Cohere Health – using AI to delay and deny care to hit an 18% return on investment.
How is that patient care first? It’s not.
I only recently learned that Humana is using a third-party company to process claims while they issue prior authorizations. So just how many millionaires and billionaires are getting OUR Medicare tax dollars to live high on the hog, while we ration care and food? I know for a fact United Healthcare has two private jets on our taxpayer dime.
First of all, I had bilateral lumbar ablations, and Humana issued a prior authorization BEFORE I had the procedure. That means my doctor “proved” I needed the care, and they gave him permission to proceed.
Months later, the bill was denied. That means the insurance company is GOING BACK on the prior authorization and refusing to pay. Something I watched: the former CEO of United Healthcare, Sir Andrew Witty, testified before the Senate that they NEVER go back on prior authorizations. What the hell do you call refusing to pay the bill? They think we are fools.
So then the person with Humana tasked to help me says that Cohere may refuse to talk to her. Are you kidding me? She was the agent, but wasn’t sure she could get answers. She was able to find out that, according to Cohere Health, my doctor didn’t prove I needed it, so they denied the bill.
If you feel like a wide-eyed cartoon character staring into the nothingness trying to understand this mess, I don’t blame you. But I fought back, and eventually they reversed the denial and paid the bill.
Since the beginning of the year, I have been sending in my therapy bills and receipts, as practically no therapists take insurance anymore in my area. They needed too many employees whose sole jobs were to fight insurance denials, so they gave up and switched to private pay. My own therapist would share that her former group got to the point where they had to hire a new billing staffer to do nothing all day but Blue Cross Blue Shield denials. That was the straw that broke the back of that office. I’m lucky I can pay the bill and still get carel so very many others can not.
With a 70% suicide rate in my community, patients with CRPS (Complex Regional Pain Syndrome), fighting to get mental health therapy can be life or death.
So I have been mailing in my bills, and they have disappeared into the void. Somehow, all the bills I mailed in, and those my provider mailed in for me, never got entered. How do you appeal what doesn’t exist? It’s enough to drive anyone insane.
Now I finally have someone receiving my bills via email, and I had to fight to get that. Here I am, near the end of October, and I’m still fighting to get my January therapy session covered.
Then I get a message telling me my Humana policy doesn’t cover telehealth appointments, according to Cohere, which is total BS. So I fight back and show them their own website that not only encourages me to use telehealth, but tries to get me to see THEIR doctors! So what they are trying to do is close the loop and keep all the money. What does that mean for me?
I don’t matter now. I can’t make the rich richer or serve them anymore in Emergency Medical Services, so I guess it’s better to deny and delay my care, maybe in hopes that I die sooner. As if I need help in that department. As if I don’t already look like I’m dying when you read my chart. My biopsy results say that I shouldn’t be able to walk at all. As if I need any more stress, any more reason for my blood pressure to be dangerous.
So I fight back again and send Humana screenshots of their own website for my policy showing that I have telehealth coverage, and I show proof they have covered prior telehealth claims from their own website!
Now they say, “Oops, my bad,” we will process the claims now as soon as I resend receipts, so I send them. Then another request for yet another claim and receipt that has been sent ten times over.
All of the for-profit so-called “health” insurance companies do these things in order to hang on to their money. We don’t matter; their grotesque greed does. Simply put, health insurance companies serve no purpose in medicine. They are a useless middleman sucking off the taxpayers to enrich themselves. Doctors at the bedside, not AI, should be making healthcare decisions. They do nothing to increase positive outcomes in healthcare, but do plenty to cause suffering and death. We need to be honest and realize it is the greatest fleecing of Americans.
Most people wouldn’t hang in this long, or would just give up when told nope, not covered, because the people on the other end of the phone are supposed to know this. Instead, you have to be your own expert, your own advocate, and your own life saver.
So stick it out, don’t quit, “don’t let the bastards get you down.”
If you need help filing an appeal, contact the Denial Defenders
Tired of all of this? Join the union, The Patients Union; visit patients.org
You are not alone.