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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

#171

Post by zzrrt »

nradov wrote: post #141
zzrrt wrote: 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...

Okay, I was too glib, but without specifically examining state laws and the percentages of patients they affect, this is also too vague. Yes, some states do require a doctor to review denials. https://www.ama-assn.org/system/files/prior-authorization-st... Now that I see this is not universal, I concede my argument doesn't prove much outside of those states.

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

#172

Post by mancerayder »

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…

Definitely write to NYT or Guardian or Atlantic about this stuff! Journalists probably have a ton of info on how messed up the system is, but if feels like you have data-backed opinions and documentation to remind yourself of examples!

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

#173

Post by mancerayder »

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…

Another idea: why can't these claim reviewers pass some sort of government or medically-licensed authorization to do this work?

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

#174

Post by DangitBobby »

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…

If you aren't legally qualified to make medical decisions then you are not allowed to use terms like "medically necessary" in your decisions. That our judges haven't bothered doesn't protect us from this obviously illegal abuse is just one of a million of illustrations of how poor our legal system is.

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

#175

Post by DangitBobby »

rainsford wrote: post #127
ceejayoz wrote: post #85

Earlier quoted context omitted.

“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…

That analogy would make sense if there were a credential that one had to have to make an authoritative decision, and the people making the decisions lacked the credential.

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

#176

Post by DangitBobby »

rainsford wrote: post #121
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.

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…

Don't be sorry.

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

#177

Post by Nomadeon »

Even if you get an approval for an expensive specialty drug, good luck.

I had the insurance written approval in my hand while the pharmacist told me it was being rejected for needing prior approval. The insurance phone rep said they could find no record of any REQUEST, let alone approval, for the drug.

So I go to the state insurance regulator. That does at least light a fire under their arse. They can't claim it's not medically necessary when I already have their approval.

During the complaint process I learn: - Front line reps don't have any access to any pre-auths. You need to talk to a supervisor. They ADMITTED the system is by design obstructive. - The person who entered my approval did it wrong and did not follow the SOP to run a test transaction that would have caught the error.

They then submit their reply to the regulator leaving out all of the above and blaming the pharmacy instead. I follow up with the regulator pointing this out. I have voice recordings.

Regulator closed it as resolved.

I'd class action their butts if I wasn't still exhausted by the experience two years later.

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

#178

Post by yks »

JohnMakin wrote: post #68

I am perplexed by the type of people that are able to stomach working in these kind of positions - how do they rationalize it? Do they really just not care? Like, in some industries that are not doing great things, or bordering on evil things, I can see sometimes how one could convince themselves they were actually doing good. But this denial stuff is nearly like, "press this button to make money, knowing you may be…

I recommend reading essays from: https://news.ycombinator.com/item?id=48090321. Tangentially related to your question.

TLDR is that it’s a job that can pay enough to keep one housed, and sometimes there are no alternatives.

I’d redirect the outrage away from the grunts denying care, and towards the leadership that set up those incentives. And even further, when the shareholders demand more profit because the line must go up, what to do?

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

#179

Post by array_key_first »

ben-johnson wrote: post #66
throwway120385 wrote: post #63

Earlier quoted context omitted.

Why not pay for these things out of taxes? I don't think you'll be so quick to defend the system if you ever find yourself needing care beyond a checkup once a year. It's designed to make the insurance carrier money by constantly having little costs slip through the cracks that should be covered. Get a dental checkup? Sorry one of your X-Rays wasn't covered but the other ones were. Now you get to spend hours fighting…

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

You can most definitely create both hospitals and doctors using money.

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

#180

Post by CalChris »

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.

In fact, MA costs the government more per person than does TM. MA may have been lobbied for as a cost saving measure. It is, in fact, a profit center for insurance companies.

https://www.kff.org/medicare/higher-and-faster-growing-spend...

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