Just two years ago, I got as though I hadn't made my deductible. It was a $2500 difference. It's much easier to have a provider refile to get their money than for me to pay them and then work through the insurer's system to get reimbursement.

As far as your provider is concerned, whether your insurance should pay or not isn't really their problem. I have never been somewhere that did not make me sign a form saying that I agreed to be responsible for whatever my insurance did not pay.

Most providers understand the shit-show that is insurance, and will drastically adjust their behavior and prices based on who is paying.

Maybe, but that doesn't help if it goes to collections like the parent part describes.

If you don't pay a bill, there's no error. The subsequent hit to interest rates on something like a mortgage outweighs most minor medical bills.

Your advice is spot on.

We had a very similar experience with Blue Cross for many years. I'd swear they have an RNG that randomly denies claims 80% of the time. You just had to fight each one on the phone.

The people on the phone only had the apparent authority to "send the claim through the system again". About a month later you'd find out what happened. If denied again, we would just repeat until we eventually got lucky with the RNG.

They did eventually pay everything they should have, but we'd average about two hours on the phone per doctor visit.

What floors me is how no one has disrupted this field yet. I have seen a few ground zero startups trying to disrupt healthcare. Make it more effecient, cut out fraud, etc but so far no one is making a dent.

Why is it so hard for some smart young folks to come along and hammer out solutions to accomplish less fraud, easier, and faster to use systems etc?

It seems like it's really REALLY hard to bust up this abortion we call healthcare in the US.

This is because anybody who knows what's going on wants health insurance outlawed. Everyone else just wants to milk sick people for every dime they have.

With specific exceptions (medical devices - those Rascal ads are there for a reason) there generally isn't a ton of fraud. What there is is a lot of middlemen each taking their own cut, which cumulatively adds up to a lot of overhead. It's the "efficiency" part that you mention.

Efficiency is a tough nut to crack but there are organizations like Kaiser Permanente that have been very successful with a vertical integration model to cut this overhead. The problem is that it's a political fight every step of the way - doctors, hospitals, insurance companies, and drug makers each have their own extremely powerful lobbies who will spend lavishly to keep their cut of the profits flowing.

Which is why we're actually moving in the opposite direction - the ACA moves away from this type of integrated care organization and towards a fee-for-service model. The idea is to have the consumer be the one choosing the cheapest MRI provider or whatever - but in practice the pricing is still entirely opaque and the public are more or less thrown to the wolves. The finest health-care plan the Heritage Foundation could devise...

And of course everyone has their own idea of how to improve efficiency, all of which translates into a lot of paperwork and red tape. That is why your insurance denies claims after all - "efficiency" (airquotes). It creeps into every aspect of medical care, especially anything having to do with Federal dollars (Medicare/Medicaid). And to be fair a lot of it is justified, it is an uphill battle to get providers to adopt even basic best-practices like checklists during surgical procedures ("remove and count all 5 pieces of gauze before you close the patient"...). Another thing that doctors fight tooth and nail is clinical decision-support tools - even though these are a value-add for the physician in many cases (did you want to order that test with contrast or without? A family doctor may not know.)

(disclosure: I worked on such a tool at my current employer)

One little-addressed area of extreme waste is generic drugs. The idea is that once your patent expires (after decades of "patent evergreening" of course) anyone can make your drug - but in practice that's not how it works, one company just dumps product on the market at cost until everyone else leaves the market, at which point they are once again free to charge whatever they want. The overhead costs of starting drug production is quite high, and in practice it's more difficult for new drugs to claim bioequivalence because the drugs involve biological steps in their production. A company is not obligated to share the organisms used in their production process and if a competitor creates their own they must repeat FDA approval processes, which are inordinately expensive.

There's a very interesting Vox piece where the author was trying to obtain an estimate of how much his son's birth would cost [1] (the video is much more informative than the article).

Suffice it to say he was impressively unsuccessful, but it gives very interesting insight into how and why the problem is so complex, just from a consumer's perspective.

[1] https://www.vox.com/2016/5/5/11591592/birth-cost-hospital-bi...