Cold Open

SPEAKER_00 0:00

I am calm, I am prepared, and I am professional. I will get through this whole rundown and I will not get derailed. And someone out there is gonna do something about this today. They deny claims every 1.2 seconds. I'm Marcus Grant, and today, how health insurance actually works. You think you have coverage. You pay your premium, you go to the doctor, insurance pays. Simple, right? Well, here's what actually happens. No is one click, and yes is a second job. 90% of denials get overturned when someone actually bites.2% of people fight. They're not betting you're wrong, they're just betting you're tired. And unlike a casino, you can't leave the table, you can't choose not to play, you're not a patient, you're a gambler, and you know what they say. The house always wins.

Morning

SPEAKER_00 1:10

Your body got stapled to someone else's spreadsheet in 1942, and nobody ever unstapled it. I'll get to why in a few weeks. For now, just know this. Your doctor is technically a subcontractor for HR. And it started as a wartime accident. Well, an accident that's been running for about 84 years. And this isn't theoretical. In internal documents from lawsuits, insurance companies have a category for patients who cost too much. Christopher McNaughton was a college student with ulcer rate of colitis. His account was flagged high dollar. Not high risk, not high complexity, high dollar. That's not a metaphor, that's a drop-down menu. He hit a number on a spreadsheet and just stopped being a patient. And here's what a former insurance executive had to say about cases just like his. And yeah, I'm quoting. Why not just deny them all and see which ones come back? From a cost perspective, it makes perfect sense. Yep, he ain't wrong. From a cost perspective, it makes perfect sense. Yep, anyway. Let me introduce you to Joey. Joey, you know him, the facilities guy, the one with all the keys. Couple years ago, Joey, something goes wrong. His feet hurt so bad he can't do his job. He drops 20 pounds without trying. And here's the part no one ever talks about. His job is how he keeps his insurance. So the body that needs the coverage is the same body that has to keep showing up to work to maintain it. That's not irony. That's the architecture. So he goes to the doctor, doctor runs some blood work, diagnosis, most likely rheumatoid arthritis. But rheumatoid arthritis doesn't just show up. It's your immune system turning on your own body, and that builds over time. You don't go from fine to debilitated in two months unless something else is happening. Joey knew that. The doctor just didn't ask the question. But you know how it goes. The doctor's a doctor. So Joey takes the prednisone. Prednisone. Boy, that stuff's great. Makes everything feel better. Joey went home after a 12-hour shift and cleaned the garage. Facilities got crack. Symptoms improve. Doctor calls are confirmed. Next step, Humera, $72,000 a year drug. Joey goes home, tells the wife. Wife decides, hey, I'm gonna look that up. Her exact words, no fucking way. She wasn't a doctor or lawyer. She just got mad enough to look, and they never went back. New doctor orders real blood work. Insurance denied it. Not medically necessary. They'd already run the cheap test and it came back clean. They bought the cheaper answer and used it to block a real one. So Joey paid out of pocket. Lime lit up the panel, nine of thirteen markers, but those turned out to be antibodies. His body had already beat that one. The Bartonella plague was the big one. That's what was still making him sick. Treatment? Well, that's where it gets crazy. Antibiotics and malaria medication at the same time. Swapping drugs every couple months. Names that sound like hallucinogens. It's like a witch doctor prescription on a napkin. But it worked. Messy, ugly, the opposite of here's a $72,000 drug, and uh I'll see you again never. But here's what doesn't make sense. Insurance denied the test. Joey paid for it. Then insurance paid for everything that followed. Every antibiotic, every appointment, every prescription. They paid to treat the disease they wouldn't pay to find. So then I get thinking, why would you cover six months of prescriptions and then then deny the one test that told the doctor which prescriptions are right? Yeah, I'll tell you why. Unless the test pays you nothing and the drugs pay you every time. Every prescription runs through a pharmacy benefits manager, a PBM. Every prescription generates a rebate. The test, zero kickback. They denied the test because the test doesn't pay them back. And they happily paid for every drug that does, including the drugs that only existed because of the tests they denied. So over two years later, Joey's 90% better, his right foot's still numb, he still shakes out his hands to get his fingers working. It's like blowing into a Nintendo cartridge. The 10% he lost? Well, that's the time infection spent doing damage while the system was too busy not finding it, then not paying to find it, then paying for everything except finding it.

Noon

SPEAKER_00 5:59

Bah. You ever work fast food? You change the box of syrup, disconnect the old one, hook up a new one, pray you don't get sticky. You stocked it, you served it. What you never saw was the rebate check that should have incorporated at the end of a month. Off the books, different deal at every location, you handle the product, you just have no idea what it actually costs. Well, neither does your manager. The real number lives on a spreadsheet, both of you will never see. Same structure, same hidden map, except instead of fountain drinks, it's your bloodstream. Joey has the good insurance, PPO. His company, they pay the claims directly. Blue Cross is just there to manage the paperwork. And Blue Cross has no legal obligation to act in Joey's or his company's best interest. What happened to Joey is in a billing error. It's not a mistake, it's the business model. Joey pays $75 a week in premiums. That's about $3,900 a year. His employer pays Blue Cross another $27,000 a year to manage the plan. We'll call it $31,000 total, flowing through Blue Cross for Joey's coverage. Now, drug companies want their drugs on the approved list. Getting on that list is like getting shelf space at Walmart. You pay for it. How? Rebates. The company that makes you MARA pays Blue Cross 30 to 40% of that $72,000 list price back as a kickback. We'll call it $25,000. One rebate, almost as valuable as the entire annual premium Joey and his employer pay. The system isn't confused about your health, perfectly clear about your value. The math says push the drug, deny the test. And if the first drug doesn't work, we'll push another drug. Every wrong answer that leads to a new prescription is a new revenue event. A correct diagnosis that ends in treatment is a revenue killer. They're not being stupid. They're not being evil. They're simply being rational. And that's the part that keeps me up at night. Nobody can see the rebate. Not Joey, not his employer, not the pharmacist, because it's a side deal off the books between Blue Cross and the drug company. And that's just one middleman. Wait until I show you the entire crew. Want to know how fast they can deny you? Cigna Doctors denied 300,000 claims over two months. And I use the word denied loosely because the average review time per claim was 1.2 seconds, which is not enough to read a file, not enough to open a file, not enough time to do anything, except click a button that says, yeah, I'm a doctor and I reviewed your case when a doctor did not actually review your case. I've spent longer choosing a sandwich. One doctor denied 121,000 claims in 60 days. If he took lunch, he denied your claims between bites. The internal system called PXDX, procedure by diagnosis. You have a diagnosis? Well, the algorithm cross-references it with the procedure. If they don't match, automatic denial. Before a human even looks at it, page 47 of their internal documents. Guess what? Yeah, they wrote it down. That's one dealer. The speed table. Deny fast, move on. There's a second one, slower but much sneakier. United Health. Yeah, those guys. They built a tool called NHPred. Instead of denying your claim outright, it predicts when you should be done healing. You're in the hospital recovering from hip replacement. Your doctor says you need three more weeks. The algorithm says patients like you usually leave in 14 days. Same age, same procedure, same zip code. So day 15, your insurer tells the facility, we're done paying. Even if you can't walk, even if your doctor is standing there looking at you and says, This person is not ready. The algorithm looked at six million patient records and they decided your recovery averaged out to 14 days. And your doctor's medical judgment about your body does not outrank that spreadsheet. A federal lawsuit abudges United Health knew the algorithm was wrong 90% of the time when families actually fought back. 90% wrong, yet still mandatory. Two dealers, one denies your claim in 1.2 seconds, the other predicts when you're healed and kicks you out early. Both are designed to do the same thing. Make you quit before you cost them money. Here's the thing. When people do appeal, 90% win. They're wrong nine times out of ten when anyone checks. Their entire profit model is don't let you check. So why don't more people appeal? Because it takes a month. Sometimes two. Because you're sick, because you're scared, because the form is 12 pages and the deadline is 14 days, and they pick those numbers very carefully. They deny your claim with an algorithm that processes 300,000 decisions in 60 days. You appeal by facts, a facts, technology from 1987, the has half the hospitals don't even have anymore because why would they? Nobody faxes anything in 2026 unless they're appealing a health insurance denial. Or confirming a timeshare reservation, which honestly might be the same level of financial decision at this point. That's not a bug in the process. That's the firewall.2% appeal. That's not a patient population. It's a personality type. That 90% gap between wrong and challenged, if it feels broken, it's because it's working. And every time the math favors the insurer, not the patient. Bah. Nice comeback, Marcus. Real professional. You've been stumbling over your words all day, breathing on the mic. Run take thirteen and you were supposed to wrap this up four hours

Night

SPEAKER_00 11:46

ago. Instead, you got a hundred tabs open, you're still rolling. This show's gonna take off like a Led Zeppelin. How's that for an opening mantra? One point two seconds. I keep coming back to it. Because that number is the whole show. That's everything wrong with the system in a unit of time, too small for a thought. That means ninety-nine point eight percent of people just just take it. Just accept the letter and I would have you know what I did for years. But ninety percent ninety percent win when they fight. So the denial isn't even real. It's a filter. Just a bet you won't check. So so if more people checked, if even five percent checked instead of point two, the math breaks. The whole model breaks. One form, one appeal, one person who doesn't accept the letter. Appeal. Just appeal. Anything. The next one that comes across your desk. Don't even think about it. Just just appeal it. Okay. You could appeal. You could request the clinical guidelines they used to deny you. You could file a complaint with your state insurance commissioner. Yeah, well, you probably won't. I know, because I didn't. Not for years. They don't have to beat you. They just have to outlast you. The casino has all the money, and it's in a ball made of the assumption that you're going to give up. And the assumption is probably correct. What the heck? My retirement is sponsored by D9. You know what I you know what I rehearsed in the shower this morning? Yeah, haha, you sick puppies. Not that. I'd drive to Minnetonka, Minnesota, United Healthcare Group headquarters. I've Googled it, street viewed it, nice campus, lots of glass. I'd carry a banker's box, color coded tabs, green for overturned, red for never appealed, and yellow for patient died during the appeal process. They won't let me see the CEO, so plan B. I buy forty seven shares of UNH stock. That's about one sixth of a share. Fractional shareholders still get to attend the annual meeting, still get to ask questions. You know what? I'd stand up, I'd start reading denied claims into the official corporate record, one by one, for my full allotted three minutes. Well yeah, that's what I was gonna do this morning in the shower. Here's what I actually did. I came out here, I opened my laptop, I sat in this chair, I'm recording take thirteen, and my 401k, it just went up. The verdict? I'm not gonna tell you these people are monsters. The incentive is money. It's always money. The system doesn't need monsters, it just needs the math to work. Joey still can't feel his right foot, and somewhere the server just stamped denied and went back to sleep. The motive? I don't know. The motive's above my pay grade. The behavior is documented. The house always wins, not because the cards are random, but because the exits through the kitchen. The receipts are in the case file. What you do with them? That's your business. Joey's wife didn't file a lawsuit, she didn't call a senator, she read the paperwork. She asked the next question. That's it, that's the move. If you do one thing this week, appeal one denial. Any denial, the next one that comes, request the clinical guidelines are used to deny you. Ninety percent went on appeal. Try. Be the point two. Be the point two. The rest is in the case file. I'm Marcus Grant, and so it goes.