Yuwipi Woman
Whack-A-Mole Queen
Indeed, that same largest provider is, from what I can tell, actually too large (don't think its illegal but they're pushing their luck) and has a bunch of associated entities where the relationship isn't quite clear. One such entity offered off-market no prior authorization plans, a huge deal for certain treatments.
For thw past couple of years my wife would get call after call about their retrospective utilization reviews, where they'd essentially deny treatment after the fact and demand money back that they'd agreed to pay. Problem is Texas actually has some ok laws here, they can't deny or review more than x days after treatment, maybe 30, and if they don't pay there's and automatic fine levied paid to the provider. Either they never bothered to look up the applicable state law or they just figured that so few people would call them on it that it'd be worth it, and we're talking about treatments that easily cost more than the premiums and max out of pocket 60-150k a year, so I understand that it's not a sustainable business model for them, but at the same time they're part of a multibillion dollar conglomerate that turns a profit year in year out. As far as she could tell these reviews are systematic and either triggered by paying a certain amount for a certain treatment or just hitting a certain amount of spend on the enrollee, which isn't legal iirc but also kinda hard to prove without years of work.
They've done things like getting non-doctors to oppose doctors opinions and then moved to getting general doctors to oppose multiple specialists determinations. They've gone so far as to have their assessors actually contact the enrollees parents, without properly explaining who they were or the nature of the communication, to find any possible reason to deny. She's hurt them through the automatic fines on a few occasions, gotten back a lot of money for providers. Shes gone so far as asking for a conference with their attorneys to try and teach them the law. Didnt happen. But we know there's a ton more of this going on and she's only one person. She tried to train another attorney to get this stuff but the law is apparently pretty dense and a lot of the subject matter just inherently dull and complex.
This is why for-profit healthcare will never work. The more care they can get away with denying, the more money they can pocket for themselves. The incentive system is all wrong if the goal is to have a healthy population. It works quite well if the goal is to rake off as much money as possible and to hell with anyone else.