4 ms·

Seems pretty similar to what a doctor might do. They get a bunch of test results and a first opinion (from doctor) then they issue a new (second) opinion of no

Seems pretty similar to what a doctor might do. They get a bunch of test results and a first opinion (from doctor) then they issue a new (second) opinion of no treatment. Doctors give out second opinions all the time; it's a thing patients do when they want to make sure the first one is correct.

ethbr1 3y ago
Doctors and medical reviewers are looking at the world through two different perspectives. Doctors have direct contact with the patient and are pursuing leads via testing and originating a treatment plan. Ergo, "what might work" A medical reviewer is limited to generated documentation only (though can request more) and is then comparing that to relevant regulations, standards of care, and reasonable/necessary tests. Additionally, they are a technical expert in recognizing fraud that may be hidden in individually-reasonable, unreasonable-in-aggregate cases. Ergo, "what can be justified" Here's the CMS-version explainer, for context: https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-and-education https://www.cms.gov/data-research/monitoring-programs/medica... Generally, criminalizing malpractice is a counter-inventive to actual system improvement. See doctors. They just add malpractice insurance, and the cost is added to everyone. If the real concern is that medical reviewers aren't fairly reviewing claims (which afaik, they generally are, contingent on documentation being available), then the supply side should be addressed -- mandate a specific, minimum review time per claim, a standard appeals chain that all insurers are subject to, and staff a centralized, independent (probably under CMS) final appeal arbiter.
- DangitBobby 3y ago
  The concern for me is that they have a perverse incentive. They aren't interested in maximizing the effectiveness of the care I receive, they are interested in minimizing their own costs. They should be held legally accountable for any negative effects their input has on me.
  - MichaelZuo 3y ago
    Based on what legal or judicial reasoning?

ethbr1 3y ago

Doctors and medical reviewers are looking at the world through two different perspectives. Doctors have direct contact with the patient and are pursuing leads via testing and originating a treatment plan. Ergo, "what might work" A medical reviewer is limited to generated documentation only (though can request more) and is then comparing that to relevant regulations, standards of care, and reasonable/necessary tests. Additionally, they are a technical expert in recognizing fraud that may be hidden in individually-reasonable, unreasonable-in-aggregate cases. Ergo, "what can be justified" Here's the CMS-version explainer, for context: https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-and-education https://www.cms.gov/data-research/monitoring-programs/medica... Generally, criminalizing malpractice is a counter-inventive to actual system improvement. See doctors. They just add malpractice insurance, and the cost is added to everyone. If the real concern is that medical reviewers aren't fairly reviewing claims (which afaik, they generally are, contingent on documentation being available), then the supply side should be addressed -- mandate a specific, minimum review time per claim, a standard appeals chain that all insurers are subject to, and staff a centralized, independent (probably under CMS) final appeal arbiter.

DangitBobby 3y ago
The concern for me is that they have a perverse incentive. They aren't interested in maximizing the effectiveness of the care I receive, they are interested in minimizing their own costs. They should be held legally accountable for any negative effects their input has on me.
- MichaelZuo 3y ago
  Based on what legal or judicial reasoning?