[zardo]

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.

[nradov]

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.

[zzrrt]

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.

[nradov]

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...

[mindslight]

This seems like a straightforward argument based on existing practice of medicine laws rather than anything specific. Your arrangement with the health "insurance" company is that they will cover treatments that are objectively medically necessary. In our society, such judgements are made by licensed domain experts with a duty of care (whether a doctor, attorney, professional engineer, etc). Someone without that license (and associated duty of care) is simply not qualified to render an opinion that counts as medical advice.

The overall situation is that the insurance company doesn't want to trust your doctor's judgement [0], so they insist on getting a second opinion about the care you might need to receive. That second opinion is still being performed by a licensed doctor who is supposed to be working in your interests - it's a straightforward practice of medicine the same as if you yourself were to go and seek out a second opinion.

[0] or really they want to play good cop / bad cop - remember "your" doctor themselves is essentially also an employee of the insurance company!

[nradov]

It might seem that way to you but that legal theory hasn't succeeded in court. Feel free to try again, though. I'm not claiming that the current legal situation is a good one but any significant change will require an Act of Congress.

[zzrrt]

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.

[teeray]

> 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.

[roenxi]

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 front, whatever is going on here is pretty clearly not insurance at this point; it'd be better just to honestly call it welfare rather than force people to redefine the word 'insurance'. It is hard to talk to people in the US about actual insurance now because they don't have a word for it any more. Politically redefining 'medicine' too would be a mistake, important conversations will become incoherent.

[ceejayoz]

“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.

[roenxi]

But you didn't build my house, and if I literally get angry with you because I think you should abandon your legal shenanigans, admit to being a builder and take on legal liability for the flaws in my house that would confuse you because you are, in fact, probably not a builder and certainly not the person who built my house.

The issue with teeray's original comment is that they are saying someone who isn't practising medicine should be considered to be a medical practitioner. In fact, in this context, teeray is annoyed with them specifically because they didn't practice anything. Your analogy became irrelevant the moment it involved you doing anything.

> “X is or is not medically necessary” seems like a decision a medical professional should determine, no?

No, that is ridiculous. If I think I need to go to a hospital I'm going to go to the hospital. I don't need qualifications to work out something is medically necessary. I'm unlikely to be involved with the medical industry at all unless I've already personally determined it is medically necessary that I consult a doctor.

As a rule of thumb, patients have the final word on what they actually consider necessary. Literally anyone can have an opinion on the subject. Like, for example, an insurance worker. If the patient or the doctor is of a different opinion then they can go pay for the work themselves. It isn't that uncommon to have to go through 3 or 4 medical professionals to find one who agrees that work is necessary; I have a cancer story like that in my family.

[rainsford]

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 after I report some weird respiratory issues, an inspector finds black mold all over the place. The landlord refuses to fix the issue because "black mold is totally fine, bro" and I get really sick. I could maybe have moved out, but I kinda feel like the landlord is going to have a bad time here.

[DangitBobby]

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.

[rainsford]

Words do in fact have meaning, which is why if you want your decision to be viewed as an insurance one rather than a medical one, you probably should avoid using phrases like "medically necessary" as justification for your decision to approve or deny insurance coverage. Using that phrase strongly suggests that while the ultimate decision was about providing or denying insurance coverage, what informed that decision was a medical determination about the actual necessity of the procedure. If you want to keep the decision firmly in the insurance realm, better considerations to mention might be expected lifetime payouts, shareholder value, and "because fuck you that's why".

[jjav]

> Nobody wants them to practice medicine, the question is whether they are they going to hand over the money or not.

This doesn't make any sense. They're not handing over money for fun, they are supposed to pay for the medical services the insurance is supposed to cover. And the only person qualified to decide if that medical service is appropriate is a doctor who specializes in the field of that specific area.

[DangitBobby]

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.

[toast0]

> The requesting provider can do it for free, or the patient can pay cash.

That might not be actually an option. Well the provider can do it for free, probably; but they may not be able to accept money for care that was denied coverage. A Medicare provider can charge patients for things outside the scope of Medicare, but generally can't charge for things in scope but deemed not medically necessary: ex if Medicare says 6 PT visits for whatever and you would like to have 8, you can't pay the provider for two more; you'd have to find a non medicare provider or come back with a fake moustache.

[irishcoffee]

I had to take my kid to an express care doctor in the US. My wife had the insurance cards and was on travel. I said I would just pay cash. They said because I had insurance I was not legally allowed to pay cash.

[nradov]

There is no such law. But many employees in healthcare provider organizations are ignorant about the law and just repeat what someone told them.

[like_any_other]

"We won't pay you" is a business decision. "Not medically necessary" is a medical opinion.

[rainsford]

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 obtain treatment seems immaterial. A doctor who flat out told a patient a certain procedure wasn't medically necessary could be legally liable if that wasn't accurate, so how is the same not true of an insurance company who has far more impact on the ability of the patient to obtain treatment?

The reality is that this is the insurance companies trying to have their cake and eat it too. They actually want to be making a medical decision in denying coverage since it gives them a legitimate reason to do so, but want to avoid any liability if that decision was wrong.

[DangitBobby]

Don't be sorry.

[rcbdev]

Sounds like a massive gap in the legislature. Someone should fix this loophole.

[Phlebsy]

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?