Insurance Companies DON'T Want You Seeing This

[00:00:00]Today, I'm going to show you guys real-world examples that is proof of how health insurance companies are ripping all of us off, guys. For years, I've been talking about how insurance in general is a scam because the entire insurance business model is you pay in a bunch of money, and the goal of the insurance company is to almost guarantee that you'll never get any of that money back. And that is through lots of sneaky things in their contracts on what's covered and what isn't. All that's constantly changing and evolving, constantly raising your premiums in order to collect more. And a lot of these things I'm going to show you guys come directly from people who either work for health insurance companies or people who work for doctors' offices and have seen a lot of the sinister things that are happening behind the scenes, okay? How about this? Insurance companies will fax paperwork to a facility or call families late on a Friday afternoon to stop coverage to sue. They do it because they know the facility workers have already left and that it won't be appealed. Then families have to come in and workers have to stay late just to fax all the appeals before the short window closes. So, they're doing this intentionally to try to make sure that you don't get a payout. That's a simple tactic like and and also the fact that things still go through facts is an absolute joke. That's something that never makes sense to me, you know, in the age of 2026 and high-speed internet and artificial intelligence and all of these amazing things we supposedly have going on that anything still works off of facts. But, that's all designed to slow you down and to make sure you don't get paid. When I worked in social work, I found a senior living facility in one of the poorest neighborhoods where basically every resident was enrolled in the same awful WellCare HMO with a horrible provider network. Half didn't know they'd even been enrolled. The other half said they were told their doctors were still in network when they weren't. It was extremely predatory and insane to see.

[00:02:10]I'm sure the rep who signed up that whole building got a nice commission check. So, here you have a senior living facility that already costs an arm and a leg for you to move into even in probably a crappy one like this one.

[00:02:25]Everybody's in the HMO network and HMOs are notoriously the worst insurance type uh to have. Had the most limited options, limited care, all that stuff. And then they get lied to and say their doctors are in network when they're not. And meanwhile, the person who sold this plan to all of these elderly people gets to walk away with a big fat paycheck. Guys, if that's not predatory, I don't know what is.

[00:02:52]I saw an ALS treatment medication get denied and delayed for a young mom of four. She died while fighting for a medication that could have helped prolong her life. Disgusting. That is disgusting. You know, these companies are so greedy and don't want to pay for anything to the point where people actually die trying to get the medicine they need to stay alive. Guys, that is just wrong and if something like that happens, these companies should be 100% liable and should have to pay the families of these victims hundreds of millions of dollars. This one says, "I did billing for 15 years and evidence-based treatments got denied as experimental or investigational every single day. Medication formulas change yearly, so patients stable on one medication suddenly have to prove all over again why they need it. Then comes the prior authorization and the appeal and 3 to 5 months of not being treated properly. Then, there's the administrative BS, lost paperwork, claims denied for timely filing, records that weren't received even when they were in the same envelope as the appeal, and peer-to-peer reviews with providers who don't know your specialty. So, this is all just like a big game of confusion on purpose in case you don't notice.

[00:04:14]Like, the whole idea is to lose things, confuse things, make you run through hoops and jump through as many hoops as possible to get what you need in the hopes that eventually you just die or give up. And clearly, based on the previous example, unfortunately, that does happen to people. And today, I am in the Creekside neighborhood here in Larkspur. And it's just so beautiful.

[00:04:38]They have these little walking paths through the actual townhouse community.

[00:04:44]Insurance will try to save money when it costs far more later. A geriatric patient needed a $200 medication to be discharged home. Insurance denied it, so the patient stayed in the hospital an extra week at a cost of about $10,000.

[00:05:00]They do this all the time, and it drives doctors nuts. And this is kind of stupid, guys. I mean, this is totally avoidable. Why would you want to spend 10 grand to save $200? It absolutely makes no sense. And the people who are in charge and making these decisions clearly have lost their minds. This one says, "A patient had suicidal ideation with a plan and intent to immediately end his life upon discharge from a psych hospital, and insurance entered a denial." Of course, he wasn't discharged because we aren't in the business of sending people off to die. I'm convinced they were okay with him dying since he was probably costing them a ton in claims. I mean, that lines up with everything we just said over the past two points. Like they are intentionally kind of killing people but getting away with it. This is all legal. None of these people are charged with murder, negligence, or anything like that. They just get to deny people's claims that end up costing them their lives for one reason or another.

[00:06:16]I'm a speech language pathologist and insurance once recouped over $2,000, which was an entire years worth of therapy for a kid with autism caused by a genetic syndrome because they don't cover autism. The child's main disability was the syndrome. Autism was one symptom. She was non-verbal and severely injuring herself out of frustration. She made major improvements after a year of speech therapy, but they didn't care. They just took back the money. Once again, what do they care if you're actually healthy or not? If the insurance plan is actually working for you the way that is supposed to. They don't. All they care about is the bottom line and increasing shareholder profits.

[00:06:59]That's what corporations are legally designed to do. Never forget that.

[00:07:04]Filing claims, okay, filing limits are huge. You usually have to file claims within a set window like 60 days, but insurance companies will sometimes sit on a claim for days or weeks. Other times we would backdate things to make them look compliant or change the receive date because we could and you had no way to prove it. I was once an investigator looking for ways to deny claims and this was one of my best tricks. Don't worry, I eventually left the business and came back to the light side of the force. I mean, this is somebody who was working for one one companies who openly admits that their only job was to find a way to deny your claim, guys. I mean, what more proof do you need than that if you ask me? If you have people out there admitting this, I don't think you need to hear anything else. But yet, there's still people out there who will rave and say they love their insurance company.

[00:08:00]And if it wasn't for health insurance, this or this or that would have happened to me. Like, yeah, maybe some people have their feel-good stories about it, but that is not as you can see. I'm in ambulance billing, and one thing that makes me furious is when insurance reprocesses and recoups years after the date of service. Sometimes two or even three years later. We don't have contracts with insurance companies, so it's usually left to the patient. We're talking about someone getting billed thousands of dollars for something that happened years ago. Why is there no statute of limitations on this? There's so many things that should be regulated in this case, you know? Because if they can't be trusted to do the right thing, which clearly they cannot be, then there should be a limit. You want to bill somebody for an ambulance ride, you have 6 months tops. You don't bill it after that, you eat that cost. That's on you.

[00:08:54]This one says you'll be upcharged for every little thing. The one I remember the most was pulse oximeter readings.

[00:09:01]The little clip that goes on your finger when you go to the doctor's office or hospital. I work for a physician who billed that at $100 for every patient. I also heard from the office manager that he used to charge for weighing people on the scale. I mean, this stuff is just obscene, guys. The fact that any of this is even happening blows my mind. How about this? Insurance companies can access your electronic medical records in some cases. Healthcare systems also share lab results, diagnoses, smoking status, screening results, and other information. It's done under the guise of quality and population health, but payers and third parties can monetize that data. They don't just get data on the care that they paid for. Your health history can be there for them to see.

[00:09:47]Another perfect example of the wrong people getting their hands on your data.

[00:09:53]During Medicare open enrollment, the reps will straight-up lie and tell patients our clinic is in network with a plan when we're not. Medicare Advantage reps are often seasonal and some are just hustling to boost their enrollment numbers. Yes, some are willing to lie to seniors and disabled people to make a quick buck. It is so easy to get scammed in the medical field, guys. I've had a lot of horror stories myself about being billed for things I shouldn't have been billed for and every time this happens, who has to deal with it? Who has to deal with the nightmare of getting the refund or getting the bill removed? It's always on you. So, all the extra stress it causes, all the extra time that it takes is a joke. And the American medical system is a joke. This one says, "I work on the sales side and the lack of regulation and consequences is infuriating. There are so many scumbag agents lying to customers and selling them crappy plans that don't protect them. Nothing is done. Agents hardly ever face consequences, so they keep doing it. So, you know, it's really hard to trust anybody in this business. You know, I've always been the type of person who believes that you don't deserve my trust unless you prove that you deserve it. And I basically treat everybody like that, especially when it's somebody I don't know or just met and there's no exceptions to that rule for me. It's just how I've always operated because people like this exist.

[00:11:21]Medicare Advantage is a scam, especially in the Midwest or rural areas. Your healthcare choices are restricted by networks, so if you need care at a larger hospital, there's a good chance it's out of network and will cost a ton.

[00:11:37]Regular Medicare with a supplement is much better. You can go to any hospital, see any doctor, skip referrals, and know your out-of-pocket costs up front. This is something that I would never know, guys. This is not me sitting here telling you. This is some industry insider telling you this. So, go ahead and rewind that part as many times you need to to understand it if you're somebody who is on Medicare and is tired of dealing with the problems that we just talked about. One of my least favorite situations is when a patient somehow gets enrolled in a 100% subsidized marketplace plan they don't understand and never use. Medicaid doesn't reflect the plan for years, so the patient thinks they only have Medicaid. Then the Medicaid MCO finds the ghost policy, recoups claims from 5 years ago, and the marketplace plan, which never paid a claim and just collected subsidized premiums, denies everything for failure to file on time.

[00:12:39]It's happened in our hospital at least five times. This one says Medicare Advantage kept assigning co-insurance to a patient well past their out-of-pocket maximum with an EOB note saying it couldn't be billed to the patient because Medicaid was secondary. The catch? Medicaid coverage was limited to birth control care, so it didn't cover her cancer treatment. More than $10,000 in chemo treatment and drugs went unpaid, and they doubled and tripled down on appeals. It wasn't just lost reimbursement, the office had already paid for those chemo drugs. As a provider, it's wild that an insurance company can use AI to deny coverage or hire someone with zero medical background to decide treatment isn't medically necessary. They can take premiums while patients assume their bills will be covered, then deny care in ways that can cause death or seriously reduce quality of life. They also pay providers less, demand tons of extra documents, and withhold payment for months or randomly deny coverage. This is coming from a doctor. You know, doctors are kind of caught up in this insurance nightmare as well, guys. Like the doctors, think about probably 90% of all doctors business it comes directly from the insurance companies. They're constantly dealing with this BS, too.

[00:14:02]And then of course a lot of doctors are part of the problem as well. And once again, you just can't trust anybody. You know who I actually trust the most are doctors that don't accept insurance at all. There are some doctors out there that perform treatments and run operations that don't deal with insurance. And I don't blame them number one for not dealing with them. And then the good thing that about them is why you can trust those doctors more in my opinion is cuz they don't have an incentive to bill you for every little thing because they don't have to try to recoup their costs through the insurance companies. So they figure out fair prices for their services and they just charge accordingly. Something that doctors who accept insurance just can't do. Insurance reps will tell patients the provider billed something wrong and that if we rebill with a different code it'll get paid. Then patients call us demanding we correct our error. But sometimes the service simply isn't covered. Custom foot orthotics, for example, are commonly excluded. Patients will say, "Insurance said they'll cover it if you bill it as medically necessary." But I work in podiatry and I always tell people it would be fraud if I fix the bill that way. So, you know, they kind of put the pressure on the doctors to bill things as fraud, which I'm sure they can get in a lot of trouble for and lose their medical license or worse because of that. And then they make the patients call in and put that extra pressure on them. Also, the insurance companies can get away without paying you once again.

[00:15:38]I own a small psych clinic, and even providers get caught in this. We had a new client with Lifewise Insurance, which we accept and verified eligibility through Availity. We submitted the claim, and it was denied as out of network. Apparently, Lifewise has three plans, and we were only in network with two. Instead of billing the client, we ate the cost of that appointment and requested to be added to the third plan for future visits. Now, that is a very nice doctor's office just offering to do something like that, and not putting the pressure on the patient for once, and actually eating the cost. Guys, I'm sure those stories like this probably rarely, if ever, happen. I had an outpatient procedure with an in-network physician at an in-network hospital. Then I got a bill from the anesthesiologist, and insurance said the anesthesiologist was out of network and not covered. I wrote them a nasty message because I didn't choose that anesthesiologist and had no way of knowing they were out of network. Thankfully, I never received more notices. Another way that they try to scam you guys, they try to say, "Oh, well, even the facility you're at is in network, the doctor here is not in network." And that's a whole 'nother scam they got going on. And you know, a lot of people say, "Oh, you have to have health insurance because what if you end up in the ER? There's an emergency."

[00:17:06]Well, guess what? During an emergency, probably the last thing on your mind is if the doctors who are treating you are in network. You know, you're sitting there dying, and then to sit there and sit up for a minute. "Oh, wait a minute.

[00:17:17]Are you a network? Oh, no. Okay, just let me go. I mean, this is the type of madness that people are facing right now in this country. As a claims examiner, medical biller since 2012, I've seen eligibility confirmed multiple times, multiple authorizations given, and treatment provided in good faith based on those authorizations, only for the plan to be rescinded months later.

[00:17:42]Suddenly, the patient is 100% responsible for medically necessary treatment that had already been authorized. If eligibility is truly in question, authorization should be paused until it's verified, not approved and reversed after care is given. I totally agree, guys. Just another way to scam you. And this is all from medical providers saying this. This isn't me saying this. People who work in this field every day and deal with these shenanigans on a daily basis are coming out and openly admitting this stuff. And I wish I could tell you there was like an easy way to avoid all this, but unfortunately, there isn't. I think the only way to avoid it is to not have insurance and you pay everything out of pocket cash and there's no surprise bills, there's no this is covered and that's not covered sort of thing. But then, of course, you're leaving yourself open to a big surprise medical expense if you get really sick or end up in the hospital or whatever. But even then, with insurance, you're not guaranteed to be covered, guys, just like homeowner's insurance. One hospital put language in doctors' and nurses' contracts saying they had to recommend the hospitals' outpatient doctors and testing services and couldn't recommend outside providers. Their imaging labs had months-long wait times, while other places could perform the same test within days. Patients who followed their doctors' referral had their diagnosis and care severely delayed. And your nurse or your doctor isn't going to tell you that they have this stipulation in their contract. Maybe they will, but what incentive do they have to tell you, you know? Not much, unless they're actually a caring person and are in the doctor business for the right reasons.

[00:19:25]What do they care? So, I don't know, guys. You let me know in the comments if you've had experiences even worse than this. Also, feel free to put your positive experiences in the comments as well. So, that way people don't lose all hope on health insurance like I have.

[00:19:43]I'm borderline considering just getting rid of health insurance altogether, even though this year I'm saving quite a bit on my health insurance compared to last year. I'm just not satisfied with the runaround, guys. I am tired of it just like everybody else in this in this story. I'm dealing with the same problems that everybody else has to deal with when you want to have something covered, and even when you go to a doctor that things are supposed to be covered, then you find out later on that, well, there's little things in this that aren't covered, or this is going to cost you extra. It's just like I'm so done with it, man. I really am.

[00:20:19]One of my goals has been for the last few years to eliminate things in my life that cause me extra stress and don't add any value to my life, and I'm starting to think that health insurance is on that list. Let me know what you think.

[00:20:32]So, if you guys enjoyed this video, make sure you subscribe to the channel, and if you don't want to wait for my next video to come out, check out this one on the screen right over here, and I'll see you in the next one.