Of course insurance companies will be using AI to send out these denials. They can’t find enough humans with the heart of their CEO’s to continue to do the work. And shareholders just put their head in the sand! I’ve known several people who have quit that job because they could not take the guilt any longer.
when our corrupt lawmakers have set up a system whereby the worst consequence of such practices for the insurers is that they have to ultimately pay the claim (nothing more or punitive that would serve to disincentivize these shenanigans), what do we really expect to happen? i don’t even blame the players, i blame the irreparably corrupt game-makers (the us govt). watching them (members of Congress) pretend to be shocked or angry about the very predictable results of the system THEY create/protect during their sham hearings is what really gets me fuming.
I thank goodness that I never needed hospitalization until I was on Medicare. Five days in the hospital plus a procedure and I didn't have to pay a single cent. We need Medicare for All, and send these insurers to the ash heap of history.
That $490,000 is figured by liars. The same liars that have lobbied over the last 60 years that allowed our health care system to transfer $79 trillion from working class to wealthy 1%.
$490,000 definitely seems excessive for the care delivered. And the denial by the insurance company also is ridiculous. The insurer and provider need to come to an agreement as to what is a reasonable charge, and then the insurer process the claim on that amount, based on the plan's provisions.
The entire healthcare ecosystem is rapacious and morally bankrupt.
Horrendous. And keep in mind that the subject of this story is a retired doctor who had the time, resources, and knowledge of the medical system to allow her to dive into what turned out to be a deliberately (by Anthem) prolonged battle. What does that say for the rest of Americans who get caught up in these endless loops of greed?
For anyone in NY, you file an online complaint with Department of Financial Services for insurance disputes. It is an easy process to file. I have done it many times as a provider and I encourage my patients to file as well. It is amazing how fast things can be solved when we complain to DFS. Sometimes just telling the person on the phone that we are about to file a complaint with DFS gets our issue resolved. Funny that.
Insurance denials are rampant and this extreme example is particularly egregious. However there is an AI solution that I wrote about earlier this year. It's called Counterforce Health AI. It's a free AI program that has a success rate in excess of 70% in overturning Insurance denials. Details are in my interview of the product's creator, Neal K Shah.
The article was good until you blamed Republicans for failing to renew the temporary subsidies. The real issue is that the insurance companies deny 20% of claims on the ACA exchange. That has nothing to do with the party that didn't vote for the insurance subsidy bill, AKA the ACA.
Mr Potter would have us believe he is fighting for a better healthcare system. However, why doesn't he include in his post the fact that the insurer LACKED the authority to dertemine Medical Necessity for Ms. Talley. Only the doctor on the scene (the ATTENDING physician) can make that determination. However, by getting Ms Talley to argue the issue of Medical Necessity, the insurer took Dr. Talley's eye completely off the ball, while gaving the insurer a clear path to denying coverage and payment.
I am always amazed by how quick Mr. Potter is to report the horors of our healthcare system, while remaining completely silent on where insurers are WRONG on the law. And, please Mr. Pottrer, if I am wrong on the determination on Medical Necessity or anything else, "PLEASE" correct me!
Lastly, as long as we continue giving insurers rights that they just don't have, we willl remain easy victims for the health insurance industry. Read the book "The Big Lie in My Healthcare Bill" from Amazon to learn what we are actually owed from our health insurance. Learn how to play this increasingly dishonest game and win.
The One Big Beautiful Bill (OBBB) cuts, timed to be after the election and start beginning of 2027, are a separate part of the cuts from the ACA on-exchange cuts (that happened 1/1/26 due to the lapse of the ACA expanded subsidies). The OBB cuts affect mostly people on the expanded-Medicaid half of the ACA, rather than the on-exchange half.
I, myself, predict massive technical foul ups when that starts, since 51 separate state and D.C. Medicaid agencies, many under-resourced and not that technically adept, have to deal with new work requirements, and more frequent (twice a year minimum) Medicaid eligibility checks.
I want to point people to a NY Times article of yesterday indicating the administration is making the work-requirements verification, in the case of people with medical issues, more difficult.
Frankly, it looks pretty bleak to me. The damage to the ACA that has been done is quite substantial, and the earliest possible attempt to reverse this would seem to be Jan 20, 2029. (Assuming all elections work out.)
Forgive me. This is substantially redundant with prior comments on HEALTH CARE un-covered.
Still, I want to put down this precise version of it, because it makes clear that there is at least one case of data that has usually been released on the ACA on-exchange coverage numbers, that has not been released by CMS.
(Thus, if it were unemployment data or inflation data that is regularly released, a thousand economists would point out the absence of data.
In this case, policy-wonky Charles Gaba caught it, and from reading his Substack, I am now aware.
I don’t know if anyone else is aware!)
(The policy issue in focus in the comment is of the lapse of the ACA expanded subsidies that the Republicans made happen on 1/1/26, and the loss of coverage from that, which numbers are starting to roll in on, which look pretty large.
As well, leaked information exists that the coverage losses have become evident to CMS internally. And that CMS is planning a misleading propagandistic response, claiming that the losses are due mainly to the administration's successful crackdown on ACA fraud.)
--
So, on the ACA expanded subsidies that were allowed to lapse 1/1/26, data has been starting to roll in from non-federal sources showing something like 3 to 5 million people, of 24 million who had coverage on the ACA exchanges in 2025, losing coverage.
This information available to the public is part of the new data that continuously rolls in from non-federal non-CMS sources, as initial very limited open-enrollment-period only data, which counts people auto-renewed as having coverage, even if they don't wind up paying the premium, gets superseded. (That limited initial data showed only a 4.9% enrollment drop for those 24 million.)
(Incidentally, you can find out about all of these coverage losses, information on which is still rolling in, the most quickly if you subscribe to Charles Gaba, ( https://charlesgaba.substack.com/ ), where his posts contain each bit of information usually on the same day it becomes available.)
In any case, after releasing the initial open-enrollment-period data for 2026 showing only a 4.9% drop in enrollment, with the big defect in the data that people who wind not paying the premium are not counted as dropping coverage, I don't believe anything has been released by CMS (Dr. Oz's Center for Medicaid and Medicare Services, which also manages the ACA).
The much larger coverage-drop numbers indicated in the KFF and NY Times reports, counting people not paying premiums as dropping, have come from other sources. (State exchanges, KFF surveys, and a major consulting company report with access to insurance company data.)
So, has the CMS been blocking the release of information on the coverage drops?
Charles Gaba actually caught one case where the data, usually presented as part of a report on Medicare and Medicaid and CHIP, was omitted.
"Until now, the summary report also included a brief mention of total effectuated ACA marketplace enrollment in Qualified Health Plans (QHPs), rounded off to the nearest 100,000. As of December effectuated enrollment was ~21.8 million people.
However, starting this month, this data point is missing...and that’s not by accident; it includes this footnote:
As of the January 2026 data, Marketplace enrollment data are no longer included in this report but will be available separately soon."
So, we may already have a case of data usually made available being suppressed.
Otherwise, on the data within CMS, I don't know if they usually release it and are holding it back, but we know they have it. Further, they appear to be preparing to falsely claim the coverage drops are due to reduction of fraud on the exchange.
The source is this recent NOTUS story by former Washington Post Reporter Paige Winfield Cunningham, which post seems to access leaked information from people inside of CMS:
"More than one in five people who enrolled in health insurance through http://healthcare.gov/ during open enrollment and in the weeks immediately following were dropped from coverage for failing to pay their first month’s premium, according to internal Centers for Medicare and Medicaid Services, or CMS, documents obtained by NOTUS that haven’t been made public.
The roughly 21% decline in enrollment in the 30 states using the federal marketplace is significantly higher than the rate of last year, when 12% of enrollees dropped off over the same time frame.
The numbers support widespread fears that the end of extra, pandemic-era subsidies, which congressional Republicans declined to extend in December, would leave Affordable Care Act plans unaffordable for some Americans.
Faced with such a stark drop in enrollment, leadership at CMS, which is led by Administrator Mehmet Oz, is seeking to attribute a majority of the enrollment declines to rooting out fraud rather than people not paying their premiums, according to three CMS sources. The sources said it’s unlikely fraud is behind most of the cancellations."
Charles conclusion is that it looks like, of 24 million people who had on-exchange ACA coverage, about 3 million (12%) are without coverage as of the current time this year, due to the lapsing of the ACA expanded subsidies on Jan 1, 2026.
--
I might as well toss this in, for those interested. I think there is starting to be evidence of the erroneous claims coming that the coverage drops are due to the administration stopping fraud on the ACA exchanges, emanating from Dr. Oz and the Paragon Health Institute. To save space, for those interested, its in a comment elsewhere, this one:
Thanks for the article. It demonstrates yet another reason to be wary of health insurance. Which is why your criticism of a Republican led Congressional failure to extend ACA coverage makes no sense to me. Using third party intermediaries, whether for profit or not, between health service (I cannot even identify it as health care anymore) providers and their patients is insane. It is a failed system if the goal is ethical treatment of human beings. And the health service providers did it to themselves. So IMO those scurrilous Republicans in Congress did the right thing.
Even if we acknowledge that the insurance company is in the wrong here, there is no way that a system that pays $490,000 to take care of a broken arm is sustainable
Of course insurance companies will be using AI to send out these denials. They can’t find enough humans with the heart of their CEO’s to continue to do the work. And shareholders just put their head in the sand! I’ve known several people who have quit that job because they could not take the guilt any longer.
when our corrupt lawmakers have set up a system whereby the worst consequence of such practices for the insurers is that they have to ultimately pay the claim (nothing more or punitive that would serve to disincentivize these shenanigans), what do we really expect to happen? i don’t even blame the players, i blame the irreparably corrupt game-makers (the us govt). watching them (members of Congress) pretend to be shocked or angry about the very predictable results of the system THEY create/protect during their sham hearings is what really gets me fuming.
I thank goodness that I never needed hospitalization until I was on Medicare. Five days in the hospital plus a procedure and I didn't have to pay a single cent. We need Medicare for All, and send these insurers to the ash heap of history.
Support Medicare for ALL acts now.
That $490,000 is figured by liars. The same liars that have lobbied over the last 60 years that allowed our health care system to transfer $79 trillion from working class to wealthy 1%.
$490,000 definitely seems excessive for the care delivered. And the denial by the insurance company also is ridiculous. The insurer and provider need to come to an agreement as to what is a reasonable charge, and then the insurer process the claim on that amount, based on the plan's provisions.
The entire healthcare ecosystem is rapacious and morally bankrupt.
Horrendous. And keep in mind that the subject of this story is a retired doctor who had the time, resources, and knowledge of the medical system to allow her to dive into what turned out to be a deliberately (by Anthem) prolonged battle. What does that say for the rest of Americans who get caught up in these endless loops of greed?
For anyone in NY, you file an online complaint with Department of Financial Services for insurance disputes. It is an easy process to file. I have done it many times as a provider and I encourage my patients to file as well. It is amazing how fast things can be solved when we complain to DFS. Sometimes just telling the person on the phone that we are about to file a complaint with DFS gets our issue resolved. Funny that.
Insurance denials are rampant and this extreme example is particularly egregious. However there is an AI solution that I wrote about earlier this year. It's called Counterforce Health AI. It's a free AI program that has a success rate in excess of 70% in overturning Insurance denials. Details are in my interview of the product's creator, Neal K Shah.
https://helenemepstein.substack.com/p/solutions-to-two-of-healthcares-most?
The article was good until you blamed Republicans for failing to renew the temporary subsidies. The real issue is that the insurance companies deny 20% of claims on the ACA exchange. That has nothing to do with the party that didn't vote for the insurance subsidy bill, AKA the ACA.
Mr Potter would have us believe he is fighting for a better healthcare system. However, why doesn't he include in his post the fact that the insurer LACKED the authority to dertemine Medical Necessity for Ms. Talley. Only the doctor on the scene (the ATTENDING physician) can make that determination. However, by getting Ms Talley to argue the issue of Medical Necessity, the insurer took Dr. Talley's eye completely off the ball, while gaving the insurer a clear path to denying coverage and payment.
I am always amazed by how quick Mr. Potter is to report the horors of our healthcare system, while remaining completely silent on where insurers are WRONG on the law. And, please Mr. Pottrer, if I am wrong on the determination on Medical Necessity or anything else, "PLEASE" correct me!
Lastly, as long as we continue giving insurers rights that they just don't have, we willl remain easy victims for the health insurance industry. Read the book "The Big Lie in My Healthcare Bill" from Amazon to learn what we are actually owed from our health insurance. Learn how to play this increasingly dishonest game and win.
And she will get better coverage in Europe too!
Sick care is Oakstreet endorsed by aarp crooks.
AI is influenced by human lobbyists.
Often the people that find ways to deny claims are promptly promoted.
The One Big Beautiful Bill (OBBB) cuts, timed to be after the election and start beginning of 2027, are a separate part of the cuts from the ACA on-exchange cuts (that happened 1/1/26 due to the lapse of the ACA expanded subsidies). The OBB cuts affect mostly people on the expanded-Medicaid half of the ACA, rather than the on-exchange half.
I, myself, predict massive technical foul ups when that starts, since 51 separate state and D.C. Medicaid agencies, many under-resourced and not that technically adept, have to deal with new work requirements, and more frequent (twice a year minimum) Medicaid eligibility checks.
I want to point people to a NY Times article of yesterday indicating the administration is making the work-requirements verification, in the case of people with medical issues, more difficult.
That's here:
https://www.nytimes.com/2026/06/01/upshot/trump-medicaid-work-requirements.html
--
Frankly, it looks pretty bleak to me. The damage to the ACA that has been done is quite substantial, and the earliest possible attempt to reverse this would seem to be Jan 20, 2029. (Assuming all elections work out.)
Forgive me. This is substantially redundant with prior comments on HEALTH CARE un-covered.
Still, I want to put down this precise version of it, because it makes clear that there is at least one case of data that has usually been released on the ACA on-exchange coverage numbers, that has not been released by CMS.
(Thus, if it were unemployment data or inflation data that is regularly released, a thousand economists would point out the absence of data.
In this case, policy-wonky Charles Gaba caught it, and from reading his Substack, I am now aware.
I don’t know if anyone else is aware!)
(The policy issue in focus in the comment is of the lapse of the ACA expanded subsidies that the Republicans made happen on 1/1/26, and the loss of coverage from that, which numbers are starting to roll in on, which look pretty large.
As well, leaked information exists that the coverage losses have become evident to CMS internally. And that CMS is planning a misleading propagandistic response, claiming that the losses are due mainly to the administration's successful crackdown on ACA fraud.)
--
So, on the ACA expanded subsidies that were allowed to lapse 1/1/26, data has been starting to roll in from non-federal sources showing something like 3 to 5 million people, of 24 million who had coverage on the ACA exchanges in 2025, losing coverage.
This information available to the public is part of the new data that continuously rolls in from non-federal non-CMS sources, as initial very limited open-enrollment-period only data, which counts people auto-renewed as having coverage, even if they don't wind up paying the premium, gets superseded. (That limited initial data showed only a 4.9% enrollment drop for those 24 million.)
There is a nice 5/19/2026 KFF report that summarizes the higher post-open-enrollment-report drops, looking to be 3 to 5 million, here https://www.kff.org/affordable-care-act/what-we-know-so-far-about-2026-aca-marketplace-enrollment-premiums-and-deductibles/ )
There is also a very good NY Times story, from a few weeks before the KFF report, showing similar numbers, from similar sources:
https://www.nytimes.com/2026/05/01/business/obamacare-enrollment-decline.html .
(Incidentally, you can find out about all of these coverage losses, information on which is still rolling in, the most quickly if you subscribe to Charles Gaba, ( https://charlesgaba.substack.com/ ), where his posts contain each bit of information usually on the same day it becomes available.)
In any case, after releasing the initial open-enrollment-period data for 2026 showing only a 4.9% drop in enrollment, with the big defect in the data that people who wind not paying the premium are not counted as dropping coverage, I don't believe anything has been released by CMS (Dr. Oz's Center for Medicaid and Medicare Services, which also manages the ACA).
The much larger coverage-drop numbers indicated in the KFF and NY Times reports, counting people not paying premiums as dropping, have come from other sources. (State exchanges, KFF surveys, and a major consulting company report with access to insurance company data.)
So, has the CMS been blocking the release of information on the coverage drops?
Charles Gaba actually caught one case where the data, usually presented as part of a report on Medicare and Medicaid and CHIP, was omitted.
Charles reports on that here: https://charlesgaba.substack.com/p/cms-posts-january-2026-medicaid-chip
Quoting Charles:
"Until now, the summary report also included a brief mention of total effectuated ACA marketplace enrollment in Qualified Health Plans (QHPs), rounded off to the nearest 100,000. As of December effectuated enrollment was ~21.8 million people.
However, starting this month, this data point is missing...and that’s not by accident; it includes this footnote:
As of the January 2026 data, Marketplace enrollment data are no longer included in this report but will be available separately soon."
So, we may already have a case of data usually made available being suppressed.
Otherwise, on the data within CMS, I don't know if they usually release it and are holding it back, but we know they have it. Further, they appear to be preparing to falsely claim the coverage drops are due to reduction of fraud on the exchange.
The source is this recent NOTUS story by former Washington Post Reporter Paige Winfield Cunningham, which post seems to access leaked information from people inside of CMS:
https://www.notus.org/healthcare/aca-healthcare-dropped-insurance-numbers-subsidies
Quoting that:
"More than one in five people who enrolled in health insurance through http://healthcare.gov/ during open enrollment and in the weeks immediately following were dropped from coverage for failing to pay their first month’s premium, according to internal Centers for Medicare and Medicaid Services, or CMS, documents obtained by NOTUS that haven’t been made public.
The roughly 21% decline in enrollment in the 30 states using the federal marketplace is significantly higher than the rate of last year, when 12% of enrollees dropped off over the same time frame.
The numbers support widespread fears that the end of extra, pandemic-era subsidies, which congressional Republicans declined to extend in December, would leave Affordable Care Act plans unaffordable for some Americans.
Faced with such a stark drop in enrollment, leadership at CMS, which is led by Administrator Mehmet Oz, is seeking to attribute a majority of the enrollment declines to rooting out fraud rather than people not paying their premiums, according to three CMS sources. The sources said it’s unlikely fraud is behind most of the cancellations."
(I and other readers of Charles Gaba's substack were pointed to the leaked information in NOTUS by his post: https://charlesgaba.substack.com/p/breaking-cms-admits-over-30-million )
Charles conclusion is that it looks like, of 24 million people who had on-exchange ACA coverage, about 3 million (12%) are without coverage as of the current time this year, due to the lapsing of the ACA expanded subsidies on Jan 1, 2026.
--
I might as well toss this in, for those interested. I think there is starting to be evidence of the erroneous claims coming that the coverage drops are due to the administration stopping fraud on the ACA exchanges, emanating from Dr. Oz and the Paragon Health Institute. To save space, for those interested, its in a comment elsewhere, this one:
https://econjared.substack.com/p/why-are-people-so-damn-mad/comment/261555717
Thanks for the article. It demonstrates yet another reason to be wary of health insurance. Which is why your criticism of a Republican led Congressional failure to extend ACA coverage makes no sense to me. Using third party intermediaries, whether for profit or not, between health service (I cannot even identify it as health care anymore) providers and their patients is insane. It is a failed system if the goal is ethical treatment of human beings. And the health service providers did it to themselves. So IMO those scurrilous Republicans in Congress did the right thing.
490k for a badly broken arm seems like a lot.
Even if we acknowledge that the insurance company is in the wrong here, there is no way that a system that pays $490,000 to take care of a broken arm is sustainable