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

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151–160 of 224 posts

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

#151
post #132

Earlier quoted context omitted.

It's going to the administration overhead. If you have to document everything and argue for every medical procedure and deal with 20+ different processes for filing claims then it takes time. And, as a provider, you have to pay someone to spend that time if you want to get paid. It doesn't help that our healthcare billing systems are so outdated and broken. I once had a doctor visit denied with the reason code that i…

No it's not. There is absolutely no way to get from $360B of insurer admin and net cost of insurance to $2.5T --- two point five trillion --- in practitioner costs on paperwork overhead. That is not a plausible argument. The numbers here are not close. They're stark.

https://news.cornell.edu/stories/2011/08/us-health-care-cost...

> A new study finds that the extra time and labor physician practices spend on interacting with insurance companies and government entities cost U.S. physicians $82,975 each per year, while doctors in Ontario spent $22,205.

> Canadian physicians follow a single set of rules, but U.S. doctors grapple with different sets of regulations, procedures, requirements, formularies and forms mandated by each health insurance plan or payer. The average U.S. doctor spent 3.4 hours per week interacting with health plans; Ontario doctors spent 2.2 hours. The bureaucratic burden falls heavily on U.S. nurses and medical practice staff, who spent 20.6 hours per physician per week on administrative duties; their Canadian counterparts spent only 2.5 hours on paperwork.

All that falls in your $2.5T bucket. And their cleaners, HR, etc. And insurers have had 15 years of innovation since that study.

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

#153
post #125
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.

> 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 say…

I had to take my kid to an express care doctor in the US. My wife had the insurance cards and was on travel. I said I would just pay cash. They said because I had insurance I was not legally allowed to pay cash.

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

#154

“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 just wish I had the money and connections to actually change the state of US of Corporate Medicine.

It will never happen.

This is largely what at least half the country wants.

“If I need to take a drug test to earn a check you better take one to get welfare.”

I’ve heard a working class person say this. I guarantee you the people who own defense contractors, the real welfare queens don't need to take a drug test.

Likewise, the horrific thought that someone unworthy might get free healthcare is appalling to half this country. They’d rather go without just to ensure *those people don’t get free healthcare.

This country doesn’t want to be fixed. It wants RFK to tell you to treat Autism with raw milk and sunshine.

Nothing much to do but try to find a civilized place to live

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

#155

Earlier quoted context omitted.

No it's not. There is absolutely no way to get from $360B of insurer admin and net cost of insurance to $2.5T --- two point five trillion --- in practitioner costs on paperwork overhead. That is not a plausible argument. The numbers here are not close. They're stark.

https://news.cornell.edu/stories/2011/08/us-health-care-cost... > A new study finds that the extra time and labor physician practices spend on interacting with insurance companies and government entities cost U.S. physicians $82,975 each per year, while doctors in Ontario spent $22,205. > Canadian physicians follow a single set of rules, but U.S. doctors grapple with different sets of regulations, procedures, require…

You haven't done the math here. Multiply the numbers out. This is what I'm talking about. How are you supposed to engage with these topics if you're literally recoiling from 7th grade arithmetic? Congratulations, taken on your own terms, you just found 3.6% worth of savings from practitioner costs.

My local grocery store wouldn't even bother issuing a coupon for that small a discount.

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

#156
post #141
post #79

Earlier quoted context omitted.

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...

This seems like a straightforward argument based on existing practice of medicine laws rather than anything specific. Your arrangement with the health "insurance" company is that they will cover treatments that are objectively medically necessary. In our society, such judgements are made by licensed domain experts with a duty of care (whether a doctor, attorney, professional engineer, etc). Someone without that license (and associated duty of care) is simply not qualified to render an opinion that counts as medical advice.

The overall situation is that the insurance company doesn't want to trust your doctor's judgement [0], so they insist on getting a second opinion about the care you might need to receive. That second opinion is still being performed by a licensed doctor who is supposed to be working in your interests - it's a straightforward practice of medicine the same as if you yourself were to go and seek out a second opinion.

[0] or really they want to play good cop / bad cop - remember "your" doctor themselves is essentially also an employee of the insurance company!

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

#157

Earlier quoted context omitted.

https://news.cornell.edu/stories/2011/08/us-health-care-cost... > A new study finds that the extra time and labor physician practices spend on interacting with insurance companies and government entities cost U.S. physicians $82,975 each per year, while doctors in Ontario spent $22,205. > Canadian physicians follow a single set of rules, but U.S. doctors grapple with different sets of regulations, procedures, require…

You haven't done the math here. Multiply the numbers out. This is what I'm talking about. How are you supposed to engage with these topics if you're literally recoiling from 7th grade arithmetic? Congratulations, taken on your own terms, you just found 3.6% worth of savings from practitioner costs. My local grocery store wouldn't even bother issuing a coupon for that small a discount.

This is one example of an aspect where insurance causes costs that are not directly attributable to the insurer in your numbers.

This isn’t seventh grade math. This is kindergarten level cause and effect.

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

#158

Earlier quoted context omitted.

You haven't done the math here. Multiply the numbers out. This is what I'm talking about. How are you supposed to engage with these topics if you're literally recoiling from 7th grade arithmetic? Congratulations, taken on your own terms, you just found 3.6% worth of savings from practitioner costs. My local grocery store wouldn't even bother issuing a coupon for that small a discount.

This is one example of an aspect where insurance causes costs that are not directly attributable to the insurer in your numbers. This isn’t seventh grade math. This is kindergarten level cause and effect.

Yes, as I said, if we accept your claim at face value, that every dollar of American practitioner-side insurance overhead --- not the delta from Canada, but every single dollar of it --- is mis-spent, you managed to identify 3.6% of the waste in the system. Congratulations.

I said earlier we'd gone round-and-round on this topic before, and I was a little burned out on it, but I didn't expect you to refute your own argument like this. I'm glad we gave it another run this time! This is a great statistic; I'll be using it elsewhere. Thank you.

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

#159

Earlier quoted context omitted.

This is one example of an aspect where insurance causes costs that are not directly attributable to the insurer in your numbers. This isn’t seventh grade math. This is kindergarten level cause and effect.

Yes, as I said, if we accept your claim at face value, that every dollar of American practitioner-side insurance overhead --- not the delta from Canada, but every single dollar of it --- is mis-spent, you managed to identify 3.6% of the waste in the system. Congratulations. I said earlier we'd gone round-and-round on this topic before, and I was a little burned out on it, but I didn't expect you to refute your own ar…

Insurance has more than one way to run the costs up; this is but one of them. Weird rebate deals with drug manufacturers. Vertical integration. Buying practices and paying them higher rates.

> I was a little burned out on it

I just did my taxes and am a little burned out by the $49k in healthcare expenses I got to deduct on them.

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

#160
I understand that nobody likes to talk about setting this threshold, but it's not some kind of unique feature of the American healthcare system. I think the article raised some reasonable concerns about EviCore, but it would be a lot stronger if it did more to contextualize denials in terms of the other quadrants (correct approval, correct denial, incorrect approval, incorrect denial). It would also be interesting to compare those statistics across types of insurers (for-profit, not-for-profit, and government).
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