These "doctors" should be barred from practicing medicine. I am not a lawyer, but it would seem that this practice also borders on criminal negligence.
> Having the weight of an MD behind a decision can be powerful, but lawyers and judges who’ve handled these sorts of cases say it can be misleading. Although doctors ultimately determine whether to cut off insurance coverage for a particular treatment, those decisions are generally not considered the practice of medicine and therefore cannot be challenged in a malpractice lawsuit. The doctors advising insurance companies can’t be individually sued on medical grounds, even if something goes wrong after the denial. As a result, their names are cited in lawsuits filed against the insurers, but they are not defendants in suits brought by people denied insurance.
That's a very different scenario than a doctor who is being paid to provide an expert opinion on the medical necessity of care. That obviously should be considered practicing medicine with all the normal liability.
These insurance doctors are not really evaluating case particulars. They are not second-guessing the diagnosis, they are looking at whether the proposed treatment is the "standard of care" for the diagnosis, and that customary less expensive/invasive treatments have been exhausted. Medicare and any other potential "single payer" government plan would do this also because sadly fraud by clinicians does exist.
For example when I had an injury I had to do 6 weeks of physical therapy (without improvement) before they would authorize an MRI scan and then surgery.
This is all just semantics. Arguably, the arbiter of what is "medically necessary" is practicing medicine. They have chosen to intercede in your care, and they should be liable for the decisions that they make leading to your health outcomes.
The legal system could just as easily have seen that the determination of which procedures are "medically necessary" is indeed part of medicine itself. It's a miracle of delusion and corruption that it went the other way.
Being an expert doesn't mean you are "practicing medicine". Suppose the medical standard is "you must examine the patient in person when creating a treatment plan."
We're going to apply that to some insurance job function operating outside standard medical practice how exactly?
These are licensed doctors (required!) being paid to explicitly evaluate the case, though, to determine if treatment is "medically necessary". Seems like a deeply different scenario.
Denying care is the default state. It's the basis of the Hippocratic Oath, "First, do no harm." I.e. the determination of whether a treatment is beneficial is made by comparing it to doing nothing.
In these cases, a clinician has already decided that care is needed. It is a third party, who is not responsible for providing care, that is making the final determination. This has little to do with the Hippocratic Oath.
It's also how first responders deal with feeling responsible if someone dies on them. They did more than nothing, so their presence improved the odds even if the result was the same.
I'm guessing it's some thin veneer of bullshit like "well, the patient can still pay $500k directly out of pocket, so we're not technically interfering with the care, just the payments!"
> Having the weight of an MD behind a decision can be powerful, but lawyers and judges who’ve handled these sorts of cases say it can be misleading. Although doctors ultimately determine whether to cut off insurance coverage for a particular treatment, those decisions are generally not considered the practice of medicine and therefore cannot be challenged in a malpractice lawsuit. The doctors advising insurance companies can’t be individually sued on medical grounds, even if something goes wrong after the denial. As a result, their names are cited in lawsuits filed against the insurers, but they are not defendants in suits brought by people denied insurance.