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> [2] The biggest contributors to these are the twin demons of prior authorization and electronic medical records. Prior authorization is when health insurance
by OrvalWintermute 4y ago
> [2] The biggest contributors to these are the twin demons of prior authorization and electronic medical records. Prior authorization is when health insurance companies require doctors to ask for permission to perform specific services for specific patients. This is incredibly time consuming (14.4 hours per week as of 2020) and also demoralizing for the physicians, as the ultimate decision on how to treat a patient is often not made by the highly-trained physician or the patient in need, but instead by a 25 year old making 40k/year reading off a script over the phone.
This is a dramatic oversimplification.
The person reading the script may issue a denial, and then there is a process of appeal, which may include other steps.
Physicians interacting with insurance companies practice what is known as a "peer to peer", where a physician discusses the case with an insurance-employed physician, often trained in the same specialty as the physician. Sometimes the notes provided by a surgeon were inadequate, sometimes they need clarification, sometimes the incorrect codes were used, and payment is retroactively denied.
There are a few things too many rejections can cause:
1 - Insurance switches
2 - Regulator problems
3 - Competing model with insurance
4 - Lawsuit, as some legal firms specifically target insurance companies for this activity
- deleted 4y ago[deleted]
- idontknowifican 4y agoincredibly apologetic for an industry that’s wholly unnecessary, that without we could just have the “peer to peer” communication and patient interest in mind. that would be terrible though, as some folks would have to pay more than they would’ve if they were able to live their whole life without needing medical care.
- OrvalWintermute 4y agoI am not apologetic, this is just a matter-of-fact response on how it works, and what happens. Keep in mind that healthcare fraud is a giant business [1] [2] I'm not trying to push any particular thing, though I do believe that the Kaiser Permanente type of business model (health maintenance organization) will eventually kill off much insurance. [1] https://www.justice.gov/usao-wdmi/health-care-fraud https://www.justice.gov/usao-wdmi/health-care-fraud [2] https://www.govinfosecurity.com/doj-healthcare-at-center-biggest-us-fraud-cases-in-2021-a-18433 https://www.govinfosecurity.com/doj-healthcare-at-center-big...
- AlexandrB 4y agoEvery time I read about how insurance works in the US medical system it's pretty plain to see that it's distorting both costs and patient care (neither for the better). How are people in the US still putting up with this garbage? How is any of this more efficient than single-payer or some other form of socialized medicine? It's absurd.
- lotsofpulp 4y agoThere are similar mechanisms in taxpayer funded healthcare countries also. The government does not simply pay doctors for any and all services they provide. At some point, there will be a person or group of persons deciding if certain services are warranted and/or to monitor for fraud.
- hattmall 4y agoIn taxpayer funded countries they mostly aren't getting paid by the procedure, and in the cases that they are it's not enough to incentive very much fraud. Socialized medicine healthcare salaries are actual salaries and far lower than earnings in the US.
- tbran 4y agoYou make it sound like it's okay for the insurance company, a middleman, to decide someone's healthcare. But insurance companies aren't collaborators. They rarely add to the process of making you healthier, they only take away options through denials. Seems silly that an insurance company allows a doctor into their network, then repeatedly questions that doctor's decisions (until you remember that insurance companies just want to make money).
- OrvalWintermute 4y agoDon't shoot the messenger
- lotsofpulp 4y ago> You make it sound like it's okay for the insurance company, a middleman, to decide someone's healthcare. The insurance company is not deciding someone’s healthcare, they are deciding if they are going to pay for specific healthcare. Providers and patients are free to engage in any healthcare they want. > Seems silly that an insurance company allows a doctor into their network, then repeatedly questions that doctor's decisions Why? Does a car insurance company pay a mechanic in their network to replace an engine for a fender bender? > (until you remember that insurance companies just want to make money). This is meaningless. Everyone “just” wants to make money.
- hattmall 4y ago> Everyone “just” wants to make money Not really, a lot of people just want to do what they love and in medicine that's fairly common.