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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 do

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.
munk-a 3y ago
As someone close to the insurance industry I suspect this would just lead to a revolving door of Doctor Nicks that get cushy jobs for life and sip margaritas by the pool while their "reputation is ruined" - we need a better approach than this like (similar to Canada) having national guidelines for treatment that for the payer to act responsibly. You don't want to know just how many bodies UHC is willing to throw under a bus in order to make .5% more money.
- jjk166 3y ago
  Set it up so if you make a mistake, you're suspended from being able to issue any denials for a month. Make a second mistake, 2 months. 3 mistakes, 4 months. 4 mistakes, 8 months... In a 40 year career each Doctor Nick would only get 9 mistakes. Maybe a month suspension for a first offense is too harsh; let's say a day instead, that's still only 14 mistakes in a career. Is the money saved from that handful of extra denials going to justify the cost of taking care of those doctors for life?
- ncallaway 3y ago
  > reputation is ruined By personally liable, I don’t mean “their reputation is harmed”, I mean “forced to file for bankruptcy, and will be paying off the court imposed damages for the rest of their life”. By professionally liable, I mean medical licenses being torn up, and their right to practice medicine being permanently revoked due to committing medical malpractice. I mean, these people need to be medical doctors, that are treated as making a medical decision, with all the requirements and liabilities that come from that. When Dr. Nick spends 1.2 seconds reviewing a patient’s file before issuing a denial, I’m proposing that being a life ruining decision for Dr. Nick.
  - munk-a 3y ago
    If UHC can get Dr. Nick to reject claims for six months before he gets canned they'll be happy to set Dr. Nick up on a caribbean island for life after he declares bankruptcy - then all the other Dr. Nicks will be happy to throw their reputation in the fire for a cushy lifestyle. The issue we've got here is that the company has an immense amount of power and we need to punish bad actors at a level appropriate to that power - instead of just going after the individual bad doctors that are replaceable and numerous (we should still go after the individuals though).

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.

munk-a 3y ago

As someone close to the insurance industry I suspect this would just lead to a revolving door of Doctor Nicks that get cushy jobs for life and sip margaritas by the pool while their "reputation is ruined" - we need a better approach than this like (similar to Canada) having national guidelines for treatment that for the payer to act responsibly. You don't want to know just how many bodies UHC is willing to throw under a bus in order to make .5% more money.

jjk166 3y ago
Set it up so if you make a mistake, you're suspended from being able to issue any denials for a month. Make a second mistake, 2 months. 3 mistakes, 4 months. 4 mistakes, 8 months... In a 40 year career each Doctor Nick would only get 9 mistakes. Maybe a month suspension for a first offense is too harsh; let's say a day instead, that's still only 14 mistakes in a career. Is the money saved from that handful of extra denials going to justify the cost of taking care of those doctors for life?
ncallaway 3y ago
> reputation is ruined By personally liable, I don’t mean “their reputation is harmed”, I mean “forced to file for bankruptcy, and will be paying off the court imposed damages for the rest of their life”. By professionally liable, I mean medical licenses being torn up, and their right to practice medicine being permanently revoked due to committing medical malpractice. I mean, these people need to be medical doctors, that are treated as making a medical decision, with all the requirements and liabilities that come from that. When Dr. Nick spends 1.2 seconds reviewing a patient’s file before issuing a denial, I’m proposing that being a life ruining decision for Dr. Nick.
- munk-a 3y ago
  If UHC can get Dr. Nick to reject claims for six months before he gets canned they'll be happy to set Dr. Nick up on a caribbean island for life after he declares bankruptcy - then all the other Dr. Nicks will be happy to throw their reputation in the fire for a cushy lifestyle. The issue we've got here is that the company has an immense amount of power and we need to punish bad actors at a level appropriate to that power - instead of just going after the individual bad doctors that are replaceable and numerous (we should still go after the individuals though).