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Insurers rely on doctors whose judgments have been criticized by courts

propublica.org

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Re: Insurers rely on doctors whose judgments have been criticized by courts

#11

Post by ceejayoz »

franktankbank wrote: post #10
ceejayoz wrote: post #5

Earlier quoted context omitted.

Oddly, it's not currently considered to be. > Having the weight of an MD behind a decision can be powerful, but lawyers and judges who’ve handled these sorts of cases say it can be misleading. Although doctors ultimately determine whether to cut off insurance coverage for a particular treatment, those decisions are generally not considered the practice of medicine and therefore cannot be challenged in a malpractice l…

> Oddly, it's not currently considered to be. Odd indeed. Is it some semantic thing? Denying care is the purest form of not practicing medicine?

I'm guessing it's some thin veneer of bullshit like "well, the patient can still pay $500k directly out of pocket, so we're not technically interfering with the care, just the payments!"

Re: Insurers rely on doctors whose judgments have been criticized by courts

#12

Post by Aunche »

Ironically, I think that the increased attention to the denial of claims plays straight into insurer's hands. Healthcare isn't expensive because insurers don't pay enough to healthcare providers. In fact, it's the opposite. The ACA mandates that at least 80% of premiums must go towards medical expenses. This means that insurers are actually incentivized to overpay for care to maximize the size of their 20% slice. If we want to decrease healthcare costs in the US, we need to focus on how insurers are failing to negotiate on behalf of consumers.

Re: Insurers rely on doctors whose judgments have been criticized by courts

#13

Post by razakel »

franktankbank wrote: post #10
ceejayoz wrote: post #5

Earlier quoted context omitted.

Oddly, it's not currently considered to be. > Having the weight of an MD behind a decision can be powerful, but lawyers and judges who’ve handled these sorts of cases say it can be misleading. Although doctors ultimately determine whether to cut off insurance coverage for a particular treatment, those decisions are generally not considered the practice of medicine and therefore cannot be challenged in a malpractice l…

> Oddly, it's not currently considered to be. Odd indeed. Is it some semantic thing? Denying care is the purest form of not practicing medicine?

They're not the responsible clinician, so they're not practicing medicine.

It's like taking legal advice from me: I'm not your lawyer (or even a lawyer) and I'm probably wrong. But it was your decision to take it.

Re: Insurers rely on doctors whose judgments have been criticized by courts

#14

Post by staticman2 »

franktankbank wrote: post #10
ceejayoz wrote: post #5

Earlier quoted context omitted.

Oddly, it's not currently considered to be. > Having the weight of an MD behind a decision can be powerful, but lawyers and judges who’ve handled these sorts of cases say it can be misleading. Although doctors ultimately determine whether to cut off insurance coverage for a particular treatment, those decisions are generally not considered the practice of medicine and therefore cannot be challenged in a malpractice l…

> Oddly, it's not currently considered to be. Odd indeed. Is it some semantic thing? Denying care is the purest form of not practicing medicine?

In many circumstances denying care is not malpractice. Even a doctor saying "I'm not taking on new patients" is technically denying care.

Re: Insurers rely on doctors whose judgments have been criticized by courts

#15

Post by azalemeth »

I'm not American and grew up (and work) in Western Europe.

Everyone is born, and, at some point, will get sick and die. Why does each of these cost tens or hundreds of thousands of dollars? I've heard American doctors at conferences describing their system as "the worst imaginable". Every American I know hates their system. It costs a lot more, has worse outcomes and shovels money and privilege towards the rich.

Why don't you change it? What are the reasons why moving to a single payer system is so bad? Denmark has the same system as the NHS, puts more money into it than the Brits do, and has some of the best health outcomes in the world. If a politician seriously suggested copying them -- with an income tax deducted at source with employee and employer contributions -- what would happen?

Re: Insurers rely on doctors whose judgments have been criticized by courts

#16

Post by ceejayoz »

razakel wrote: post #13
franktankbank wrote: post #10

Earlier quoted context omitted.

> Oddly, it's not currently considered to be. Odd indeed. Is it some semantic thing? Denying care is the purest form of not practicing medicine?

They're not the responsible clinician, so they're not practicing medicine. It's like taking legal advice from me: I'm not your lawyer (or even a lawyer) and I'm probably wrong. But it was your decision to take it.

These are licensed doctors (required!) being paid to explicitly evaluate the case, though, to determine if treatment is "medically necessary". Seems like a deeply different scenario.

Re: Insurers rely on doctors whose judgments have been criticized by courts

#17

Post by londons_explore »

Aunche wrote: post #12

Ironically, I think that the increased attention to the denial of claims plays straight into insurer's hands. Healthcare isn't expensive because insurers don't pay enough to healthcare providers. In fact, it's the opposite. The ACA mandates that at least 80% of premiums must go towards medical expenses. This means that insurers are actually incentivized to overpay for care to maximize the size of their 20% slice. If…

> incentivized to overpay for care to maximize the size of their 20% slice.

This.

You see it anytime you mandate some profit cap or limit as a percentage of revenue. Companies will just manipulate the other variable to get more profits. Or they'll buy other related companies so they can do sneaky internal pricing shenanigans.

Re: Insurers rely on doctors whose judgments have been criticized by courts

#18

Post by Spivak »

Aunche wrote: post #12

Ironically, I think that the increased attention to the denial of claims plays straight into insurer's hands. Healthcare isn't expensive because insurers don't pay enough to healthcare providers. In fact, it's the opposite. The ACA mandates that at least 80% of premiums must go towards medical expenses. This means that insurers are actually incentivized to overpay for care to maximize the size of their 20% slice. If…

I mean I guess but it would still be a huge improvement in real people's lives if the burden was flipped and insurance companies had to prove fraud to deny a claim.

I think we want the opposite when it comes to negotiations and want instance companies to all have to pay out the cash price. The first step to making it possible to not need insurance for most care is making everyone pay the same.

Re: Insurers rely on doctors whose judgments have been criticized by courts

#19

Post by alistairSH »

azalemeth wrote: post #15

I'm not American and grew up (and work) in Western Europe. Everyone is born, and, at some point, will get sick and die. Why does each of these cost tens or hundreds of thousands of dollars? I've heard American doctors at conferences describing their system as "the worst imaginable". Every American I know hates their system. It costs a lot more, has worse outcomes and shovels money and privilege towards the rich. Why…

Combo of the truly wealthy buy politicians AND many professionals and union employees have employer-subsidized health plans AND 100 years of “socialism bad!” messaging from the political right.

Re: Insurers rely on doctors whose judgments have been criticized by courts

#20

Post by teknikl »

Aunche wrote: post #12

Ironically, I think that the increased attention to the denial of claims plays straight into insurer's hands. Healthcare isn't expensive because insurers don't pay enough to healthcare providers. In fact, it's the opposite. The ACA mandates that at least 80% of premiums must go towards medical expenses. This means that insurers are actually incentivized to overpay for care to maximize the size of their 20% slice. If…

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