[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.