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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

#121

Post by rainsford »

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.

Sorry, but this feels like a lot of weasel lawyer doublespeak nonsense. Denying insurance coverage for a specific procedure for a specific patient based on whether you think that procedure is necessary is absolutely making a specific medical decision that will impact the treatment of that patient. The idea that this does not constitute practicing medicine is absurd and the fact that the patient can potentially still obtain treatment seems immaterial. A doctor who flat out told a patient a certain procedure wasn't medically necessary could be legally liable if that wasn't accurate, so how is the same not true of an insurance company who has far more impact on the ability of the patient to obtain treatment?

The reality is that this is the insurance companies trying to have their cake and eat it too. They actually want to be making a medical decision in denying coverage since it gives them a legitimate reason to do so, but want to avoid any liability if that decision was wrong.

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

#122

Post by tptacek »

ceejayoz wrote: post #115
tptacek wrote: post #114

Earlier quoted context omitted.

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…

It literally breaks practice and net cost of insurance out!

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

#123

Post by ceejayoz »

tptacek wrote: post #122
ceejayoz wrote: post #115

Earlier quoted context omitted.

> 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…

It literally breaks practice and net cost of insurance out!

> It literally breaks practice and net cost of insurance out!

But it's not a "Cost of Health Insurance" item. It's an expense at the practicioner level! They have to factor that non-billable time into what they charge for the procedure!

Read their definitions: https://www.cms.gov/files/document/quick-definitions-nationa...

"Administration" is the insurer's side of it.

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

#124

Post by tt24 »

ceejayoz wrote: post #119
tt24 wrote: post #113

Earlier quoted context omitted.

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.

Yeah they are. Americans engage in more unhealthy eating, crime, and drug use than Australians. It’s very easy for me to believe that they’re 3 times as sick.

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

#125

Post by toast0 »

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.

> The requesting provider can do it for free, or the patient can pay cash.

That might not be actually an option. Well the provider can do it for free, probably; but they may not be able to accept money for care that was denied coverage. A Medicare provider can charge patients for things outside the scope of Medicare, but generally can't charge for things in scope but deemed not medically necessary: ex if Medicare says 6 PT visits for whatever and you would like to have 8, you can't pay the provider for two more; you'd have to find a non medicare provider or come back with a fake moustache.

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

#127

Post by rainsford »

ceejayoz wrote: post #85
roenxi wrote: post #78

Earlier quoted context omitted.

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…

“X is or is not medically necessary” seems like a decision a medical professional should determine, no? Subject to licensing and liability? If I build you a house and tell you the roof trusses aren’t necessary, you’d be pretty peeved.

I think the right analogy here is that I'm a renter and the person who built my house (builder) is different from the person who paid for the house (landlord). The builder said the roof needed trusses but the landlord decided they weren't "structurally necessary" and refused to pay for them. The roof collapses on me...does the landlord escape liability?

Maybe an even better analogy is that I live in a rented home and after I report some weird respiratory issues, an inspector finds black mold all over the place. The landlord refuses to fix the issue because "black mold is totally fine, bro" and I get really sick. I could maybe have moved out, but I kinda feel like the landlord is going to have a bad time here.

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

#129

Post by ceejayoz »

tt24 wrote: post #124
ceejayoz wrote: post #119

Earlier quoted context omitted.

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.

Yeah they are. Americans engage in more unhealthy eating, crime, and drug use than Australians. It’s very easy for me to believe that they’re 3 times as sick.

Australia is very close behind the US in obesity and illicit drug use.

Side note: I'm an Australian citizen, living in the States.

An Australian hospital doesn't need a billing/collections department and the docs don't sit on appeals calls with insurance; when my wife broke her foot visiting, they basically didn't know how to bill her (for surgery and three days in a ward!). My son needed a badly ingrown toenail treated on a separate visit there last year; they just treated it and sent us on our way, no charge, despite his being a tourist.

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

#130

Post by tptacek »

ceejayoz wrote: post #123
tptacek wrote: post #122

Earlier quoted context omitted.

It literally breaks practice and net cost of insurance out!

> It literally breaks practice and net cost of insurance out! But it's not a "Cost of Health Insurance" item. It's an expense at the practicioner level! They have to factor that non-billable time into what they charge for the procedure! Read their definitions: https://www.cms.gov/files/document/quick-definitions-nationa... "Administration" is the insurer's side of it.

This is special pleading.
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