[lp4v4n]

>The popular image of a denial is an insurer overruling a doctor on whether a treatment is needed. That is the exception. Only about 5% of denied in-network claims were turned down because the care was deemed not medically necessary. The rest were administrative, for an excluded service, for a missing referral or prior authorization, or for a reason the insurer never specified.

When an insurance company denies a health claim overruling a doctor, it can be necessarily concluded that either:

1. somehow the company knows more about the patient's condition and the doctor is wrong

2. the doctor is defrauding the system and the insurance company caught the doctor cheating

3. the company is defrauding its clients.

There is no middle ground honestly, and yet "5% of denied in-network claims were turned down because the care was deemed not medically necessary".

This is absolutely crazy and evil. I would expect a few thousand cases annually and probably for million of cases you get denied what you pay for because "we detected your doctor is wrong and we're not paying".

>In fact the single largest category, 36% of denials, was an unexplained "other." A system that rejects tens of millions of claims a year and files more than 1/3 of those rejections under no stated reason is hard for an outsider, or a member, to audit.

I can't even imagine getting lifesaving care denied because of "other". I didn't know things were so grim in the USA and honestly now I'm kinda surprised that more people are not getting "Luigi'd".

[FireBeyond]

Having worked at companies that built software for health insurers, I have seen the "evil" you describe. From "hey, can we mine the claims database for suspected/confirmed familial relationships and look at possible diagnoses to assign risk profiles?" No, you can't. "Why not? It's in the database." Because it's federally illegal. "Oh. So you won't expose that data?" We won't.

In this case, two things:

The system decides on the initial denial at most insurers. And when a claims adjuster reviews, the system is presumed to be accurate, and the adjuster has to provide reasoning to overturn the system's denial (this is before the denial has been returned to the provider). It's not "assume the provider was correct", but "we've decided to deny it, give the system reasons why we shouldn't". And that person reviewing it is often an LPN (no shade thrown at LPNs, but they shouldn't be overriding physician decisions, doubly so given an absent history).

How this has affected me personally: I had, for most of my life, a severely deviated septum. I spent most of my life mouth breathing because I could barely pull enough air through my nostrils to make breathing that way not an active effort. I finally went to an ENT who confirmed, sure enough, an approximately ninety per cent deviation. "Great, so lets schedule surgery". ENT: "Slow down. First I have to prescribe you these two nasal sprays so that when you come back in four weeks and report no change, because to both our disappointment, the sprays didn't realign and open up the cartilage in your nose, then I can submit the pre-auth to your insurer and they won't immediately reject it." What a fucking joke.

> "we detected your doctor is wrong"

It's not even that your doctor is wrong, it's "our nurses/expert systems disagree with your doctor so we're not paying".

[umpalumpaaa]

It should be noted that they use the term “medically necessary” which is a very low standard.

There is also “medically reasonable”.

For example getting your teeth cleaned professionally is not medically necessary. But it’s medically reasonable.

I don’t want a health insurance that only does “Medically necessary” things.

[codeddesign]

Dental is completely different than medical in the U.S. and a different insurer/carrier. Sorry, but comparing apples to oranges here.

[akramachamarei]

You shouldn't be getting downvoted.

For those who don't know, I'd recommend the Freakonomics The Economics of Everyday Things episode on dental insurance. IIRC, dental "insurance" has little in common with insurance in general. As a financial product, it's more like an invested savings account.

[bonsai_spool]

> 5% of denied in-network claims were turned down because the care was deemed not medically necessary".

I think the truth is murkier than what you're providing. With the caveat that I am presenting a strong case here that likely isn't what occurs most of the time, consider this:

A person may require long-term therapy after an illness. There are data suggesting that beginning this therapy works better once you attain a certain level of clinical recovery in the hospital. There are also data suggesting that it's better to begin the long-term therapy as early as possible.

Both sets of data are, on their face, credible. There is no obvious reason to always believe one set of data over another. Reasonable people can make reasonable arguments to reasonable listeners for either case. Note that this does not mean that there is not a 'correct' interpretation for any given person's clinical situation!

So what does your insurance company favor? Obviously it will always favor the less expensive option, and there will be no way for them to be convinced otherwise because the underlying question is just not well-determined.

[rainsford]

But in a case where either treatment choice could be reasonable, doesn't it seem like a better answer for the insurance company to defer to your doctor rather than their own assessment? Whoever is making that determination at the insurance company doesn't know you, hasn't treated you, may or may not have more expertise on the specific illness than your doctor, and as you pointed out the insurance company doctor is ultimately motivated by keeping costs low more than they are motivated by keeping you healthy.

Obviously I can see why the insurance company would prefer to be making decisions about your treatment, but it's not obvious why any of the rest of us should view that as an optimal or even acceptable way of running healthcare. It's essentially the car insurance model but with vastly higher consequences, and it's not great even when it comes to car insurance.

[tbrownaw]

4. It's something that might help a bit, but the patient would still be fine without. Ie, a disagreement over what "necessary" means.

[BrenBarn]

That is still the insurer saying they know more about the medical situation than the doctor. The doctor is the one who is equipped to decide what is necessary.

[Georgelemental]

The doctor is not infallible. He or she is likely extremely busy, and under many pressures, e.g.:

- patients who adamantly insist on X treatment, make a fit and threaten a bad review, even though they don't need it

- fear of malpractice suits (e.g. 99.9% chance treatment is unnecessary and a waste of money, but in the 0.1% case I might get sued to oblivion if I didn't prescribe it)

- intense lobbying from pharma companies who spend boatloads of money trying to convince them to prescribe their products

In general, they don't directly pay the costs of using limited healthcare resources, but they can pay serious costs for failing to use them, so their incentives are skewed.

Our current system is far from ideal. But a system where a single person gets to make all the decisions, while foisting all the financial burden on someone else, would collapse within a week. Someone has to be the bad guy to sometimes say "we can't afford this, sorry".

[tfrancisl]

... which many would argue is between a patient and their doctor. We dont pay premiums for no reason, and the insurance company isnt really allowed to determine what "necessary" means.

[cucumber3732842]

You ever been to an obstinate DMV? Dealt with an obstinate permitting office? They all act like this. They unilaterally concoct rules that make it hard for honest people doing honest things to get the outcomes they ought to.

Healthcare ain't no different. Bureaucracy gonna bureaucracy.

[colonCapitalDee]

There is absolutely a middle ground? The healthcare system, like any system, has an incentive structure. Doctors are incentivized to prescribe treatments, because that's how they make money for themselves and their practice. Doctors are not angels sent from heaven, they're people like you and me, and they respond to incentives like you and me. It's also well known that people strongly prefer receiving treatment over not receiving treatment, even when the cost to their health of receiving that treatment outweighs the expected benefit! Given that people push their doctors into prescribing treatments, and doctors are incentivized to go along with it... you would obviously expect some proportion of prescribed treatments to not be medically necessary. 5% sounds about right. And the kicker is that denying these treatments improves health outcomes for the general population, because those medical resources can get routed to the people who actually need them. Every successful public health system has an opposing force built in to it to limit the spurious consumption of scare medical resources, because without such a force costs balloon and the system becomes unsustainable. Not to defend the US healthcare system of course, our cost problem is worse than anywhere else...

[bonsai_spool]

> Doctors are incentivized to prescribe treatments, because that's how they make money for themselves and their practice.

This is literally illegal! Physicians cannot refer patients to entities they own or have an interest in.

What is perverse is that, while we have the Stark Law to constrain physician behavior, we've decided that it's okay if a diffuse group like a non-physician-owned hospital chain enforces rules to this effect.

[FireBeyond]

Diagnostic imaging companies - each of the big ones (Siemens, GE, Philips) all offer in-house financing on very favorable terms for MRI, CT, etc., that they specifically advertise to physicians. They also all offer specialist consulting help to facilitate you getting a CoN (Certificate of Need) for your facility. Hell, they also will help you find other physicians in your area who'd like to go in with you on setting up a DI facility, and they will assist with spinning up the practice.

We then find that physicians who own a DI practice (or a share in one) refer their patients to diagnostic imaging at rates several standard deviations above other physicians and at rates that are "statistically improbable" when correlated to underlying ICD-10 diagnostic codes.

[bonsai_spool]

Everything above is fair, if true. I don't see a reference in your answer so I can't assess the quality of evidence.

The point is that they cannot refer you to one of their companies. Of course, there may not be a meaningfully-competitive local market, so patients may end up needing to go to the physician-owned imaging facility. I do not thing this is a large issue for most of the US population though it's probably an issue on a spatial basis.

[FireBeyond]

> Of course, there may not be a meaningfully-competitive local market, so patients may end up needing to go to the physician-owned imaging facility.

Certificates of Need. A legal requirement in most states for creating a new healthcare facility. Ostensibly to make sure that the population in that area has adequate healthcare options. But lobbied for by healthcare facility and hospital owners, it actually surveys other providers (your competitors) in the area and asks if their revenue would be adversely affected by you opening up. Too much of this, and no CoN for you.

[lostlogin]

> This is literally illegal! Physicians cannot refer patients to entities they own or have an interest in.

There has to be a done of exceptions to this.

You see a cardiologist and they recommend a stent. They aren’t going to recommend a different cardiologist does it.

You see a doctor, and they refer you for a test. They have a share portfolio that contains shares in the facility they referred to.

Medicine is riddled with potential conflicts of interest. Managing them is what professionals are supposed to do and what regulators are supposed to enforce.

I don’t live in the US, I’m a n Mew Zealand. Sadly, I am aware of behaviour that looks like corruption in our system.

[bonsai_spool]

> You see a cardiologist and they recommend a stent. They aren’t going to recommend a different cardiologist does it.

Things must be different in NZ.

First, it's true that you're going to want to go to who your doctor knows/recommends. The law in the US is just that they can't refer you to a group they own/their spouse owns, or for which they get a financial benefit.

Next, you're speaking about the doctor doing a consult visit before doing a procedure. That is not the same thing as ordering a treatment for you to go get the treatment elsewhere—which describes what happens you go to the pharmacist to get drugs.

Finally, the cardiologist you see in the office is almost certainly not doing stents for you as those are very distinct skillsets (in the US).

[dogmatism]

>Finally, the cardiologist you see in the office is almost certainly not doing stents for you as those are very distinct skillsets (in the US).

Umm, what? No. It's exceedingly rare for an interventional cardiologist in the US not to do office work. The average number of PCI/yr is like 50 or something. Plus if one spent all one's time in the cath lab, they'd have a spinal fusion, knee replacement, thyroid cancer, and cataracts.

But what you are trying to get at is that there is law about self-referral ("Stark law") but in reality there are exceptions that render it fairly useless

[bonsai_spool]

> But what you are trying to get at is that there is law about self-referral ("Stark law") but in reality there are exceptions that render it fairly useless

What are the exceptions that render it useless? I have never heard of them in my 10+ years of hearing about it.

I did not know that I-cards do office work, not my area of medicine.

IR is in the angio lab daily without cataracts, thyroid cancer, etc., so that part of your statement is clearly not true.

I also don't understand what you mean about knee replacements... humans are generally capable of standing without requiring surgical intervention.