If insurance companies are for profit then they are incentivized to deny coverage. This fucking sucks.
"Not Medically Necessary": Helping America's Health Insurers Deny Coverage
61–70 of 224 posts
Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage
#62Earlier quoted context omitted.
Physician and Hospital resources is a real zero sum game, how do you fairly regulate the medical landscape so those who's lives will benefit most from a procedure will receive the procedure? Who decides this? You? Should we allow everyone in the world who needs a procedure to receive one free and get ahead in line for Americans who need the same procedure? That's what the current climate looks like with unbridaled im…
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Are they? I would love to hear how you would solve those problems rather than make a blythe, thoughtless remark
Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage
#63“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…
Physician and Hospital resources is a real zero sum game, how do you fairly regulate the medical landscape so those who's lives will benefit most from a procedure will receive the procedure? Who decides this? You? Should we allow everyone in the world who needs a procedure to receive one free and get ahead in line for Americans who need the same procedure? That's what the current climate looks like with unbridaled im…
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 for a $13.00 cost. Oh you're at the max for this service for the year because we accumulated the estimated cost when you started calling doctors about what the after-insurance cost will be. Wait a minute this out-patient consult is actually a surgery because you saw a surgeon so it must have been a surgery, and it's not medically necessary to have the surgery without the consult.
Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage
#64Earlier quoted context omitted.
Physician and Hospital resources is a real zero sum game, how do you fairly regulate the medical landscape so those who's lives will benefit most from a procedure will receive the procedure? Who decides this? You? Should we allow everyone in the world who needs a procedure to receive one free and get ahead in line for Americans who need the same procedure? That's what the current climate looks like with unbridaled im…
Every other country seems to solve it
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Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage
#65Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage
#66Earlier quoted context omitted.
Physician and Hospital resources is a real zero sum game, how do you fairly regulate the medical landscape so those who's lives will benefit most from a procedure will receive the procedure? Who decides this? You? Should we allow everyone in the world who needs a procedure to receive one free and get ahead in line for Americans who need the same procedure? That's what the current climate looks like with unbridaled im…
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
Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage
#67The problem here is one of balance.
As with so many situations where you have unreasonable corporate behavior the problem is the economics favors making wrong decisions. Thus there will be little attempt to prevent those wrong decisions. The only real fix is to make wrong decisions cost--look at airlines. You end up with more passengers that seats, you pay. It went a long way towards addressing the problem. (But it should have been higher and it should be indexed to inflation.)
But note the insurance is not always the bad guy. Patients want things that aren't medically warranted, especially when the right answer is "do nothing". And doctors like to run up the bill.
And note this article is focusing on things other than medical decisions--but describing a system that could only be a problem if they are making wrong medical decisions. How they decide what claims to examine is irrelevant, what matters is if they are making wrong medical decisions. It very much needs to be considered the practice of medicine and a denial should only come from someone of at least the same specialization as the doctor making the request. And "not medically necessary" should require an evaluation of why, you don't get to just say "no".
Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage
#68I 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 denying someone critical care that could kill them or cause them harm" and you're comfortable just mashing that button? How do they sleep at night? Or are there just a lot of really gung ho believers that hate provider billing with a passion and believe most of it is waste and they truly know better? Is it a bunch of sociopaths? How this can exist as an industry is crazy to me, I wouldn't even know how to hire, I'd expect the vast majority of applicants upon finding out would say "ew, no" but I guess I have a rosier view of humanity that does not align with reality.
Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage
#69Medicare 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…
I’m 40, on Social Security Disability Insurance and recently became eligible for Medicare.
After years on Kaiser because of familiarity, when I became eligible for Medicare, I had to make a choice between original Medicare or Medicare Advantage.
It’s incredible expensive to buy into adequate coverage if you’re under 65 and on disability and want original Medicare, but after the mixed experience I had with Kaiser, I wouldn’t have it any other way.
As I have some serious health conditions, I signed up with Plan G Extra and a high coverage tier for Part D. It’s going to cost about $1300/mo plus an additional $202.90/mo for part B, but it’s better than having to worry about future health issues putting me in financial ruin.
Nice to preserve choice being responsible for at most a $283 deductible per year on top of the monthly cost.
I had a 3 day hospital stay in December 2024 that was $75,000 and I didn’t have to pay for it, so it was worth it to have good coverage.
Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage
#70Earlier 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.
> 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.