美国为何存在医疗保险理赔拒绝问题？
Why The U.S. Has A Health Care Claim Denial Problem
译文简介
联合健康保险公司（UnitedHealthcare）一直是公众对健康保险行业日益不满的焦点。
正文翻译
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.
联合健康保险公司（UnitedHealthcare）一直是公众对健康保险行业日益不满的焦点。该公司首席执行官布赖恩·汤普森（Brian Thompson）在12月的 brutal 谋杀事件标志着一个转折点，加剧了对保险公司拒绝赔付的审视。尽管有大量报道指出理赔拒绝的情况日益增多，但由于系统碎片化，几乎无法追踪保险公司拒绝理赔的频率。对于大多数美国人来说，根本没有地方查询保险公司拒赔的比例。观看上面的影片了解更多信息。
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Notice that collecting the premium is never a problem.
注意到收取保费从来不是问题。
原创翻译：龙腾网 https://www.ltaaa.cn 转载请注明出处
In America , health is a business , and that is exaclty the problem. Healthcare should be a human RIGHT.
在美国，健康是一项生意，这正是问题所在。医疗保健应该是人权。
This is disgusting when you’re fighting for your life shouldn’t have to be fighting with insurance to get the care you need
当你在为生命而战时，应该不必与保险公司斗争以获得所需的护理，这太恶心了。
We need to remove the profit motive from health insurance.
我们需要将盈利动机从健康保险中剔除。
原创翻译：龙腾网 https://www.ltaaa.cn 转载请注明出处
When profit margins are more important than a life..
That's the plot of every hitman story
当利润比生命更重要时...
这就是每个职业杀手故事的情节
Healthcare bullies the sick and dying.
医疗保健欺负生病和垂死的人。
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.
我真高兴我不住在美国。四周前我以为自己中风了，打了急救电话，到了医院，做了CT和MRI扫描，幸运的是得到了完全确认。对我来说，全部费用为零。我在英国唯一需要支付的是我的国民保险缴款，比大多数美国人支付的保险费用要低得多，甚至如果你收入较低，你也会得到全额保障。
...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!
..似乎没和任何医生沟通过，除非我错过了什么。公众根本不知道医生们为了争取正确的治疗、药物和病人的正义需要经历什么。这太疯狂了！
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
这位视频编辑忽略了一个重要的事实，那就是制药公司通过游说将禁止医保谈判药品价格的法律推行。美国国会和制药行业应该为药品价格上涨负责。
Who would've thought the privatization of public health system would be a problem.
谁能想到公共卫生系统的私有化会成为一个问题。
Why ?? I’ll give you guys two very simple answer: Greed and Money.
为什么？我给你们两个非常简单的答案：贪婪和金钱。
原创翻译：龙腾网 https://www.ltaaa.cn 转载请注明出处
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，这正是我遇到的情况。他们一直拒绝我的手术，拒绝说我需要去找这个专家和那个专家，直到我终于见到外科医生时，已经拖了太久（三个月），他们告诉我那就像是重新把我的膝盖弄断一样。我的LCL已经以一个奇怪的角度愈合，并且形成了大量的瘢痕组织，他们得把它切除并重新修复，即使修复了，我还是得在10年内做膝关节置换手术，所以他们又一次拒绝了，说这样做没有帮助，我只需要等到膝关节置换的时候再说。之后我彻底放弃了。
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
我们美国人怎么变得这么愚蠢了？我们通过选举那些从健康公司拿钱为其服务的立法者，允许这种事情发生。
原创翻译：龙腾网 https://www.ltaaa.cn 转载请注明出处
In the USA healthcare is a profit model but should be a utility.
在美国，医疗保健是一个利润模型，但它应该是一个公共服务。
Medical insurance is the second most profitable industry in the entire world under oil that's all you need to know
医疗保险是全球第二大最赚钱的行业，仅次于石油，这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.
拒绝理赔的最大原因（占所有理赔的三分之一）是“没有给出理由”，而《平价医疗法案》要求保险公司提供拒绝理赔的理由。自《平价医疗法案》通过以来已经15年了，为什么保险公司没有因为这种明显缺乏透明度而被追责？“不符合医疗必要性”仅占拒绝的1%，但看起来应该是拒绝的主要原因，因为很多人似乎无法获得或负担得起医生开出的治疗。
The Chief Physician is most likely reading off a scxt from pre arranged questions. The fact hes from united healthcare is also very untrustworthy.
这位首席医生很可能在读预先安排好的问题脚本。再加上他来自联合健康公司，这让人非常不信任。
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??
解决方案非常简单。保险公司不应该拒绝任何理赔，除非是在可验证的欺诈案件中。如果怀疑有欺诈行为，首先需要彻底调查，如果发现欺诈行为，就需要对所有相关人员提起指控，只有在此之后才能拒绝理赔。
这将制止大量腐败，并挽救无数生命，包括首席执行官。但是你敢打赌这永远不会发生吗？
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.
很多美国人说他们生活在世界上最好的国家。其实并不是。但是，如果美国能从其他国家吸取经验，实施全民医保，它将迈出成为世界最好的国家之一的重要一步。
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.
我不明白为什么有人会在评论区为健康保险公司辩护。保险是一种储蓄基金，你和其他人支付保费，以便在困难时能使用它。所以，保险并不会因为政府控制它而改变。政府的全民医疗是一家非盈利组织，可以接受公民的审查，而私营医疗则完全以盈利为目的，而非关注公民。
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.
对我个人而言，拒绝理赔并不是问题，问题在于不透明，不知道某些治疗是否会被覆盖。在这些医院或诊所工作的接待员根本不知道他们在说什么，所以这些账单的突然出现是最大的烦恼。
U.S healthcare is three major cartels fighting over $: insurance, hospital systems, and providers.
美国的医疗保健系统是三个主要集团在争夺利益：保险公司、医院系统和医疗提供者。
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.
一位家庭成员需要进行一个突出椎间盘手术。手术中心核实了保险覆盖范围，并确认一切在网络内。预约是在感恩节后的星期一。
然而，在黑色星期五的邮件中收到了通知，说由于手术中心的地址不在网络内，手术未被批准，尽管医生是网络内的。由于是假期周末，电话无法联系上任何人来挑战这封信，整个周末都在为一项绝对需要的手术而焦虑。结果是一个人工智能公司犯了错误。
手术顺利进行，但随后收到的账单远高于预期。又是一次人工智能的错误，中心的工作人员不得不花费更多时间来纠正这个错误。真是浪费时间，我们的医疗系统就是被这些公司弄得一团糟。
我不明白为什么那么多美国人选择这种系统而不是全民医保。它令人焦虑、令人沮丧、不断变化、令人心碎、充满错误，而且费用高得离谱。试想一下，只需要去最近的医院或任何你选择的医生那里，就能获得你需要的治疗，不需要经历这么多复杂的手续和繁琐的工作。
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?
作为一名医生，我们没有时间去上诉或进行同行间的讨论。我们需要在电话上等待很长时间，才能和一个根本不是我们"同行"的人说话。如果他们决定如何处理病人，那我们取得医学学位又有什么用呢？
原创翻译：龙腾网 https://www.ltaaa.cn 转载请注明出处
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?
虽然从技术上讲，健康保险在法律上仍然是强制要求的，但没有保险的人不再面临罚款。这项更新的法律于2019年生效，使得个人强制保险条款变得不再相关。然而，一些州则实施了他们自己版本的个人强制保险条款，包括税收处罚。那么我想问，为什么人们还要为一个根本不提供服务的东西付钱？
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.
否认、拖延、剥夺。这是保险公司的座右铭。没有国家资助的医疗保健和价格监管使得美国的医疗保健非常昂贵。这个关键行业任由大型制药公司主宰，这些公司在制造阿片类药物成瘾危机中扮演了可疑的角色。它们还通过放松监管与监管者合作，为有害产品赢得批准。
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
因为健康保险公司贪婪且以利润为驱动；这很简单。而且非常令人沮丧，因为没有简单的解决方案。全民医保也有严重问题。
The root is a "health care problem," not a "health care denial problem." And the two issues are very different.
根本问题是“医疗保健问题”，而不是“医疗保健拒绝问题”。这两个问题非常不同。
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.
我不理解美国的健康保险。一个人可能支付了25年的健康保险费，然后需要用到保险时，可能会因自付费用而破产。想想看，一个50岁的人每月支付1000美元，扣除额是9000美元，这可能是每年21,000美元。哦，对了，它每年都会重新开始。如果你在生死边缘无法继续支付保险费，你可能会失去保险，即使你已经支付了25年的健康保险。
The Constitution gives us the right to life, liberty and the pursuit of happiness. Healthcare is a right. You can’t live without healthcare.
宪法赋予我们生命、自由和追求幸福的权利。医疗保健是基本权利，没有医疗保健你无法生存。
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.
两年前我做了膝盖软骨移植手术。医生告诉我，我需要使用CPM机器来确保我体内移植的软骨能被接受并且没有疤痕组织。但保险公司告诉我，因为我没有更换人工关节，所以这不算医学上必需的。我为三个月使用该设备支付了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.
这就是当一个国家太穷而无法提供医疗保健时的情况，而且仅有的其他国家就是巴布亚新几内亚。很高兴我生活在一个人道且理智的国家。美国的口号应该是“你的健康是我们的生意，而不是我们的关心”，这样更诚实。
I love how CNBC made this video about denials and explaining the possible reasons why, but we all know it's human greed.
我喜欢CNBC做了这个视频，讲解拒绝赔付的原因和可能的原因，但我们都知道，归根结底是人类的贪婪。
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!
为什么保险公司要走到这种极端拒绝赔付的地步？如果保险公司员工和管理层不把自己的工作仅仅看作是“做我的工作”，那么Luigi事件就不必发生了。所谓的“做我的工作”会对患者和家庭产生真实的后果。这里有很多其他工作，员工本可以选择，但他们却选择为这些保险公司工作，协助拒绝患者的护理。保险公司的员工和医疗主管（特别是那些在保险公司拥有最终决定权的医疗主管）将个人的利润/财富置于患者的福祉之上。没有任何借口可言。这些员工选择为保险公司工作，就是为了自己的钱包。没有人会被迫去做伤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。我们这里有一个全民医保系统，这意味着无论贫富，所有医疗费用都是由税收支付的。美国人经常告诉我，我们的税比他们高，这是真的，但当你从“所有费用都是由公民支付”这个原则出发时，你就明白了。所以，我缴纳税款。美国人也缴纳税款。但他不能享受免费医疗。他必须购买保险（你看，这让他们的费用增加），因此，很多人负担不起。所以，如果所有费用最终都是由公民支付，为什么美国的保险公司却能获得巨额利润？我们将你们支付给这些公司的利润，用于我们的健康。
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.
你必须是道德上彻底腐化，才能在今天的医疗或保险行业生存。我建议任何涉及这些行业的人，都好好照照镜子，反思一下你在多少人的生命上造成了伤害，而不是帮助了多少生命。
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.
作为一个加拿大人，我现在在欧洲和英国度假，因为我真的害怕在美国生病或发生意外。我会购买一份不错的保险。在美国，医院的账单简直是乱开，可能我还得费力去和他们争辩。至少我知道在海外，账单基本上就是成本价。
原创翻译：龙腾网 https://www.ltaaa.cn 转载请注明出处
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!
我最讨厌的是他们告诉我必须先去看全科医生，才能去看专科医生，而我明明已经知道自己有什么问题。我不需要把我断了的胳膊带去看全科医生再告诉我它断了，然后才能去看骨科医生！
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.
在我看来：拒赔的情况得不到上诉，因为这个过程依赖医生来做，而他们不会得到额外的时间、补偿或奖励。额外的障碍被设置为使上诉过程繁琐、不便且耗时，因此医生最终会放弃。医院集团看中有私人保险的病人，因为他们支付的费用明显高于医疗保险设定的公正标准。医院为所有服务谈判高额费用，因为他们网络中的至少一位保险公司会支付这些虚高的费用。而自费或被拒赔的病人则会被这些虚高的费用“碾压”。美国医疗费用比其他所有国家都要高的原因就在于，这些钱全都被私人保险公司和医院集团 siphon 走了。如果能切换到全民医疗保险，这些问题一夜之间就能解决，但要想让国会放弃那么多丰厚的游说资金和竞选资金，简直是不可能的。