alt Hacker News> Insurance is already required to cover preventive care services which are justified by a clear cost-benefit analysis at no cost to the patient.
I am clearly not saying they literally don’t cover any preventative care. I think most people agree that insurance companies’ idea of what is “justified” is far too narrow. What is “clear” is also often very opaque. That’s the issue I’m pointing to. US health insurance is a terrible experience.
And who cares if the analysis costs me nothing? Why is that something I should be grateful for?
Most people don't understand the system well enough to even have an informed opinion on the subject. Commercial insurance companies get a lot of criticism for denying claims or prior authorization requests, and some of that criticism is well deserved due to errors or artificial friction. But for the most part they make very few decisions about what care is justified.
At a first level the federal government publishes a set of medically unlikely edits used to deny claims when procedure codes don't align with diagnosis codes. It's used by Medicare, and most Medicaid agencies and commercial health plans have also adopted it.
https://www.cms.gov/medicare/coding-billing/national-correct...
At the next level most commercial health plans have adopted clinical care guidelines published by vendors like MCG. These vendors take publications from specialist medical societies and codify them to determine what's medically justified and set step therapy requirements.
https://www.mcg.com/solutions/care-guidelines/
At the final level, providers can appeal denials to human nurses and doctors who do case review at insurance companies (peer-to-peer). In a huge healthcare system there are always patients with unique needs who don't fit the pattern in published care guidelines. Dealing with those appeals is a major administrative burden and often badly managed on both sides of the adversarial interaction.
Most US-based HN users are on commercial self-funded group health plans sponsored by their employers. The Affordable Care Act (ACA / Obamacare) establishes a baseline for what's covered but ultimately the decisions are made by employer HR departments. Insurance companies would be happy to offer custom health plans that paid every claim at 100% with zero denials or prior authorization requirements; it would mean less work and higher profits for them. But no employer wants to pay for that so the insurance companies take measures to hold down costs.