r/PatientPowerUp 24d ago

Explanation of each party involved in the US medical insurance system and how they interact or influence each other

3 Upvotes

Please give corrections or ask follow-up questions as needed.

Employers set up insurance packages for employees. The employers typically use other companies called Brokers to negotiate rates with insurance. Brokers may have other services like meeting with employees to advise them on which types if insurance to take. The broker typically gets commission from the insurance company for each policy sold.

Carriers are the actual insurance companies. The broker may advise an employer to use different carriers for each benefit (each type of insurance). So medical could be BlueCross while pharmacy is CVS. Different companies for different insurance types. Brokers also advise employers when to change carriers, so your insurance carriers could change every year.

Providers are anyone who gives healthcare related service, which could be an individual doctor/therapist/etc or it could be a larger entity like a laboratory, pharmacy, and so on.

Provider Networks are the set of all providers who signed contracts with the carrier to follow that insurance companies' rules. Technically the carrier doesn't control clinical decisions, but in reality it creates financial incentive for providers to discourage services, since patients often can't afford uncovered services (i.e. the provider risks not getting paid). This is where things like "prior authorization" come from for example.

Claims are notification to the carrier that they need to pay for a patient's procedure/drug/etc. The amount paid varies based on the contract between carrier and provider as well as the contract between patient and carrier (aka the benefit).

Clearinghouses are data hubs. Providers send claims here to get routed to the next appropriate entity. They generally charge per transaction, say $0.15 per claim. But they make money by having millions of claims flow through.

Pharmacy Benefit Managers (PBM) are companies that act as administrative assistants to pharmacies. They handle numbers and paperwork while the actual pharmacy focus on dispensing.

Third Party Administrators (TPA) also act as administrative assistants but with broader purpose than a PBM. The TPA works with every other player, the employer, the broker, the carrier, the PBMs, other TPAs... They do things like track which employees are eligible for which benefit, send out insurance cards, track claims and how much is spent, etc.

Vertical Integration is when a parent company owns more than one of the above entity types. For example, CVS Health owns the CVS pharmacies, the CaremarkRx PBM, and Aetna health insurance.


r/PatientPowerUp 1d ago

GPT-5 outperforms licensed human experts by 25-30% and achieves SOTA results on the US medical licensing exam and the MedQA benchmark

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4 Upvotes

r/PatientPowerUp 2d ago

GPT-5 outperformed doctors on the US medical licensing exam

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3 Upvotes

r/PatientPowerUp 2d ago

Violated of HIPAA and advanced directive

7 Upvotes

https://chng.it/gWBdJnyGZZ

This petition ismy only recourse against the PA that left me with a second brain injury


r/PatientPowerUp 3d ago

Most US neurologists prescribing MS drugs have received pharma industry cash | Nearly 80% of US neurologists prescribing drugs for multiple sclerosis (MS) received at least one pharma industry payment, with higher volume prescribers more likely to be beneficiaries, 5 year study finds

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3 Upvotes

r/PatientPowerUp 3d ago

Evidence that hospital employees in the US feel justified in abusing patients despite WHO guidelines

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6 Upvotes

r/PatientPowerUp 3d ago

Verbal approach to involuntary psych patients

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5 Upvotes

r/PatientPowerUp 4d ago

The End of Medical Credentialism?

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open.substack.com
5 Upvotes

r/PatientPowerUp 5d ago

Founder of Google's Generative AI Team Says Don't Even Bother Getting a Law or Medical Degree, Because AI's Going to Destroy Both Those Careers Before You Can Even Graduate

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futurism.com
5 Upvotes

r/PatientPowerUp 5d ago

Same Service, Different Price: Trilliant Health Report Reveals Unexplainable Differences in Actual Healthcare Prices | Morningstar

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3 Upvotes

r/PatientPowerUp 7d ago

Ozempic sued for $2 billion for causing blindness and stomach complications.

3 Upvotes

r/PatientPowerUp 8d ago

High charge at urgent care

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3 Upvotes

r/PatientPowerUp 10d ago

A $101,000 knee replacement? Why hospital charges vary so much.

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usatoday.com
1 Upvotes

r/PatientPowerUp 11d ago

200 dollar bill for refusing an ambulance

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7 Upvotes

r/PatientPowerUp 12d ago

AI Is the New Dr Google — Across the Globe

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medscape.com
3 Upvotes

r/PatientPowerUp 12d ago

Good bill

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3 Upvotes

r/PatientPowerUp 13d ago

A visit to the ER costs her $100k

12 Upvotes

r/PatientPowerUp 14d ago

Full office visit co-pay charged for MyChart message

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3 Upvotes

r/PatientPowerUp 15d ago

My mom had a stroke; that's the BEST part of what happened next. HCA Healthcare gave us medical missteps, refusal to provide records for an Adult Protective Services case, and legal evasion. An HCA Healthcare facility held my mom hostage for over half of her remaining life

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7 Upvotes

r/PatientPowerUp 16d ago

The other UHC!

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6 Upvotes

r/PatientPowerUp 17d ago

AI will transform the doctor-patient relationship | STAT

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3 Upvotes

r/PatientPowerUp 17d ago

Your claim may be denied if your name is too long (for example) but you can refute this

4 Upvotes

As I've mentioned elsewhere many of these companies are built on old software from the 1980s. These software include arbitrary choices from the original designer, like a system might only allows 15 characters for a last name. If yours is "Robertson-Stevenson" it will be stored as "Robertson-Steve".

This would actually be OK if only the one company was involved, but your claim will typically bounce between multiple companies before it's resolved. For example, the Clearinghouse routes your claim to a TPA who sends it to a Payment Processor for review. The processor has no limit on name length but they received "Robertson-Steve" (either the clearinghouse or the tpa have a limit). Their automated review process detects no one by that name so it rejects the claim.

This sort of thing happens regularly, so companies have a "manual review" process but they don't always do it of their own volition. If your claim is denied you can appeal, but specifically you can request a manual review. Explicitly state you believe the automated system made an error. And if you have any specific evidence (e.g. the denial had a shortened version of your name on it) you should mention this as well. And of course keep all your documentation, bills, etc, until you get it resolved.


r/PatientPowerUp 17d ago

ER Bill for 2 yr old checkup

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7 Upvotes

r/PatientPowerUp 17d ago

From WebMD to AI chatbots: How innovation has empowered patients to take control of their health | EurekAlert!

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eurekalert.org
1 Upvotes

r/PatientPowerUp 18d ago

Illinois has made it illegal for patients to use AI tools to manage their own health in order to protect and enrich the medical establishment

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healthcarefinancenews.com
2 Upvotes