“The algorithm cannot say no, however. If it finds problems, it sends the request for review to a team of in-house nurses and doctors who consult company medical guidelines. Only doctors can issue a final denial.”
As a physician, I’ve had to speak to these so called “peers” in a peer to peer denials with both my clinic and hospital setting. They are usually people who aren’t physicians as a first line of their defense, ie therapist, nurses, etc. This weeds out the providers who either don’t care about the patient denial and blindly accept the denial, or patient has to take matters in their own hands just to get the care they need/deserve. Or worse, in the hospital that means the patient gets hit with a huge bill (already an insane number in the US even with insurance, so don’t get me started on this) or it gets delegated to another provider who has to deal with it. Quite often patients get denied medical and rehab services, esp after something debilitating like a stroke, trauma/accident, etc. and at that point the peer to peer is to weed the provider out. Usually someone will tell the patient you’ve been denied, either go home without the services they need or you fight it.
I fight it. Can’t count the number of times I’ve spoken to someone not in the field of medicine or if they are, not my field of medicine (both Family/Hospital Medicine). Often I’m fighting with an MD or “practitioner” who is some other field like a gynecologist about hospital medicine services or rehab. I’ve even had the pleasure of talking to a physical therapist and didn’t let me get a word in as we began the peer to peer. I now start of by asking for their credentials and field of speciality and demand a peer of my field to do the denying if they are so adamant about it “not being medically necessary”.
I have so much to say and could write a book about it. I just wish I had the money and connections to actually change the state of US of Corporate Medicine.
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.
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.
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?
This is good to hear. My mother was a PA for a private practice and also would often call the insurance providers to challenge denials, often from people far from the relevant specialty. By her accounts she was usually able to reverse the denials.
It's like any time spend on billing or administrative work, it's baked into the costs. (Administrative costs is a big component of rising healthcare costs.)
Depending on the issue, the patient may be needed to provide supporting paperwork, like previous diagnoses or treatment for providers. Other than that, not really, short of taking legal action.
First off, thank you for taking the time to do it. I know most people don't agree on many things today, but most Americans agree the current system is stacked against them. Not to search very far, I have good insurance and I still have to deal with things that border on criminal.
seriously consider that book if you can fill it up with these types of stories. A book like this could be a huge hit, get this issue even more spotlight and maybe some fixes.
Physician and Hospital resources is a real zero sum game, how do you fairly regulate the medical landscape so those who's lives will benefit most from a procedure will receive the procedure?
Who decides this? You?
Should we allow everyone in the world who needs a procedure to receive one free and get ahead in line for Americans who need the same procedure? That's what the current climate looks like with unbridaled immigration under progressives.
Why not pay for these things out of taxes? I don't think you'll be so quick to defend the system if you ever find yourself needing care beyond a checkup once a year. It's designed to make the insurance carrier money by constantly having little costs slip through the cracks that should be covered. Get a dental checkup? Sorry one of your X-Rays wasn't covered but the other ones were. Now you get to spend hours fighting for a $13.00 cost. Oh you're at the max for this service for the year because we accumulated the estimated cost when you started calling doctors about what the after-insurance cost will be. Wait a minute this out-patient consult is actually a surgery because you saw a surgeon so it must have been a surgery, and it's not medically necessary to have the surgery without the consult.
Because there are a finite number of doctors and hospital beds and you can't create either by throwing more money at the problem. You didn't actually read the content did you
Do they? Which countries have solved it? In Canada, the wait is so long for free specialized procedures that many patients choose euthanasia instead. Can't imagine it's better anywhere else. Which countries have solved it?
In the early 2000s I got a job right out of highschool working at a Blue Cross Blue Shields call center. I thought it was going to be customer service but it was insurance claims. Training was supposed to be 6 weeks but they pushed me live after just 2. I had no idea what I was doing. After floundering for a couple weeks trying to learn to basically be a fuckin doctor, I just started approving everything. "Patient needs emergency surgery for X" "Approved". The whole experience was completely insane.
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.
With Medicare Advantage you sign over your Medicare rights+benefits to a private insurer. This may save you some money, especially early on. In fairness, not really a lot and the $0/mo plans are a scam. With Medicare Advantage, you will then have to argue with an insurance company for the rest of your life. You'll have to deal with preauthorizations and a restricted network.
With Traditional Medicare, what's covered is spelled out pretty clearly ahead of time. Docs know it. You know it. There's literally an app for that. With Medicare Advantage, medically necessary is at the discretion of the private insurance company.
Here is the scenario from a relative: he had a heart event which ended up needing a stent. He had to argue with Kaiser while this was going on. Kaiser is 240,000 people. He is one.
Medicare Advantage is very profitable.
It is possible to switch back from MA to TM which really revolves around your Medigap plan. You are guaranteed issue for Medigap plans for about 3 months before/after you turn 65. After that, you will have to undergo medical underwriting.
"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 has. If Medicare covered Medicare's part, the Plan F provider has to pay their part. They don't get to question it. I don't even see hospital bills, just statements that it's been paid for.
The theory behind Medicare Advantage is that it would cost the government less than traditional Medicare because the private insurer would be more efficient. Guess what happened.
> In 2022, Carelon settled a lawsuit for $13 million that alleged the company, then called AIM, had used a variety of techniques to avoid approving coverage requests. Among them: The company set its fax machines to receive only 5 to 10 pages.
Who are the people who sleep at night after designing these policies?
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.
As with so many situations where you have unreasonable corporate behavior the problem is the economics favors making wrong decisions. Thus there will be little attempt to prevent those wrong decisions. The only real fix is to make wrong decisions cost--look at airlines. You end up with more passengers that seats, you pay. It went a long way towards addressing the problem. (But it should have been higher and it should be indexed to inflation.)
But note the insurance is not always the bad guy. Patients want things that aren't medically warranted, especially when the right answer is "do nothing". And doctors like to run up the bill.
And note this article is focusing on things other than medical decisions--but describing a system that could only be a problem if they are making wrong medical decisions. How they decide what claims to examine is irrelevant, what matters is if they are making wrong medical decisions. It very much needs to be considered the practice of medicine and a denial should only come from someone of at least the same specialization as the doctor making the request. And "not medically necessary" should require an evaluation of why, you don't get to just say "no".
I am perplexed by the type of people that are able to stomach working in these kind of positions - how do they rationalize it? Do they really just not care? Like, in some industries that are not doing great things, or bordering on evil things, I can see sometimes how one could convince themselves they were actually doing good. But this denial stuff is nearly like, "press this button to make money, knowing you may be denying someone critical care that could kill them or cause them harm" and you're comfortable just mashing that button? How do they sleep at night? Or are there just a lot of really gung ho believers that hate provider billing with a passion and believe most of it is waste and they truly know better? Is it a bunch of sociopaths? How this can exist as an industry is crazy to me, I wouldn't even know how to hire, I'd expect the vast majority of applicants upon finding out would say "ew, no" but I guess I have a rosier view of humanity that does not align with reality.
> Connecticut’s Insurance Department recently reviewed EviCore and Carelon. It found no problems with Carelon. EviCore was fined $16,000 this year for more than 77 violations found in a review of 196 files.
$16k is such a low fine that it’d be funny if it wasn’t so sad. fines should be increased to actually represent a threat to the company - maybe as a % of yearly profit?
Geiz-ist-geil-healthcare is, according to many election results anyway, what most US citizens want; everything else is communism/socialism/woke/leftist/[...].
“The algorithm cannot say no, however. If it finds problems, it sends the request for review to a team of in-house nurses and doctors who consult company medical guidelines. Only doctors can issue a final denial.”
As a physician, I’ve had to speak to these so called “peers” in a peer to peer denials with both my clinic and hospital setting. They are usually people who aren’t physicians as a first line of their defense, ie therapist, nurses, etc. This weeds out the providers who either don’t care about the patient denial and blindly accept the denial, or patient has to take matters in their own hands just to get the care they need/deserve. Or worse, in the hospital that means the patient gets hit with a huge bill (already an insane number in the US even with insurance, so don’t get me started on this) or it gets delegated to another provider who has to deal with it. Quite often patients get denied medical and rehab services, esp after something debilitating like a stroke, trauma/accident, etc. and at that point the peer to peer is to weed the provider out. Usually someone will tell the patient you’ve been denied, either go home without the services they need or you fight it.
I fight it. Can’t count the number of times I’ve spoken to someone not in the field of medicine or if they are, not my field of medicine (both Family/Hospital Medicine). Often I’m fighting with an MD or “practitioner” who is some other field like a gynecologist about hospital medicine services or rehab. I’ve even had the pleasure of talking to a physical therapist and didn’t let me get a word in as we began the peer to peer. I now start of by asking for their credentials and field of speciality and demand a peer of my field to do the denying if they are so adamant about it “not being medically necessary”.
I have so much to say and could write a book about it. I just wish I had the money and connections to actually change the state of US of Corporate Medicine.
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.
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.
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?
This is good to hear. My mother was a PA for a private practice and also would often call the insurance providers to challenge denials, often from people far from the relevant specialty. By her accounts she was usually able to reverse the denials.
As someone who needs expensive medication, thank you. I appreciate it.
2 questions:
It's unpaid time, but that'll just get factored into the rates charged for billable things like appointments and procedures.
It's like any time spend on billing or administrative work, it's baked into the costs. (Administrative costs is a big component of rising healthcare costs.)
Depending on the issue, the patient may be needed to provide supporting paperwork, like previous diagnoses or treatment for providers. Other than that, not really, short of taking legal action.
First off, thank you for taking the time to do it. I know most people don't agree on many things today, but most Americans agree the current system is stacked against them. Not to search very far, I have good insurance and I still have to deal with things that border on criminal.
Two, that book may be a good idea:D
seriously consider that book if you can fill it up with these types of stories. A book like this could be a huge hit, get this issue even more spotlight and maybe some fixes.
Physician and Hospital resources is a real zero sum game, how do you fairly regulate the medical landscape so those who's lives will benefit most from a procedure will receive the procedure?
Who decides this? You?
Should we allow everyone in the world who needs a procedure to receive one free and get ahead in line for Americans who need the same procedure? That's what the current climate looks like with unbridaled immigration under progressives.
These are hard questions. What's the answer?
Why not pay for these things out of taxes? I don't think you'll be so quick to defend the system if you ever find yourself needing care beyond a checkup once a year. It's designed to make the insurance carrier money by constantly having little costs slip through the cracks that should be covered. Get a dental checkup? Sorry one of your X-Rays wasn't covered but the other ones were. Now you get to spend hours fighting for a $13.00 cost. Oh you're at the max for this service for the year because we accumulated the estimated cost when you started calling doctors about what the after-insurance cost will be. Wait a minute this out-patient consult is actually a surgery because you saw a surgeon so it must have been a surgery, and it's not medically necessary to have the surgery without the consult.
Because there are a finite number of doctors and hospital beds and you can't create either by throwing more money at the problem. You didn't actually read the content did you
These are actually pretty easy questions as long as you’re not an asshole.
Are they? I would love to hear how you would solve those problems rather than make a blythe, thoughtless remark
Every other country seems to solve it
Do they? Which countries have solved it? In Canada, the wait is so long for free specialized procedures that many patients choose euthanasia instead. Can't imagine it's better anywhere else. Which countries have solved it?
> 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.
You want to try to change things? Great. So write the book!
In the early 2000s I got a job right out of highschool working at a Blue Cross Blue Shields call center. I thought it was going to be customer service but it was insurance claims. Training was supposed to be 6 weeks but they pushed me live after just 2. I had no idea what I was doing. After floundering for a couple weeks trying to learn to basically be a fuckin doctor, I just started approving everything. "Patient needs emergency surgery for X" "Approved". The whole experience was completely insane.
“ I just started approving everything. "Patient needs emergency surgery for X" "Approved".”
Did they ding you for bad performance after a while? Your job was to maximize denials, not approvals.
That was the correct course of action.
Thank you for your service!
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.
With Medicare Advantage you sign over your Medicare rights+benefits to a private insurer. This may save you some money, especially early on. In fairness, not really a lot and the $0/mo plans are a scam. With Medicare Advantage, you will then have to argue with an insurance company for the rest of your life. You'll have to deal with preauthorizations and a restricted network.
With Traditional Medicare, what's covered is spelled out pretty clearly ahead of time. Docs know it. You know it. There's literally an app for that. With Medicare Advantage, medically necessary is at the discretion of the private insurance company.
Here is the scenario from a relative: he had a heart event which ended up needing a stent. He had to argue with Kaiser while this was going on. Kaiser is 240,000 people. He is one.
Medicare Advantage is very profitable.
It is possible to switch back from MA to TM which really revolves around your Medigap plan. You are guaranteed issue for Medigap plans for about 3 months before/after you turn 65. After that, you will have to undergo medical underwriting.
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 has. If Medicare covered Medicare's part, the Plan F provider has to pay their part. They don't get to question it. I don't even see hospital bills, just statements that it's been paid for.
Plan G is one step down from that.
The theory behind Medicare Advantage is that it would cost the government less than traditional Medicare because the private insurer would be more efficient. Guess what happened.
I think the logic of running a more efficient company is true - they are making more money operating them than the government can/is.
The insurers are such behemoths and so largely vertically integrated it is controlling the system instead of improving it.
Notice how there is rarely ever any new competition in the health insurance space to drive down pricing.
If you look at any health insurers profit split right now they are making all of their gains on medicare advantage.
> In 2022, Carelon settled a lawsuit for $13 million that alleged the company, then called AIM, had used a variety of techniques to avoid approving coverage requests. Among them: The company set its fax machines to receive only 5 to 10 pages.
Who are the people who sleep at night after designing these policies?
They sleep very soundly on a bed made of money.
There is an unlimited pool of people without empathy. Never forget that.
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.
Worse, we spend more in tax dollars on it than any other country total, and then add on the private spending on top. We do the worst of both worlds.
https://commons.wikimedia.org/wiki/File:OECD_health_expendit...
(And we’re middling in outcomes!)
... and that money isn't going to insurers.
The problem here is one of balance.
As with so many situations where you have unreasonable corporate behavior the problem is the economics favors making wrong decisions. Thus there will be little attempt to prevent those wrong decisions. The only real fix is to make wrong decisions cost--look at airlines. You end up with more passengers that seats, you pay. It went a long way towards addressing the problem. (But it should have been higher and it should be indexed to inflation.)
But note the insurance is not always the bad guy. Patients want things that aren't medically warranted, especially when the right answer is "do nothing". And doctors like to run up the bill.
And note this article is focusing on things other than medical decisions--but describing a system that could only be a problem if they are making wrong medical decisions. How they decide what claims to examine is irrelevant, what matters is if they are making wrong medical decisions. It very much needs to be considered the practice of medicine and a denial should only come from someone of at least the same specialization as the doctor making the request. And "not medically necessary" should require an evaluation of why, you don't get to just say "no".
I am perplexed by the type of people that are able to stomach working in these kind of positions - how do they rationalize it? Do they really just not care? Like, in some industries that are not doing great things, or bordering on evil things, I can see sometimes how one could convince themselves they were actually doing good. But this denial stuff is nearly like, "press this button to make money, knowing you may be denying someone critical care that could kill them or cause them harm" and you're comfortable just mashing that button? How do they sleep at night? Or are there just a lot of really gung ho believers that hate provider billing with a passion and believe most of it is waste and they truly know better? Is it a bunch of sociopaths? How this can exist as an industry is crazy to me, I wouldn't even know how to hire, I'd expect the vast majority of applicants upon finding out would say "ew, no" but I guess I have a rosier view of humanity that does not align with reality.
Evilcore is a fitting name.
> Connecticut’s Insurance Department recently reviewed EviCore and Carelon. It found no problems with Carelon. EviCore was fined $16,000 this year for more than 77 violations found in a review of 196 files.
$16k is such a low fine that it’d be funny if it wasn’t so sad. fines should be increased to actually represent a threat to the company - maybe as a % of yearly profit?
our system is so fucked dude
Yes trying to read that article my brain refused to parse "EviCore" as anything but "EvilCorp". Every time.
Multiplier times price of necessary care denied? One can dream.
How do you get accountable people in charge of healthcare policy?
By playing Super Mario brothers with those that are not?
I am a member of a community that had an extremely high rate of HIV infection, and watched dozens of people die, in the 1990s. It was pretty awful.
I found out that many insurance companies deliberately delayed approving procedures, in the hope that it would kill the patient.
back then, there was no AI. The decisions were made by humans.
Sometimes, people suck.
If insurance companies are for profit then they are incentivized to deny coverage. This fucking sucks.
Medically speak, I'm sure we can all find several businesses that arn't necessary.
Geiz-ist-geil-healthcare is, according to many election results anyway, what most US citizens want; everything else is communism/socialism/woke/leftist/[...].