"Not Medically Necessary": Helping America's Health Insurers Deny Coverage
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Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage
#2Medically speak, I'm sure we can all find several businesses that arn't necessary.
Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage
#3“The algorithm cannot say no, however. If it finds problems, it sends the request for review to a team of in-house nurses and doctors who consult company medical guidelines. Only doctors can issue a final denial.”
As a physician, I’ve had to speak to these so called “peers” in a peer to peer denials with both my clinic and hospital setting. They are usually people who aren’t physicians as a first line of their defense, ie therapist, nurses, etc. This weeds out the providers who either don’t care about the patient denial and blindly accept the denial, or patient has to take matters in their own hands just to get the care they need/deserve. Or worse, in the hospital that means the patient gets hit with a huge bill (already an insane number in the US even with insurance, so don’t get me started on this) or it gets delegated to another provider who has to deal with it. Quite often patients get denied medical and rehab services, esp after something debilitating like a stroke, trauma/accident, etc. and at that point the peer to peer is to weed the provider out. Usually someone will tell the patient you’ve been denied, either go home without the services they need or you fight it.
I fight it. Can’t count the number of times I’ve spoken to someone not in the field of medicine or if they are, not my field of medicine (both Family/Hospital Medicine). Often I’m fighting with an MD or “practitioner” who is some other field like a gynecologist about hospital medicine services or rehab. I’ve even had the pleasure of talking to a physical therapist and didn’t let me get a word in as we began the peer to peer. I now start of by asking for their credentials and field of speciality and demand a peer of my field to do the denying if they are so adamant about it “not being medically necessary”.
I have so much to say and could write a book about it. I just wish I had the money and connections to actually change the state of US of Corporate Medicine.
Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage
#4Medically speak, I'm sure we can all find several businesses that arn't necessary.
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Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage
#5“The algorithm cannot say no, however. If it finds problems, it sends the request for review to a team of in-house nurses and doctors who consult company medical guidelines. Only doctors can issue a final denial.” As a physician, I’ve had to speak to these so called “peers” in a peer to peer denials with both my clinic and hospital setting. They are usually people who aren’t physicians as a first line of their defens…
As someone who needs expensive medication, thank you. I appreciate it.
2 questions:
* This time, is it paid? Is it billable? Is it part of the visit I pay for?
* What can I - as a patient - do to make this process easier?Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage
#6America cannot, as a country, discover a reasonable approach to managing health care costs because Americans do not have a sufficient core set of shared political values. The solution is to end regulation at the federal level, and allow the states to determine what regulations they may deem appropriate. As a New Hampshire libertarian, I do not want Californian progressives telling me how our state must manage health care spending, and I am sure they feel the same way about me.
Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage
#7America cannot, as a country, discover a reasonable approach to managing health care costs because Americans do not have a sufficient core set of shared political values. The solution is to end regulation at the federal level, and allow the states to determine what regulations they may deem appropriate. As a New Hampshire libertarian, I do not want Californian progressives telling me how our state must manage health…
As long as you accept the outcome of “drop dead” when something happens to you.
Problem is you’ll go right to the emergency room when you have a heart attack.
Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage
#8“The algorithm cannot say no, however. If it finds problems, it sends the request for review to a team of in-house nurses and doctors who consult company medical guidelines. Only doctors can issue a final denial.” As a physician, I’ve had to speak to these so called “peers” in a peer to peer denials with both my clinic and hospital setting. They are usually people who aren’t physicians as a first line of their defens…
As someone who needs expensive medication, thank you. I appreciate it. 2 questions: * This time, is it paid? Is it billable? Is it part of the visit I pay for? * What can I - as a patient - do to make this process easier?
It's unpaid time, but that'll just get factored into the rates charged for billable things like appointments and procedures.
Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage
#9“The algorithm cannot say no, however. If it finds problems, it sends the request for review to a team of in-house nurses and doctors who consult company medical guidelines. Only doctors can issue a final denial.” As a physician, I’ve had to speak to these so called “peers” in a peer to peer denials with both my clinic and hospital setting. They are usually people who aren’t physicians as a first line of their defens…
In the early 2000s I got a job right out of highschool working at a Blue Cross Blue Shields call center. I thought it was going to be customer service but it was insurance claims. Training was supposed to be 6 weeks but they pushed me live after just 2. I had no idea what I was doing. After floundering for a couple weeks trying to learn to basically be a fuckin doctor, I just started approving everything. "Patient needs emergency surgery for X" "Approved". The whole experience was completely insane.
Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage
#10America cannot, as a country, discover a reasonable approach to managing health care costs because Americans do not have a sufficient core set of shared political values. The solution is to end regulation at the federal level, and allow the states to determine what regulations they may deem appropriate. As a New Hampshire libertarian, I do not want Californian progressives telling me how our state must manage health…
I think the vast majority of people agree on the generalities and care enough about solving the issue to be able to come to an agreement on the particulars. The problem is that the people who get rich off the current system won't agree to any solution that reduces their profits, and have thus far managed to fillibuster attempts at such a solution through a combination of buying politicians and propagandizing certain segments of the population into rejecting solutions that would benefit them.