美國為何存在醫(yī)療保險理賠拒絕問題？
Why The U.S. Has A Health Care Claim Denial Problem
譯文簡介
聯(lián)合健康保險公司（UnitedHealthcare）一直是公眾對健康保險行業(yè)日益不滿的焦點。
正文翻譯
UnitedHealthcare has been at the center of growing public frustration with the health insurance industry. The brutal killing of its CEO, Brian Thompson, in December marked a turning point, intensifying scrutiny over insurers' denial of coverage. Despite numerous reports highlighting a rise in claim denials, the fragmented system makes it nearly impossible to track how often insurers reject claims. For most Americans, there's no place to look up insurer denial rates. Watch the video above to learn more.
聯(lián)合健康保險公司（UnitedHealthcare）一直是公眾對健康保險行業(yè)日益不滿的焦點。該公司首席執(zhí)行官布賴恩·湯普森（Brian Thompson）在12月的 brutal 謀殺事件標志著一個轉(zhuǎn)折點，加劇了對保險公司拒絕賠付的審視。盡管有大量報道指出理賠拒絕的情況日益增多，但由于系統(tǒng)碎片化，幾乎無法追蹤保險公司拒絕理賠的頻率。對于大多數(shù)美國人來說，根本沒有地方查詢保險公司拒賠的比例。觀看上面的影片了解更多信息。
評論翻譯
很贊 ( 4 )
收藏
Notice that collecting the premium is never a problem.
注意到收取保費從來不是問題。
原創(chuàng)翻譯：龍騰網(wǎng) http://top-shui.cn 轉(zhuǎn)載請注明出處
In America , health is a business , and that is exaclty the problem. Healthcare should be a human RIGHT.
在美國，健康是一項生意，這正是問題所在。醫(yī)療保健應(yīng)該是人權(quán)。
This is disgusting when you’re fighting for your life shouldn’t have to be fighting with insurance to get the care you need
當(dāng)你在為生命而戰(zhàn)時，應(yīng)該不必與保險公司斗爭以獲得所需的護理，這太惡心了。
We need to remove the profit motive from health insurance.
我們需要將盈利動機從健康保險中剔除。
原創(chuàng)翻譯：龍騰網(wǎng) http://top-shui.cn 轉(zhuǎn)載請注明出處
When profit margins are more important than a life..
That's the plot of every hitman story
當(dāng)利潤比生命更重要時...
這就是每個職業(yè)殺手故事的情節(jié)
Healthcare bullies the sick and dying.
醫(yī)療保健欺負生病和垂死的人。
I’m so glad I don’t live in the US. Four weeks ago I thought I was having a stroke. Called an ambulance, got to hospital, had CT and MRI scans and fortunately given the all clear. Total cost to me, nothing. All I pay in the UK is my National Insurance contributions which is a lot lower than most Americans pay in insurance and even if you’re low payed you’re fully covered.
我真高興我不住在美國。四周前我以為自己中風(fēng)了，打了急救電話，到了醫(yī)院，做了CT和MRI掃描，幸運的是得到了完全確認。對我來說，全部費用為零。我在英國唯一需要支付的是我的國民保險繳款，比大多數(shù)美國人支付的保險費用要低得多，甚至如果你收入較低，你也會得到全額保障。
...didnt talk to any physicians, unless I missed it. The public has no clue what doctors have to go through to fight for the right treatment, right medication, and justice for patients. Its madness!
..似乎沒和任何醫(yī)生溝通過，除非我錯過了什么。公眾根本不知道醫(yī)生們?yōu)榱藸幦≌_的治療、藥物和病人的正義需要經(jīng)歷什么。這太瘋狂了！
What this video editor neglects to discuss is that pharma lobbied into law a ban on Medicare negotiating down drug prices. Congress and pharmaceutical industry is to blame for higher drug costs in the US
這位視頻編輯忽略了一個重要的事實，那就是制藥公司通過游說將禁止醫(yī)保談判藥品價格的法律推行。美國國會和制藥行業(yè)應(yīng)該為藥品價格上漲負責(zé)。
Who would've thought the privatization of public health system would be a problem.
誰能想到公共衛(wèi)生系統(tǒng)的私有化會成為一個問題。
Why ?? I’ll give you guys two very simple answer: Greed and Money.
為什么？我給你們兩個非常簡單的答案：貪婪和金錢。
原創(chuàng)翻譯：龍騰網(wǎng) http://top-shui.cn 轉(zhuǎn)載請注明出處
When I tore my ACL in my LCL in 2022 this is exactly what happened to me. They kept denying my surgery and denying my surgery saying that I needed to go to this specialist and that specialist by the time I actually got to see the surgeon. It had been too long(3 month) and it was explained to me that it would be like breaking my knee all over again. my LCL had found itself but on a weird angle and created a bunch of scar tissue and they would have to cut it out and redo it and even if they did, I would still need a knee replacement within 10 years so they denied it again stating that it wouldn’t help and that I just need to wait till I need the knee replacement. After that after that I gave up.
2022年我撕裂了我的ACL和LCL，這正是我遇到的情況。他們一直拒絕我的手術(shù)，拒絕說我需要去找這個專家和那個專家，直到我終于見到外科醫(yī)生時，已經(jīng)拖了太久（三個月），他們告訴我那就像是重新把我的膝蓋弄斷一樣。我的LCL已經(jīng)以一個奇怪的角度愈合，并且形成了大量的瘢痕組織，他們得把它切除并重新修復(fù)，即使修復(fù)了，我還是得在10年內(nèi)做膝關(guān)節(jié)置換手術(shù)，所以他們又一次拒絕了，說這樣做沒有幫助，我只需要等到膝關(guān)節(jié)置換的時候再說。之后我徹底放棄了。
Why have we Americans gotten so stupid? We are allowing this to happen by voting for legislators who take money from health companies to do their bidding
我們美國人怎么變得這么愚蠢了？我們通過選舉那些從健康公司拿錢為其服務(wù)的立法者，允許這種事情發(fā)生。
原創(chuàng)翻譯：龍騰網(wǎng) http://top-shui.cn 轉(zhuǎn)載請注明出處
In the USA healthcare is a profit model but should be a utility.
在美國，醫(yī)療保健是一個利潤模型，但它應(yīng)該是一個公共服務(wù)。
Medical insurance is the second most profitable industry in the entire world under oil that's all you need to know
醫(yī)療保險是全球第二大最賺錢的行業(yè)，僅次于石油，這就是你需要知道的全部。
The top category (1/3 of all claims) for denying a claim was "no reason given," and yet the ACA required insurance companies to provide a reason for denying claims. It's been 15 years since the ACA was passed, so why are insurance companies not being held responsible for this obvious lack of transparency? "Not medically necessary" is only 1% of rejections and yet it seems like that should be the top reason listed for a rejection given how frequently people seem to be unable to receive or afford care their doctor prescribes.
拒絕理賠的最大原因（占所有理賠的三分之一）是“沒有給出理由”，而《平價醫(yī)療法案》要求保險公司提供拒絕理賠的理由。自《平價醫(yī)療法案》通過以來已經(jīng)15年了，為什么保險公司沒有因為這種明顯缺乏透明度而被追責(zé)？“不符合醫(yī)療必要性”僅占拒絕的1%，但看起來應(yīng)該是拒絕的主要原因，因為很多人似乎無法獲得或負擔(dān)得起醫(yī)生開出的治療。
The Chief Physician is most likely reading off a scxt from pre arranged questions. The fact hes from united healthcare is also very untrustworthy.
這位首席醫(yī)生很可能在讀預(yù)先安排好的問題腳本。再加上他來自聯(lián)合健康公司，這讓人非常不信任。
The solution to this is VERY simple. Insurance companies should NOT be allowed to deny ANY claims, except in cases of verifiable fraud. In cases where fraud is suspected, they need to investigate it thoroughly FIRST, then if fraud is found, charges need to be filed against any and all involved, and only then can you deny the claim.
That would put a stop to SO much corruption, and save SO many lives, CEOs included. But how much you wanna bet it would NEVER happen??
解決方案非常簡單。保險公司不應(yīng)該拒絕任何理賠，除非是在可驗證的欺詐案件中。如果懷疑有欺詐行為，首先需要徹底調(diào)查，如果發(fā)現(xiàn)欺詐行為，就需要對所有相關(guān)人員提起指控，只有在此之后才能拒絕理賠。
這將制止大量腐敗，并挽救無數(shù)生命，包括首席執(zhí)行官。但是你敢打賭這永遠不會發(fā)生嗎？
A lot of Americans say they live in the best country in the world. It’s not. However, if US learned from other countries and incorporated universal healthcare, it will take a huge leap towards being among the best.
很多美國人說他們生活在世界上最好的國家。其實并不是。但是，如果美國能從其他國家吸取經(jīng)驗，實施全民醫(yī)保，它將邁出成為世界最好的國家之一的重要一步。
I don’t understand why people defend health insurance companies in the comment section. Insurance is a savings fund that you and others pay a premium for so that you can have access to it at hard time. So, insurance does not change just because the government controls it. Government universal health care is a non profit organization that can be scrutinized by its citizens while private healthcare is all about profit, not about its citizens.
我不明白為什么有人會在評論區(qū)為健康保險公司辯護。保險是一種儲蓄基金，你和其他人支付保費，以便在困難時能使用它。所以，保險并不會因為政府控制它而改變。政府的全民醫(yī)療是一家非盈利組織，可以接受公民的審查，而私營醫(yī)療則完全以盈利為目的，而非關(guān)注公民。
For me personally, the denial isn't the problem, so much as it is the opacity and nor knowing if something will or won't be covered. The receptionists working in these hospitals or clinics never know what they are saying and so he surprise nature of these bills are the biggest annoyance.
對我個人而言，拒絕理賠并不是問題，問題在于不透明，不知道某些治療是否會被覆蓋。在這些醫(yī)院或診所工作的接待員根本不知道他們在說什么，所以這些賬單的突然出現(xiàn)是最大的煩惱。
U.S healthcare is three major cartels fighting over $: insurance, hospital systems, and providers.
美國的醫(yī)療保健系統(tǒng)是三個主要集團在爭奪利益：保險公司、醫(yī)院系統(tǒng)和醫(yī)療提供者。
A family member needed a surgery for a bulging spinal disc. The surgery center checked everything about insurance coverage and confirmed everything was in network. Appointment was for the Monday after Thanksgiving.
一位家庭成員需要進行一個突出椎間盤手術(shù)。手術(shù)中心核實了保險覆蓋范圍，并確認一切在網(wǎng)絡(luò)內(nèi)。預(yù)約是在感恩節(jié)后的星期一。
然而，在黑色星期五的郵件中收到了通知，說由于手術(shù)中心的地址不在網(wǎng)絡(luò)內(nèi)，手術(shù)未被批準，盡管醫(yī)生是網(wǎng)絡(luò)內(nèi)的。由于是假期周末，電話無法聯(lián)系上任何人來挑戰(zhàn)這封信，整個周末都在為一項絕對需要的手術(shù)而焦慮。結(jié)果是一個人工智能公司犯了錯誤。
手術(shù)順利進行，但隨后收到的賬單遠高于預(yù)期。又是一次人工智能的錯誤，中心的工作人員不得不花費更多時間來糾正這個錯誤。真是浪費時間，我們的醫(yī)療系統(tǒng)就是被這些公司弄得一團糟。
我不明白為什么那么多美國人選擇這種系統(tǒng)而不是全民醫(yī)保。它令人焦慮、令人沮喪、不斷變化、令人心碎、充滿錯誤，而且費用高得離譜。試想一下，只需要去最近的醫(yī)院或任何你選擇的醫(yī)生那里，就能獲得你需要的治療，不需要經(jīng)歷這么多復(fù)雜的手續(xù)和繁瑣的工作。
As a physician, we do not have time to appeal and do peer to peer. We are on the phone for a long time just to speak to someone who is not really our "peer". What use is it to get our medical degree if they dictate how we take care of our patients?
作為一名醫(yī)生，我們沒有時間去上訴或進行同行間的討論。我們需要在電話上等待很長時間，才能和一個根本不是我們"同行"的人說話。如果他們決定如何處理病人，那我們?nèi)〉冕t(yī)學(xué)學(xué)位又有什么用呢？
原創(chuàng)翻譯：龍騰網(wǎng) http://top-shui.cn 轉(zhuǎn)載請注明出處
Although technically, health insurance is still required by law, uninsured individuals no longer face fines. This upxed law took effect in 2019, making the individual mandate irrelevant. Some states, however, enacted their versions of the individual mandate, which includes tax penalties. Then I ask, why are people paying for something that does not provide the service?
雖然從技術(shù)上講，健康保險在法律上仍然是強制要求的，但沒有保險的人不再面臨罰款。這項更新的法律于2019年生效，使得個人強制保險條款變得不再相關(guān)。然而，一些州則實施了他們自己版本的個人強制保險條款，包括稅收處罰。那么我想問，為什么人們還要為一個根本不提供服務(wù)的東西付錢？
Deny,delay,depose. This is the motto of insurance companies. Absence of state funded healthcare and price regulation makes healthcare very expensive in the US. This critical sector is left to the whims of big pharma which is dubious for its role in creation of an opioid addiction crisis in the country. Its also responsible for playing loose with regulators and winning clearances for their harmful products.
否認、拖延、剝奪。這是保險公司的座右銘。沒有國家資助的醫(yī)療保健和價格監(jiān)管使得美國的醫(yī)療保健非常昂貴。這個關(guān)鍵行業(yè)任由大型制藥公司主宰，這些公司在制造阿片類藥物成癮危機中扮演了可疑的角色。它們還通過放松監(jiān)管與監(jiān)管者合作，為有害產(chǎn)品贏得批準。
Because health insurance companies are greedy and profit-driven; it's pretty simple. And it's so frustrating, because there is no easy solution. Universal health care has serious issues too
因為健康保險公司貪婪且以利潤為驅(qū)動；這很簡單。而且非常令人沮喪，因為沒有簡單的解決方案。全民醫(yī)保也有嚴重問題。
The root is a "health care problem," not a "health care denial problem." And the two issues are very different.
根本問題是“醫(yī)療保健問題”，而不是“醫(yī)療保健拒絕問題”。這兩個問題非常不同。
I don't understand America health insurance. A person can pay for health insurance for 25 years, then needs it, and go broke due to out of pockets expenses. Think about it, a 50 years old person pays $1000.00 per month with a $9000.00 deductible that's a possible $21,000.00 per years. Oh, yes, it starts again everyday year. You can lose your insurance while on your death bed it you can't continue paying your 25 years + health insurance.
我不理解美國的健康保險。一個人可能支付了25年的健康保險費，然后需要用到保險時，可能會因自付費用而破產(chǎn)。想想看，一個50歲的人每月支付1000美元，扣除額是9000美元，這可能是每年21,000美元。哦，對了，它每年都會重新開始。如果你在生死邊緣無法繼續(xù)支付保險費，你可能會失去保險，即使你已經(jīng)支付了25年的健康保險。
The Constitution gives us the right to life, liberty and the pursuit of happiness. Healthcare is a right. You can’t live without healthcare.
憲法賦予我們生命、自由和追求幸福的權(quán)利。醫(yī)療保健是基本權(quán)利，沒有醫(yī)療保健你無法生存。
I had a cartilage transplant in my knee 2 years ago. The doctor told me I needed to use a CPM machine to make sure the cartilage that they put in would be taken by my body and not have any scar tissue. Insurance told me that it was not medically necessary because I did not get any artificial joints replaced. I paid $900 for the three months I used it.
兩年前我做了膝蓋軟骨移植手術(shù)。醫(yī)生告訴我，我需要使用CPM機器來確保我體內(nèi)移植的軟骨能被接受并且沒有疤痕組織。但保險公司告訴我，因為我沒有更換人工關(guān)節(jié)，所以這不算醫(yī)學(xué)上必需的。我為三個月使用該設(shè)備支付了900美元。
This is what happens when your country is too poor to have healthcare besides, the only other country Papua new Guinea . Glad I live in a humane and sane country . America's slogan should be your health care is our business not our concern it would be more honest.
這就是當(dāng)一個國家太窮而無法提供醫(yī)療保健時的情況，而且僅有的其他國家就是巴布亞新幾內(nèi)亞。很高興我生活在一個人道且理智的國家。美國的口號應(yīng)該是“你的健康是我們的生意，而不是我們的關(guān)心”，這樣更誠實。
I love how CNBC made this video about denials and explaining the possible reasons why, but we all know it's human greed.
我喜歡CNBC做了這個視頻，講解拒絕賠付的原因和可能的原因，但我們都知道，歸根結(jié)底是人類的貪婪。
Why insurnace has to go that far on denials? Luigi didn't have to happen if insurance companies employees and managements don't just see their work as merely "doing my job".
Their so called "doing my job" has real life consequences to patients and families.
There are plenty of other jobs out there where these employees could have worked for, but instead, they choose to work for and assist these insurance companies to deny patient care.
These insurance companies' employees and MEDICAL DIRECTORS (Especially the insuance companies' Medical Directors who has the ULTIMATE DECISION TO deny patient care cases) choose their self-profit/wealth over patients welfare.
There is no play-arounds with words. Those employees choose to work for insurnace companies for their own pockets $$. No one can be forced to take a job where "doing my job" will hurt vulnerable patients and other people!
為什么保險公司要走到這種極端拒絕賠付的地步？如果保險公司員工和管理層不把自己的工作僅僅看作是“做我的工作”，那么Luigi事件就不必發(fā)生了。所謂的“做我的工作”會對患者和家庭產(chǎn)生真實的后果。這里有很多其他工作，員工本可以選擇，但他們卻選擇為這些保險公司工作，協(xié)助拒絕患者的護理。保險公司的員工和醫(yī)療主管（特別是那些在保險公司擁有最終決定權(quán)的醫(yī)療主管）將個人的利潤/財富置于患者的福祉之上。沒有任何借口可言。這些員工選擇為保險公司工作，就是為了自己的錢包。沒有人會被迫去做傷害脆弱患者和其他人的工作！
I am Canadian. We have a universal health care system here, which means that from the poorest to the richest, all health care is paid for by taxes.
Americans often tell me that we pay much more taxes than they do, and it's true, but when you start from the principle that everything is paid for by the citizen without a doubt. So, I pay taxes.
An American pays taxes. But he is not entitled to free care. He must take out insurance (do you see that it increases their cost) and so, a large number of people cannot afford it.
So, if everything is always paid for by the citizen, why do insurance companies make huge profits in the American way? We, everything you give in profit to these companies, we use it for our health.
我是加拿大人。我們這里有一個全民醫(yī)保系統(tǒng)，這意味著無論貧富，所有醫(yī)療費用都是由稅收支付的。美國人經(jīng)常告訴我，我們的稅比他們高，這是真的，但當(dāng)你從“所有費用都是由公民支付”這個原則出發(fā)時，你就明白了。所以，我繳納稅款。美國人也繳納稅款。但他不能享受免費醫(yī)療。他必須購買保險（你看，這讓他們的費用增加），因此，很多人負擔(dān)不起。所以，如果所有費用最終都是由公民支付，為什么美國的保險公司卻能獲得巨額利潤？我們將你們支付給這些公司的利潤，用于我們的健康。
You basically have to be morally bankrupt to exist anywhere in the medical or insurance industry today.. I recommend anybody involved in these industries to take a long look at yourself in the mirror and reflect on how many lives you ruined in relation to how many lives you could’ve helped.
你必須是道德上徹底腐化，才能在今天的醫(yī)療或保險行業(yè)生存。我建議任何涉及這些行業(yè)的人，都好好照照鏡子，反思一下你在多少人的生命上造成了傷害，而不是幫助了多少生命。
As a Canadian, I holiday in Europe and the UK now since I shudder at getting sick or having an accident in the USA. And I carry decent insurance. Hospitals in the USA just dream up their bills which I may or may not have to fight. At least I know overseas the bill is essentially at cost.
作為一個加拿大人，我現(xiàn)在在歐洲和英國度假，因為我真的害怕在美國生病或發(fā)生意外。我會購買一份不錯的保險。在美國，醫(yī)院的賬單簡直是亂開，可能我還得費力去和他們爭辯。至少我知道在海外，賬單基本上就是成本價。
原創(chuàng)翻譯：龍騰網(wǎng) http://top-shui.cn 轉(zhuǎn)載請注明出處
What I hate the most is when they tell me to see a GP in order to pay a specialist when I already know what’s wrong. I don’t need to take my broken arm to a GP just to tell me it’s broken so I can go to an orthopedist!
我最討厭的是他們告訴我必須先去看全科醫(yī)生，才能去看?？漆t(yī)生，而我明明已經(jīng)知道自己有什么問題。我不需要把我斷了的胳膊帶去看全科醫(yī)生再告訴我它斷了，然后才能去看骨科醫(yī)生！
In my opinion: Denials are not appealed because the process depends on the doctors to do it, and they get no additional time, compensation, or incentive to do so. Additional roadblocks are installed to make the appeal process onerous, inconvenient, and time consuming to the doctor, so they eventually just give up. Hospital conglomerates salivate over privately insured patients because they get paid significantly more than the fair rates established by Medicare. Hospitals negotiate inflated rates for all their services, because at least one insurer in their network will pay the inflated rate. Self pay or claims-denied patients then get absolutely annihilated when being billed these inflated rates. There's a reason why American healthcare costs so much when compared to all other countries - all of that money is being siphoned off by private insurers and hospital conglomerates. All of these problems could go away overnight by switching to Medicare for all, but good luck getting congress to turn down all of that juicy lobby money and campaign funding.
在我看來：拒賠的情況得不到上訴，因為這個過程依賴醫(yī)生來做，而他們不會得到額外的時間、補償或獎勵。額外的障礙被設(shè)置為使上訴過程繁瑣、不便且耗時，因此醫(yī)生最終會放棄。醫(yī)院集團看中有私人保險的病人，因為他們支付的費用明顯高于醫(yī)療保險設(shè)定的公正標準。醫(yī)院為所有服務(wù)談判高額費用，因為他們網(wǎng)絡(luò)中的至少一位保險公司會支付這些虛高的費用。而自費或被拒賠的病人則會被這些虛高的費用“碾壓”。美國醫(yī)療費用比其他所有國家都要高的原因就在于，這些錢全都被私人保險公司和醫(yī)院集團 siphon 走了。如果能切換到全民醫(yī)療保險，這些問題一夜之間就能解決，但要想讓國會放棄那么多豐厚的游說資金和競選資金，簡直是不可能的。