It is shadiness, because the odds are that you wil make a mistake and they will hold it against you. The whole private insurance setup exists to find ways to delay and poasibly deny coverage.

That is also why you pick what you will be covered for before the year starts, as if you can predict which major medical issues you will have in the upcoming year. Better pick a bunch of stuff that isn’t likely, and they can deny when you didn’t pick the obscure one!

I wish I could Thanos-snap the entire health insurance industry out of existence. It’s a giant, bloated, bureaucratic middle-man that makes the whole process more expensive, time-consuming, and complicated.

I’ve wondered what would happen if people went on a health insurance strike. If everyone (or a large part of the population) cancelled their health insurance, and just negotiated on price directly with providers.

I tore an achilles tendon last year. Doc wanted me in physical therapy, but PT wouldn’t take me because they needed an MRI showing the position and size of the tear.

PT was very clear. Tendons don’t show up on xrays.

Doctor was very clear. Tendons don’t show up on xrays.

Podiatrist was very clear. Tendons don’t show up on xrays.

Aetna: “You didn’t do an xray first, MRI denied.”

Sounds to me like either your doctor’s billing department or your insurance company sucks. (Or both)

In the decade I’ve had my current insurance, I don’t think I’ve ever had to call them.

I still think our healthcare system is absolute bullshit, but I don’t think this is a specific problem inherent to it.

We have all become unwilling, unpaid employees of every company in their pursuit of higher profits. It’s a feature, not a bug.

Corporations have discovered that there is no real downside (for them) when they don’t function. Customer satisfaction no longer has much of an impact on their profits because the few companies left in each sector are doing the exact same thing.

IMO this is yet another side effect of unchecked corporate power. It’s the same reason prices have risen so rapidly and corporate profits have reached 70 year highs. We are dealing with near monopolies and the billionaire class who created them. Until our government addresses the problem it’s not going to get any better.

In other words it’s not going to get better in our lifetimes.

They get paid when the least amount of people they insure use their services. They’re not incentivized to help those they’ve insured. The less they have to pay out to providers, the better the executive bonuses. Thus, they are diligent in collecting premiums, but can just sit on their hands when it comes to paying out.

The more the system denies and delays a claim, the fewer insured people are willing or able to put themselves through the bureaucracy gauntlet, the fewer pay outs.

They’re not in the business of insurance, they’re in the business of making money from the business of insurance. It’s over-complicated on purpose.

If you fail to run the gauntlet, or give up in frustration, the insurance company doesn’t have to pay. They could absolutely make this process easier, but the incompetence works in their favor.

I’ve lived in single payer countries as well as in the US, and the incompetence is the same everywhere. In my experience the big difference is in universal healthcare countries the rules are very strictly defined and there’s very little scope for exceptions, so either you qualify or you don’t. The other issue is that even if you qualify there’s often a multi-month waiting list for treatment.

Healthcare practices vary in how much they are willing to run interference for you on insurance. Most of them will at least try “pretty hard” to help with the claims because it’s good for their income stream to do so. However, sometimes you’ll find yourself using a provider who can’t be bothered with staffing up and/or supervising it to make sure it gets done. In my (limited, anecdotal) experience, this seems to happen more often with specialists or niche providers.

Or sometimes it’s your insurance plan. It might have so many byzantine rules and/or shitty admins that it’s just too much work for even a crackerjack provider staff to deal with it. So they end up kicking it back to you and saying “good luck”. If this happens enough, the practice may stop accepting that plan in the future.

It is unique to the way healthcare works in the USA. I don’t know why, the complete system looks broken. I can only tell you we pay less for healthcare here in Europe and we don’t have to call unless it’s really complicated and a rare situation. I’m sorry if that sound a bit off and doesn’t help…

One of the biggest advantages I see from living under single payer health care is that I don’t have to put in extra clerical work like you describe. Sure, the insurance company should be able to pick up a phone, but In my opinion, the responsibility should rest on the hospital - they are the ones demanding a payout.