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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

#141

Post by nradov »

zzrrt wrote: post #79
nradov wrote: post #45

Earlier quoted context omitted.

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.

If it's not medicine, why do they say the word "medical"? Why does the insurance company pay a doctor to do it, if they could pay someone cheaper to say those words? I'm not a doctor or lawyer, but if I had to guess, the answers are that the law requires it be a doctor exercising their medical training, while the company tries to hide behind arguments like this to get around the law.

Your guess would be wrong. At least at the federal level there is no such law. (It's possible that some states might have more stringent laws.)

https://healthlaw.org/wp-content/uploads/2025/11/Vanneman_Pr...

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

#142

Post by ceejayoz »

tptacek wrote: post #139
ceejayoz wrote: post #133

Earlier quoted context omitted.

Oh, now who's dodging? If an insurer manages to double a doctor's administrative costs for billing/appeals/etc., where does it show up in your tables, per your link's PDF of definitions?

You have no evidence for this argument. It's just vibes. The numbers here are stark . It's not like it's close, between providers and insurers. Insurers are almost literally a rounding error.

You asserted "the macro NHE table from last year… simply refutes the argument you're trying to make", but that claim is false. You are welcome to answer the question about where "doc spends two hours on phone arguing with UHC" falls in the expenditure list; it's not insurance, but it's caused by it.

> Insurers are almost literally a rounding error.

Again, the argument is that the raw cost of health insurance does not reflect its externalities imposed on the other items in your list; that insurers drive up hospital and practice costs, as they have to staff up enormous amounts of staff and expensive physician time to deal with the insurer.

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

#143

Post by tptacek »

ceejayoz wrote: post #142
tptacek wrote: post #139

Earlier quoted context omitted.

You have no evidence for this argument. It's just vibes. The numbers here are stark . It's not like it's close, between providers and insurers. Insurers are almost literally a rounding error.

You asserted "the macro NHE table from last year… simply refutes the argument you're trying to make", but that claim is false. You are welcome to answer the question about where "doc spends two hours on phone arguing with UHC" falls in the expenditure list; it's not insurance, but it's caused by it. > Insurers are almost literally a rounding error. Again, the argument is that the raw cost of health insurance does not…

$360B in admin/net cost of insurance. $2.5T in practitioner costs.

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

#144

Post by ceejayoz »

tptacek wrote: post #143
ceejayoz wrote: post #142

Earlier quoted context omitted.

You asserted "the macro NHE table from last year… simply refutes the argument you're trying to make", but that claim is false. You are welcome to answer the question about where "doc spends two hours on phone arguing with UHC" falls in the expenditure list; it's not insurance, but it's caused by it. > Insurers are almost literally a rounding error. Again, the argument is that the raw cost of health insurance does not…

$360B in admin/net cost of insurance. $2.5T in practitioner costs.

> $2.5T in practitioner costs.

Some of which is those practicioners' admin cost from dealing with the insurers. (And, you know, doing the actual work.)

Denials are nice and cheap. Fighting them is not.

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

#145

Post by anarticle »

I think in the case of Optum + UnitedHealthCare being the Scylla and Charybdis of a healthcare situation, we should break up this style of business. Owning both sides of the equation means there is no competition if you are unlucky enough to find this combination.

Feels like two wolves negotiating on how much of the sheep (the sheep is you) they get to eat.

Dare I ask, who is for the "consumer"? If we should even use those words in this system, which in my mind should be for a nation keeping its citizens alive and well both of their own sake and the state's sake.

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

#146

Post by missedthecue »

wrs wrote: post #33
CalChris wrote: post #26

Medicare has a similar issue. When you sign up at 65, you have to make a first big decision, Traditional Medicare (yay!) or private Medicare Advantage (boo!). Traditional Medicare consists of Part A (hospitals), Part B (doctors) and Part D (drugs). Part A+B don't cover everything so you have a Medigap plan. I have Plan G which has very little paperwork. All up, I spend about $400/mo and I'm very happy with A+B+G+D. W…

The theory behind Medicare Advantage is that it would cost the government less than traditional Medicare because the private insurer would be more efficient. Guess what happened.

Well the only ways to make any sort of insurance pool (whether it's run by the government or a private organization, for or non profit) more efficient is to deny more payouts or aggressively select for a less risky risk-pool. Medicare insures everyone over age 65, so the second option doesn't work. You can't just leave half the elderly uninsured because they're fat and likely to run up $100,000 in knee replacements. So you have to deny more claims.

Insurance is brutally simple. Money in, money out. Trying to make your back office more lean with tech and automation has extremely limited returns, because the back office is such a small portion of the total cost structure. 95-100% of costs in any given insurance operation are claims. So everything to do making things more efficient and reducing costs has to do with reducing claims.

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

#148

Post by nradov »

The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) is driving some industry improvements in this area and there's a lot of opportunity for technologists to help implement it. While the rule mostly only applies to Medicare Advantage health plans, many payers are voluntarily implementing the same HL7 Da Vinci Project Prior Authorization Burden Reduction APIs across all lines of business. These APIs give providers standard ways to check whether prior authorization is required for a plan of treatment, find out exactly what documentation the health plan requires, and then submit the prior auth request. This won't solve the problem of improper denials but will at least reduce delays and errors.

https://www.cms.gov/priorities/burden-reduction/overview/int...

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

#149

Post by tiahura »

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…

https://www.snopes.com/fact-check/hipaa-medical-hack-insuran...

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

#150

Post by bparsons »

Thought I would remind people here of this simple, but mostly unknown fact about American healthcare:

American taxpayers invest more public dollars per capita in healthcare than anyone in the world. This before a single cent is paid into the private insurance system. Through Medicare, Medicaid, VA and other public health programs, you pay about 40% more public dollars per-capita than the most socialist, gold plated single payer system anywhere else.

You are not only getting ripped off by your insurer, but you are getting ripped off a public system, which has more than enough money to provide every man, woman and child with a lifetime of world-class, free at the point of service universal healthcare.

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