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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

#81

Post by recursivecaveat »

khriss wrote: 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.

A family member recently got a routine physcial blood test panel taken. The company made 3(!) separate overcharge billing errors associated with this one screening. Their doctor had to be pulled in and wasted a considerable amount of time clearing this up, doing stuff like affirming to their support that the documentation from their own front desk was accurate. Maybe for every $100 of doctor time they waste they collect $101 from patients who give up. No wonder its a black hole of money.

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

#82

Post by ben-johnson »

nick__m wrote: post #76
ben-johnson wrote: post #64

Earlier quoted context omitted.

[flagged]

I live in Québec, Canada and the longest I had to wait was 3 months for a gallbladder ablation. And my wife, who is on her fourtht year of ribociclib to prevent her spinal metastasis (breast cancer) from coming back, have timely periodical CT-PET and IRM scans. MAID is popular not because of lack of care but because Québécois values their autonomy and quality of life above being simply alive for the longest time poss…

In the US nobody waits three months for a simple gall bladder ablation. What's crazy is you think that's normal. She has 'timely' scans because they are made months in advance.

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

#83

Post by js2 »

Animats wrote: post #37
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…

Yes. "Medicare Advantage" = HMO. All the usual HMO problems. The best Medigap plan is Plan F, which is no longer available to new subscribers. "Discontinuation of Medicare Plan F was a strategic decision aimed at promoting responsible healthcare spending and ensuring the financial sustainability of the Medicare program." It covers just about everything Medicare doesn't pay, including the various deductibles Medicare…

MA is not necessarily an HMO. It's up to the operator. Some are HMOs, some are PPOs, some are neither.

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

#84

Post by ben-johnson »

throwway120385 wrote: post #65
ben-johnson wrote: post #64

Earlier quoted context omitted.

[flagged]

> In Canada, the wait is so long for free specialized procedures that many patients choose euthanasia instead. This claim is so outlandish that I'd like to see some sources for it.

[flagged]

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

#85

Post by ceejayoz »

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…

“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.

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

#86

Post by analog31 »

ben-johnson wrote: post #64
hdgvhicv wrote: post #56

Earlier quoted context omitted.

Every other country seems to solve it

[flagged]

Wait times in my region are 12-24 months. My "annual" appointments with generalists occur roughly 18 months apart, and usually involve being seen by a PA or NP.

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

#87

Post by ceejayoz »

ben-johnson wrote: post #82
nick__m wrote: post #76

Earlier quoted context omitted.

I live in Québec, Canada and the longest I had to wait was 3 months for a gallbladder ablation. And my wife, who is on her fourtht year of ribociclib to prevent her spinal metastasis (breast cancer) from coming back, have timely periodical CT-PET and IRM scans. MAID is popular not because of lack of care but because Québécois values their autonomy and quality of life above being simply alive for the longest time poss…

In the US nobody waits three months for a simple gall bladder ablation. What's crazy is you think that's normal. She has 'timely' scans because they are made months in advance.

My dermatologist books nine months in advance. My wife’s neurologist books six months out. Long waits are absolutely a thing in the US. A surgery she needed took 18 months to go through.

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

#89

Post by ceejayoz »

ben-johnson wrote: post #84
throwway120385 wrote: post #65

Earlier quoted context omitted.

> In Canada, the wait is so long for free specialized procedures that many patients choose euthanasia instead. This claim is so outlandish that I'd like to see some sources for it.

[flagged]

https://en.wikipedia.org/wiki/Assisted_suicide_in_the_United...

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

#90

Post by nonfamous »

ben-johnson wrote: post #84
throwway120385 wrote: post #65

Earlier quoted context omitted.

> In Canada, the wait is so long for free specialized procedures that many patients choose euthanasia instead. This claim is so outlandish that I'd like to see some sources for it.

[flagged]

Sources do not support claim.
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