Medical Insurance Worker Gets Accused of Slacking on Claims, Decides to Upend the System

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Ally Perry • Writer and Editor
Jul 12, 2023 8:00 PM EDT

It's not exactly an unpopular opinion to say that the medical system in the US is screwed up. Almost everyone but the uberwealthy has a horror story of themselves or somebody they know struggling for fair and affordable treatment. The main culprit in many of these tales comes in the form of insurance companies; considering that they're meant to help their customers pay for the healthcare they need, they sure as heck don't enjoy doing it.

Someone who knows this all too well is u/jthememeking, who once held a job processing medical insurance claims. After becoming depressed with constantly having to deny people, they decided to hand in their notice and started slacking off.

When management noticed this, they started criticizing—so the reluctant employee got back to work in a rather different way. Fellow Redditors commended them, but also had their own gripes surrounding the world of health insurance. There's no easy way out.

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  • 01
    Font - 1 S r/MaliciousCompliance u/jthememeking. 17h 1 2 Stop slacking off and get to those insurance denials? Sure thing boss This happened a few years ago, but was reminded of it because a lot of it is becoming public.
    via jthememeking
  • 02
    Font - Insurance companies are not your friends and will do everything they can do save money, including not paying for your medically necessary services. There's a lot of news coming out about insurance companies using algorithms to deny claims and doctors signing off on them. Before algorithms, they would have minimum wage employees reading over these claims for the doctors instead. Thats what I was. I was 19 years old, working for a insurance companies denying claims. I would be the first lin
    via jthememeking
  • 03
    Font - This job was the easiest, yet most miserable job experience I ever had. I was only able to last a few months there. During my last 2 weeks, I was really slacking off. I was just so burned out. I couldn't stand denying yet ANOTHER case where someone needed meds and the insurance company didn't want to pay for them. I was reprimanded for not working hard enough and getting processed.
    via jthememeking
  • 04
    Rectangle - Insert malicious compliance. I worked faster than I ever had before. That's because I approved every case that came before. Every doctor I spoke to, I just gave them approval. Every prior authorization I saw was approved.
    via jthememeking
  • 05
    Font - During my first week, I did this once and was told to not do it again because I have to follow company guidelines, but I didn't care at this point. I probably was able to approve 50+ cases before I quit. I hope it made it difference to those people. Fuck health insurance companies.
    via jthememeking
  • 06
    Font - sammyno55 17h Where were you this past week? I went to see my GP on Friday afternoon and had 2 prescriptions called in to the pharmacy. I received a message that they were ready for pickup around 5 PM. I arrived at the pharmacy a bit before 6 and one of the meds was denied by the insurance company. I called the insurance company and talked to a person (he may have been on the West Coast and was still at work). He indicated that the doctor needed to approve the medication. I asked isn't th
    via sammyno55
  • 07
    Font - MorganRose99 17h I worked in a pharmacy for over a year, and the pharmacist I worked with was one of the best in the county (possibly the state). One day she was talking to a costumer and I overheard her say "I've been working here for 14 years and I still don't understand insurance." No offence, but it makes sense that those Prior Authorizations could have been based on someone still young enough to be in highschool basically just going "yeah, sure" or "nah, not good enough." Fuck insura
    via MorganRose99
  • 08
    Font - o jthememeking OP • 17h It's unreal. I had doctors and pharmacist yell at me a lot for going against them. Their rage was completely understandable. It was rough because the doctors who were going above and beyond for their patients are amazing doctors. Good people doing right by their patients, getting told no by some kid. I would file prior authorizations for them, because I knew a kot of the insider tricks to get them approved. I would fax them over to the doctors office so they could
    via jthememeking
  • 09
    Rectangle - DefrockedWizard1 +2•16h When I was a working physician, the worst part of my life was dealing with insurance stuff. Now that I'm disabled and can't work, the worst part of my life is dealing with insurance stuff EXT 2
    via DefrockedWizard1
  • 10
    Organism - CdnPoster +2 17h What exactly is the point of insurance if they're going to deny claims willy-nilly??? : Reply ↑ Vote ↓ PipsqueakPilot To return value to the shareholders. What else would an American corporation be for? +2.17h
    via CdnPoster
  • 11
    Organism - farrenkm +3•17h First of all, thank you for serving the people instead of the company! But this raises the question -- what were you allowed to approve that wouldn't get you in trouble?
    via farrenkm
  • 12
    Font - jthememeking OP. 17h Prior authorization are what I worked on the majority of the time. The most common issue with a PA was a patient not trying another medication or procedure first. Or maybe the insurance company would want patients to be on a different brand of medication. What I did was look through the PA and see if they including the patients history and whether or not they checked all the boxes to be approved for the new medication. Honesty, a lot of the issues were doctors not kno
    via jthememeking
  • 13
    Font - Every-Requirement-13 16h What pisses me off, is why they think they have the right to dictate the quality of life someone lives. Especially when WE are the ones paying for the damn insurance!!! I've had a surgical procedure denied because of the "temporary code" that is used to classify it. It's a newer non invasive surgery so I don't have to have my joint fused together with bolts, but my doctor said the insurance would probably approve the old school surgery method. Like I'm in my 40's
    via Every-Requirement-13
  • 14
    Font - nansi35 • 14h You have to really get on their ass as your own advocate. I was diagnosed with cancer. My chemo was approved but they didn't approve radiation. They didn't deny it, they just were dragging their feet. Chemo and radiation therapy work together which is why you have them together usually. I had to call them and tell them that my cancer had no doubt spread in the freaking 2 months that I was waiting for any treatment and per one of my oncologists I may now need additional treat
    via nansi35
  • 15
    Font - dsdvbguutres +3•15h Let's privatize health insurance, and let the insurance company determine whether the insurance company should cover the cost of healthcare. Dictionary definition of conflict of interest.
    via dsdvbguutres

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insurance employee malicious compliance medicine hospital doctor reddit thread Reddit money
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