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

propublica.org

41–50 of 224 posts

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

#41

America cannot, as a country, discover a reasonable approach to managing health care costs because Americans do not have a sufficient core set of shared political values. The solution is to end regulation at the federal level, and allow the states to determine what regulations they may deem appropriate. As a New Hampshire libertarian, I do not want Californian progressives telling me how our state must manage health…

I think the vast majority of people agree on the generalities and care enough about solving the issue to be able to come to an agreement on the particulars. The problem is that the people who get rich off the current system won't agree to any solution that reduces their profits, and have thus far managed to fillibuster attempts at such a solution through a combination of buying politicians and propagandizing certain…

Healthcare is ~17% GDP

Slavery was estimated at ~12% and "hey, you need to lose a few % of your margin and actually pay those people" started a war.

Now, there's an argument to be made about ideology, geographic concentration of industry, etc. doing a fair bit of lifting kicking that off (their own neighbors telling them to stop surely would have gone over better than a bunch of smarmy northerners in their ivory towers telling them the same thing). But the fact remains that you cannot make a large fraction of the country take a haircut without causing strife.

The only way to fix this "nicely" at this point is to boil the frog over decades.

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

#42

“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…

First off, thank you for taking the time to do it. I know most people don't agree on many things today, but most Americans agree the current system is stacked against them. Not to search very far, I have good insurance and I still have to deal with things that border on criminal.

Two, that book may be a good idea:D

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

#43
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.

... and that money isn't going to insurers.

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

#44

Earlier quoted context omitted.

[flagged]

yes... sarcasm... Totally unrelated. In traditional stories, as anyone ever been upset when the knight slays the dragon at the end because the dragon was hoarding all the gold and killing the townspeople? I was never upset when the dragon got slayed. EDIT: Yeesh. I guess people here really like it when the dragon wins. Oh well. I guess people have to die so the dragon can hoard the wealth.

have they managed to wrangle a jury yet?

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

#45
post #12

“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 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.

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

#46

Earlier quoted context omitted.

[flagged]

yes... sarcasm... Totally unrelated. In traditional stories, as anyone ever been upset when the knight slays the dragon at the end because the dragon was hoarding all the gold and killing the townspeople? I was never upset when the dragon got slayed. EDIT: Yeesh. I guess people here really like it when the dragon wins. Oh well. I guess people have to die so the dragon can hoard the wealth.

Not even. Just look at it by the numbers. If one in every 10k, 20k, IDK but surely you don't even need 1:1k, life alteringly aggrieved people threw what was left of their lives away getting even instead of just taking it the sheer economics would make most of the bad stuff stop.

This applies to just about everything, not just medical.

The suffering in society always reaches equilibrium with the pushback and modern people are very, very, very docile so we're made to suffer a lot.

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

#47

“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…

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.

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

#49
> In 2022, Carelon settled a lawsuit for $13 million that alleged the company, then called AIM, had used a variety of techniques to avoid approving coverage requests. Among them: The company set its fax machines to receive only 5 to 10 pages.

Who are the people who sleep at night after designing these policies?

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

#50
post #12

“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 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.

Right? Lawyers can get into deep shit if they misrepresent their ability to well, represent a client on a case outside of their area of competence. How are medical professionals that often won't even tell you what they think about a test result and refer you to a specialist to actually get a diagnosis able to ethically represent what a patient actually needs?
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