Rising insurance denials in the US, fueled by AI-powered algorithms, are prompting lawsuits against major insurers like UnitedHealth and Cigna, alleging widespread improper claim denials. The extremely low appeal rate, despite a high reversal rate upon appeal, highlights the system’s inherent flaws and the difficulty patients face navigating complex appeals processes. New AI tools are emerging to automate appeals, but lasting change requires broader healthcare reform, addressing high costs and ensuring equitable access to coverage. Experts emphasize the need for human oversight of automated systems and industry standardization to reduce denials stemming from administrative errors.
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US physicians are accusing major health insurance companies of prioritizing profits over patient health, leading to deadly delays in crucial medical procedures. These delays, exemplified by a six-month delay in a patient’s PET scan resulting in their death, are described as a calculated business strategy to maximize profits. Doctors cite frustrating interactions with under-qualified insurance representatives during “peer-to-peer” reviews and the overall demoralizing effect of a system that forces them to act as insurance experts. Ultimately, a fundamental system overhaul, potentially moving toward a single-payer healthcare system, is proposed as the only viable solution to address these systemic issues.
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Regence BlueCross BlueShield of Utah’s denial of coverage for the FDA-approved cancer drug Perjeta, prescribed by a specialist for a patient’s breast cancer treatment, exemplifies a critical flaw in the healthcare system. This denial contradicts established clinical guidelines and expert consensus, forcing the family to potentially shoulder over $160,000 in out-of-pocket costs. This case highlights how insurance companies obstruct access to necessary life-saving treatments, leaving patients in a precarious situation. The urgent need for systemic reform, including universal healthcare, is underscored by this and countless similar experiences.
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The situation is truly disheartening: a medical student, facing a potentially life-threatening condition, is having her crucial medication denied by her insurance company. She reports that despite numerous attempts to get authorization, including submitting extensive documentation and appeals, the insurer, Blue Cross and Blue Shield of Kansas City, remains steadfast in its refusal to cover the medication, Promacta (Eltrombopag), for her immune thrombocytopenia.
This isn’t an isolated incident; many people share similar experiences with insurance companies putting profits over patients’ well-being. Stories abound of individuals forced into repeated emergency room visits for necessary treatments simply because their insurance company won’t cover the medication from an out-of-state pharmacy or insists on generic alternatives despite documented ineffectiveness or harmful side effects.… Continue reading
John Q. Hosedrinker 
Matt Underwood