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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

#111

Post by tt24 »

singleshot_ wrote: post #54
jmspamerton wrote: post #13

Earlier quoted context omitted.

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 im…

[flagged]

Dang, can we take a look at this one please? It’s not a productive, helpful, or interesting comment. Thanks!

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

#112

Post by ceejayoz »

freeone3000 wrote: post #103
ben-johnson wrote: post #66

Earlier quoted context omitted.

Because there are a finite number of doctors and hospital beds and you can't create either by throwing more money at the problem. You didn't actually read the content did you

The doctor has already managed to find time for the service - she’s seen you. Potentially even done the procedure. The hospital has made room for you. The resource is already consumed by you, like a restaurant meal. The question is who is picking up the check, when you already have a subscription service paid for.

And the doc is also spending a shocking amount of their time on the phone yelling at the insurance company flacks, as a bonus.

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

#113

Post by tt24 »

ceejayoz wrote: post #31
khriss wrote: post #30

The worst part, simultaneously soul crushing and apocalyptic rage inducing is that we get these outcomes after spending more per capita on healthcare than pretty much any country on the planet.

Worse, we spend more in tax dollars on it than any other country total , and then add on the private spending on top. We do the worst of both worlds. https://commons.wikimedia.org/wiki/File:OECD_health_expendit... (And we’re middling in outcomes!)

Yeah because we consume way more than other countries

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

#114

Post by tptacek »

ceejayoz wrote: post #108
tptacek wrote: post #106

Earlier quoted context omitted.

Show me the more recent NHE table where this effect shows up and I'll be ready to have the conversation, but right now this seems like a dodge. Whatever effect you're describing, if it's material, has to have started after the NHE data I just posted, from 2023. I don't remember thinking that the health system in 2022 was good. Fun thing about the NHE: you can project it as far back as you want. The data is there.

> Whatever effect you're describing, if it's material, has to have started after the NHE data I just posted, from 2023. What? Insurers have been playing this game far further back than 2023. If an insurer doubles the time a doc has to fight over denials and has to hire extra billing staff to assist, where do you imagine that cost shows up?

I feel like we've been in this argument before, and I like you just fine as a commenter, but do feel like you're tying yourself into knots to avoid a simple conclusion plainly supported by the data. I didn't post a trend story about what companies are doing or who they're acquiring; I posted the macro NHE table from last year. It simply refutes the argument you're trying to make.

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

#115

Post by ceejayoz »

tptacek wrote: post #114
ceejayoz wrote: post #108

Earlier quoted context omitted.

> Whatever effect you're describing, if it's material, has to have started after the NHE data I just posted, from 2023. What? Insurers have been playing this game far further back than 2023. If an insurer doubles the time a doc has to fight over denials and has to hire extra billing staff to assist, where do you imagine that cost shows up?

I feel like we've been in this argument before, and I like you just fine as a commenter, but do feel like you're tying yourself into knots to avoid a simple conclusion plainly supported by the data. I didn't post a trend story about what companies are doing or who they're acquiring; I posted the macro NHE table from last year. It simply refutes the argument you're trying to make.

> I posted the macro NHE table from last year.

Again: how will the “insurers force provider costs up” show up in said tables?

It’s caused by the insurer. It shows as a provider’s cost. But it doesn’t mean said doc is making any more money at the end of the day.

The insurer does, though! Their 20% cut got bigger, and the "computer says no" denials are cheap!

TL;DR: Where in your link does "doc spends needless hours on phone fighting insurer" show up as a cost?

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

#116

Post by rainsford »

roenxi wrote: post #78
teeray wrote: post #70

Earlier quoted context omitted.

> Legally speaking the health plan employee isn't practicing medicine in that circumstance Feels like convenient lawcraft to wash the health plan employee’s hands of liability. I’m sure the prevailing popular opinion would be that this is practicing medicine.

If "convenient lawcraft" is the new slang for "words have meanings" then absolutely. Insurance company employees talking about insurance is practising insurance. Nobody wants them to practice medicine, the question is whether they are they going to hand over the money or not. Money is not a form of medicine, even if the person deciding where it gets sent is medically qualified. Although on the words having meanings f…

Words do in fact have meaning, which is why if you want your decision to be viewed as an insurance one rather than a medical one, you probably should avoid using phrases like "medically necessary" as justification for your decision to approve or deny insurance coverage. Using that phrase strongly suggests that while the ultimate decision was about providing or denying insurance coverage, what informed that decision was a medical determination about the actual necessity of the procedure. If you want to keep the decision firmly in the insurance realm, better considerations to mention might be expected lifetime payouts, shareholder value, and "because fuck you that's why".

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

#117

Post by like_any_other »

nradov wrote: post #45
zardo wrote: post #12

Earlier quoted context omitted.

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.

Legally speaking the health plan employee isn't practicing medicine in that circumstance. The requesting provider is still free to treat the patient, they just won't be reimbursed by the health plan. The requesting provider can do it for free, or the patient can pay cash. I do understand that those aren't realistic options in most cases, I'm just explaining the legal distinction.

"We won't pay you" is a business decision. "Not medically necessary" is a medical opinion.

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

#118

Post by sarchertech »

wingspar wrote: post #71
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’ve saved a message that was reposted by Bill Ackman on dealing with denials. Thankfully, never had occasion to use it yet: >> So, your doctor ordered a test or treatment and your insurance company denied it. That is a typical cost saving method. OK, here is what you do: 1. Call the insurance company and tell them you want to speak with the "HIPAA Compliance/Privacy Officer" (By federal law, they have to have one) 2…

I wonder if there are any records of people having success with this tactic.

It certainly sounds like something that could work.

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

#119

Post by ceejayoz »

tt24 wrote: post #113
ceejayoz wrote: post #31

Earlier quoted context omitted.

Worse, we spend more in tax dollars on it than any other country total , and then add on the private spending on top. We do the worst of both worlds. https://commons.wikimedia.org/wiki/File:OECD_health_expendit... (And we’re middling in outcomes!)

Yeah because we consume way more than other countries

Do we consume more, or are we running the price of everything needlessly higher with a goofy setup?

Americans are not inherently three times as sick as Australians.

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

#120

Post by tempaccount5050 »

vjvjvjvjghv wrote: post #47
tempaccount5050 wrote: post #9

Earlier quoted context omitted.

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…

“ I just started approving everything. "Patient needs emergency surgery for X" "Approved".” Did they ding you for bad performance after a while? Your job was to maximize denials, not approvals.

I didn't stay long enough to find out, but yeah, they probably would have. The pressure was definitely to default to deny it. That's what the run books (very few) were defaulted to. It was really just a bunch of expendable people to deny claims. The turnover was wild for obvious reasons.
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