alt Hacker NewsComplaints about denied claims or prior authorization requirements should generally be directed at employer HR departments. Most HN users in the USA probably have employer-sponsored group health plans, and often those are self-funded where the insurance company doesn't actually bear any risk but just administers the plan. Commercial insurers would be happy to sell plans that pay every claim that comes in at 100% with zero denials. It would be less work for them. But naturally employers don't want to pay for that, so the HR departments have the insurance carriers impose more restrictive coverage rules to hold down medical expenses.
> Commercial insurers would be happy to sell plans that pay every claim that comes in at 100% with zero denials. It would be less work for them. But naturally employers don't want to pay for that, so the HR departments have the insurance carriers impose more restrictive coverage rules to hold down medical expenses.
This is not my experience as a buyer of health plans on healthcare.gov, or as a buyer of health plans as an employer (where the employer is not self insuring). The prior authorizations and denials happen all the same.
Additionally, the premiums are the same between employers’ self insured plans and healthcare.gov plans, so the coverage must be similar.
https://www.kff.org/health-costs/how-aca-marketplace-costs-c...
>In 2024, individual market insurance premiums averaged $540 per member per month, slightly below the average $587 per member per month premium for fully-insured employer coverage.
The idea that health insurers can simply spend more to earn more is not passing the smell test.