8 ms·

ok great, so I should get to know why things get denied. Maybe... they just can't deny without a reasonable alternative that your doctor agrees with? Like fine

ok great, so I should get to know why things get denied. Maybe... they just can't deny without a reasonable alternative that your doctor agrees with? Like fine deny name brand prescription for generic. The idea that your Doctor... who actually knows what is going on wants to do something and your Insurance can just say no is ridiculous. If we are so worried about Doctors doing unnecessary things to get money from Insurance than lets tackle that also.

vondur 3y ago
My childhood doctor in the late 70's hated insurance companies over this. I'd hear him on the phone arguing with the insurance company reps asking if they had a MD Degree and would like explain the denial to him. Interesting to hear back in the day.
- nerdjon 3y ago
  I have to imagine many do, it sucks since what the hell are their options. I would like to think that most doctors at least care somewhat. I can't imagine how they feel if they think someone truly needs something and insurance just says no. I know my sister at one point was having some critical medication for her denied so the doctor just kept giving her sample packs. I went through an issue with a medication for me and it was still never resolved.
  - nradov 3y ago
    In many cases that issue can be resolved through an appeals process. But this takes extra time for providers, and they don't get paid for that. Insurers may also require step therapy. Try a cheaper treatment first, then if the patient fails to respond they will authorize a more expensive option.
    - nerdjon 3y ago
      I call bullshit. I went through multiple appeal processes, my doctor tried to file multiple on my behalf, I called, and nothing. They don't care.
- RankingMember 3y ago
  Sounds like you had a good doc. These days it seems like the insurance companies have won- every doctor I talk to has the most beaten-down expression when I ask them about coding and their relationship with insurance companies. For most I talk to, they got into medicine to help people, but find themselves spending a frustrating amount of their time fighting with insurance.
  - LesZedCB 3y ago
    the youtube channel dr glaucomflecken did a series on this that were pretty funny https://www.youtube.com/watch?v=Vp7u58R41N8&list=PLpMVXO0TkGpdvjujyXuvMBNy6ZgkiNb4W https://www.youtube.com/watch?v=Vp7u58R41N8&list=PLpMVXO0TkG...
  - vondur 3y ago
    Yeah, he was a cantankerous one. Always telling my Mom to quit smoking while he himself would be smoking at the same time. The 70's were an interesting time to be a child.
nradov 3y ago
Payer coverage rules typically do include that. This is known as step therapy. If a physician requests prior authorization for a branded medication then the insurer might deny it and recommend trying the generic alternative first. A lot of these issues arise because providers fail to review payer coverage rules before deciding on a treatment plan. And in fairness to providers, this takes extra time which they don't get paid for and the rules are inconsistent between payers. The new HL7 Da Vinci Project prior authorization burden reduction standards can help automate this to an extent by giving providers an API to check coverage rules in real time. https://www.hl7.org/fhir/us/davinci-crd/ https://www.hl7.org/fhir/us/davinci-crd/ At a fundamental level, medical insurance has to involve some form of cost control and care rationing. Much of what insurers do is preventing waste, fraud, and abuse by verifying that treatments are medically necessary as per current best practices and balancing costs versus benefits. Unfortunately, patients sometimes get caught in the middle.
- bugglebeetle 3y ago
  > Much of what insurers do is preventing waste, fraud, and abuse Medical insurers are the waste, fraud, and abuse.
  - lotsofpulp 3y ago
    US government employees would be doing the same things for Medicare and Medicaid and Tricare. Outsourcing that work to “insurers” helps keep the heat off the politicians.
    - coredog64 3y ago
      Not true for Medicare. How it works is that Medicare splits the US up into regions (can’t remember if it’s currently 5 or 7). For each of these regions, a private medical insurance company handles all of the claims paperwork and the money for said claims comes from Uncle Sugar. This is also why it’s disingenuous when folks trot out the “claim dollars per Federal employee” argument for Medicare. Note: I’m not talking about Medicare Advantage which is a separate program whereby Medicare pays the premiums for private health insurance plans.
bugglebeetle 3y ago
It’s even worse than that: now they have a bunch of corrupt medical practitioners who they use to rubber stamp denials to make them more legally defensible. Most often, they’re literally just clicking “CONFIRM” on some machine-generated auto-denial.
- FireBeyond 3y ago
  Very much so. They'll get presented with several bullet points of reasons for denial based on their system, and be asked "do you see any need to disagree with this reasoning?" rather than any form of differential workup.
ncallaway 3y ago
I’ve long believed that denials that come from an insurance company should be required to: - come from an individual doctor (not just be signed off, but the doctor originates the denial) - the doctor must be personally named and identified to the patient as the party responsible for the denial - that doctor is *personally* and *professionally* liable for harms that befall the patient from a wrongful denial
- ceejayoz 3y ago
  I'd add a requirement that said doctor have practiced in the relevant specialty within the last decade.
  - haneefmubarak 3y ago
    This simply incentivizes a rapidly revolving door between practice and insurance, with a likely effect of making the actual practioners as a populace more friendly to the insurance companies in general (in expectation of quid pro quo).
    - ceejayoz 3y ago
      There's something deeply wrong when a gastroenterologist who hasn't seen a patient in person for decades can deny a neurosurgical procedure. Maybe you make it like jury duty; if you're a practicing doc, you periodically get randomly assigned some appeals in your speciality to review. The current system already has a massive quid-pro-quo; if you aren't willing to spend 1.2 seconds to deny tens of thousands of claims a month (not an exaggeration! https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims https://www.propublica.org/article/cigna-pxdx-medical-health...), they'll find someone else. The docs and companies doing these "independent" reviews are completely captured by the industry already.
      - JumpCrisscross 3y ago
        > Maybe you make it like jury duty; if you're a practicing doc, you periodically get randomly assigned some appeals Or send appeals to a committee of randomly-rotating reviewers. The state could administer the service to promote fairness and lessen the cost to the insurer.
vkou 3y ago
> The idea that your Doctor... who actually knows what is going on wants to do something and your Insurance can just say no is ridiculous. Death panels for a captive market, so it's all good.
- ThunderSizzle 3y ago
  Republicans were a couple decades too late when they said single payer or Obamacare would bring death panels. We already have death panels wifh medicare, medicaid, and workplace insurance. It'd just be changed to a federal-government sanctioned death panel system. Probably with an expected goal of deaths, and if the target isn't being met, methods to be encouraged to bring it about...
  - sobkas 3y ago
    > Republicans were a couple decades too late when they said single payer or Obamacare would bring death panels. We already have death panels wifh medicare, medicaid, and workplace insurance. > It'd just be changed to a federal-government sanctioned death panel system. Probably with an expected goal of deaths, and if the target isn't being met, methods to be encouraged to bring it about... It's not how healthcare work in other industrialised countries.
    - ThunderSizzle 3y ago
      USA isn't other industrialized countries. Any single payer system would be in context of the existing economic and political system, much like Obamacare was in comparison to other countries. Regardless, I think the answer is transparency, reduced regulations (e.g. removing income tax penalties for just paying people more to then buy their own health insurance), and clear upfront pricing. Those steps should be done before any attempt to further ruin health care even more. Most of the things people hate about health care and insurance are encouraged or enforced by the feds.
Madmallard 3y ago
"Like fine deny name brand prescription for generic." This is bad too if you have more experience or misfortune with chronic medication usage. You can't sue for medication side effects from generic medications.

vondur 3y ago

My childhood doctor in the late 70's hated insurance companies over this. I'd hear him on the phone arguing with the insurance company reps asking if they had a MD Degree and would like explain the denial to him. Interesting to hear back in the day.

nerdjon 3y ago
I have to imagine many do, it sucks since what the hell are their options. I would like to think that most doctors at least care somewhat. I can't imagine how they feel if they think someone truly needs something and insurance just says no. I know my sister at one point was having some critical medication for her denied so the doctor just kept giving her sample packs. I went through an issue with a medication for me and it was still never resolved.
- nradov 3y ago
  In many cases that issue can be resolved through an appeals process. But this takes extra time for providers, and they don't get paid for that. Insurers may also require step therapy. Try a cheaper treatment first, then if the patient fails to respond they will authorize a more expensive option.
  - nerdjon 3y ago
    I call bullshit. I went through multiple appeal processes, my doctor tried to file multiple on my behalf, I called, and nothing. They don't care.
RankingMember 3y ago
Sounds like you had a good doc. These days it seems like the insurance companies have won- every doctor I talk to has the most beaten-down expression when I ask them about coding and their relationship with insurance companies. For most I talk to, they got into medicine to help people, but find themselves spending a frustrating amount of their time fighting with insurance.
- LesZedCB 3y ago
  the youtube channel dr glaucomflecken did a series on this that were pretty funny https://www.youtube.com/watch?v=Vp7u58R41N8&list=PLpMVXO0TkGpdvjujyXuvMBNy6ZgkiNb4W https://www.youtube.com/watch?v=Vp7u58R41N8&list=PLpMVXO0TkG...
- vondur 3y ago
  Yeah, he was a cantankerous one. Always telling my Mom to quit smoking while he himself would be smoking at the same time. The 70's were an interesting time to be a child.

nradov 3y ago

Payer coverage rules typically do include that. This is known as step therapy. If a physician requests prior authorization for a branded medication then the insurer might deny it and recommend trying the generic alternative first. A lot of these issues arise because providers fail to review payer coverage rules before deciding on a treatment plan. And in fairness to providers, this takes extra time which they don't get paid for and the rules are inconsistent between payers. The new HL7 Da Vinci Project prior authorization burden reduction standards can help automate this to an extent by giving providers an API to check coverage rules in real time. https://www.hl7.org/fhir/us/davinci-crd/ https://www.hl7.org/fhir/us/davinci-crd/ At a fundamental level, medical insurance has to involve some form of cost control and care rationing. Much of what insurers do is preventing waste, fraud, and abuse by verifying that treatments are medically necessary as per current best practices and balancing costs versus benefits. Unfortunately, patients sometimes get caught in the middle.

bugglebeetle 3y ago
> Much of what insurers do is preventing waste, fraud, and abuse Medical insurers are the waste, fraud, and abuse.
- lotsofpulp 3y ago
  US government employees would be doing the same things for Medicare and Medicaid and Tricare. Outsourcing that work to “insurers” helps keep the heat off the politicians.
  - coredog64 3y ago
    Not true for Medicare. How it works is that Medicare splits the US up into regions (can’t remember if it’s currently 5 or 7). For each of these regions, a private medical insurance company handles all of the claims paperwork and the money for said claims comes from Uncle Sugar. This is also why it’s disingenuous when folks trot out the “claim dollars per Federal employee” argument for Medicare. Note: I’m not talking about Medicare Advantage which is a separate program whereby Medicare pays the premiums for private health insurance plans.

bugglebeetle 3y ago

It’s even worse than that: now they have a bunch of corrupt medical practitioners who they use to rubber stamp denials to make them more legally defensible. Most often, they’re literally just clicking “CONFIRM” on some machine-generated auto-denial.

FireBeyond 3y ago
Very much so. They'll get presented with several bullet points of reasons for denial based on their system, and be asked "do you see any need to disagree with this reasoning?" rather than any form of differential workup.

ncallaway 3y ago

I’ve long believed that denials that come from an insurance company should be required to: - come from an individual doctor (not just be signed off, but the doctor originates the denial) - the doctor must be personally named and identified to the patient as the party responsible for the denial - that doctor is *personally* and *professionally* liable for harms that befall the patient from a wrongful denial

ceejayoz 3y ago
I'd add a requirement that said doctor have practiced in the relevant specialty within the last decade.
- haneefmubarak 3y ago
  This simply incentivizes a rapidly revolving door between practice and insurance, with a likely effect of making the actual practioners as a populace more friendly to the insurance companies in general (in expectation of quid pro quo).
  - ceejayoz 3y ago
    There's something deeply wrong when a gastroenterologist who hasn't seen a patient in person for decades can deny a neurosurgical procedure. Maybe you make it like jury duty; if you're a practicing doc, you periodically get randomly assigned some appeals in your speciality to review. The current system already has a massive quid-pro-quo; if you aren't willing to spend 1.2 seconds to deny tens of thousands of claims a month (not an exaggeration! https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims https://www.propublica.org/article/cigna-pxdx-medical-health...), they'll find someone else. The docs and companies doing these "independent" reviews are completely captured by the industry already.
    - JumpCrisscross 3y ago
      > Maybe you make it like jury duty; if you're a practicing doc, you periodically get randomly assigned some appeals Or send appeals to a committee of randomly-rotating reviewers. The state could administer the service to promote fairness and lessen the cost to the insurer.

vkou 3y ago

> The idea that your Doctor... who actually knows what is going on wants to do something and your Insurance can just say no is ridiculous. Death panels for a captive market, so it's all good.

ThunderSizzle 3y ago
Republicans were a couple decades too late when they said single payer or Obamacare would bring death panels. We already have death panels wifh medicare, medicaid, and workplace insurance. It'd just be changed to a federal-government sanctioned death panel system. Probably with an expected goal of deaths, and if the target isn't being met, methods to be encouraged to bring it about...
- sobkas 3y ago
  > Republicans were a couple decades too late when they said single payer or Obamacare would bring death panels. We already have death panels wifh medicare, medicaid, and workplace insurance. > It'd just be changed to a federal-government sanctioned death panel system. Probably with an expected goal of deaths, and if the target isn't being met, methods to be encouraged to bring it about... It's not how healthcare work in other industrialised countries.
  - ThunderSizzle 3y ago
    USA isn't other industrialized countries. Any single payer system would be in context of the existing economic and political system, much like Obamacare was in comparison to other countries. Regardless, I think the answer is transparency, reduced regulations (e.g. removing income tax penalties for just paying people more to then buy their own health insurance), and clear upfront pricing. Those steps should be done before any attempt to further ruin health care even more. Most of the things people hate about health care and insurance are encouraged or enforced by the feds.

Madmallard 3y ago

"Like fine deny name brand prescription for generic." This is bad too if you have more experience or misfortune with chronic medication usage. You can't sue for medication side effects from generic medications.