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"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

#11

Post by ervine »

d_burfoot wrote: post #6

America 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…

What's a libertarians take on how health care should work? Completely privatized, completely socialized, somewhere in between?

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#12

Post by zardo »

vanc_cefepime wrote: post #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 defens…

I feel like this should really be something people should lose their license over.

By deeming something not medically necessary they are (in my opinion) effectively practicing medicine. If they aren't qualified to practice that specialty, or aren't acting in the patients interest we should really be getting malpractice suits on them and stripping medical licenses.

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#13

Post by jmspamerton »

vanc_cefepime wrote: post #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 defens…

Physician and Hospital resources is a real zero sum game, how do you fairly regulate the medical landscape so those who's lives will benefit most from a procedure will receive the procedure?

Who decides this? You?

Should we allow everyone in the world who needs a procedure to receive one free and get ahead in line for Americans who need the same procedure? That's what the current climate looks like with unbridaled immigration under progressives.

These are hard questions. What's the answer?

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#14

Post by expedition32 »

selectodude wrote: post #7
d_burfoot wrote: post #6

America 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.

Yep they will move to California the moment they get cancer. Never trust a libertarian.

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#15

Post by datsci_est_2015 »

ervine wrote: post #11
d_burfoot wrote: post #6

America 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…

What's a libertarians take on how health care should work? Completely privatized, completely socialized, somewhere in between?

“I’ll put out this fire for you if you pay me $5000”

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#16

Post by jmspamerton »

f33d5173 wrote: post #10
d_burfoot wrote: post #6

America 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…

so, your answer is OMG, they are making money!11! It's not a money probelm, it's a resources problem. We simply don't have enought hospital resources to serve everyone in the us. it's not making money, it's not having enough beds and skilled people to do the work.

Get an MD and help out, then you'll discover how you really DONT want the government to tell you which patients to serve.

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#17

Post by ceejayoz »

jmspamerton wrote: post #16
f33d5173 wrote: post #10

Earlier quoted context omitted.

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…

so, your answer is OMG, they are making money!11! It's not a money probelm, it's a resources problem. We simply don't have enought hospital resources to serve everyone in the us. it's not making money, it's not having enough beds and skilled people to do the work. Get an MD and help out, then you'll discover how you really DONT want the government to tell you which patients to serve.

> It's not a money probelm, it's a resources problem.

Most people would consider money a resource, and quite a few rural hospitals are closing because of a lack of that specific resource.

> you'll discover how you really DONT want the government to tell you which patients to serve

Yeah, wait until you hear about private for-profit insurers doing that instead.

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#18

Post by paulddraper »

OptionOfT wrote: post #5
vanc_cefepime wrote: post #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 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 like any time spend on billing or administrative work, it's baked into the costs. (Administrative costs is a big component of rising healthcare costs.)

Depending on the issue, the patient may be needed to provide supporting paperwork, like previous diagnoses or treatment for providers. Other than that, not really, short of taking legal action.

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#19

Post by [deleted] »

ervine wrote: post #11
d_burfoot wrote: post #6

America 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…

What's a libertarians take on how health care should work? Completely privatized, completely socialized, somewhere in between?

[deleted]

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#20

Post by evulhotdog »

tempaccount5050 wrote: post #9
vanc_cefepime wrote: post #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 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 ne…

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