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Even more fun is when your doctor refers you to a specialist that's in-network, but your insurance comes up with a bunch of reasons to deny it. How did we coll

Even more fun is when your doctor refers you to a specialist that's in-network, but your insurance comes up with a bunch of reasons to deny it. How did we collectively decide that it's okay for insurance companies to overrule medical professionals?

gruez 2y ago
AFAIK the overruling is done by a "medical professional" as well, albeit one that's on the insurance company's payroll.
- jandrese 2y ago
  That "medical professional" has literally 90 seconds to review your case and say yes/no. They've never met you. They don't know your doctor. All they have are some notes on the case, a billing code, and a quota to reach every day. They get bonuses based on how much money they save the insurance company. All of that cost savings makes US healthcare cost double what it does anywhere else in the world.
  - nradov 2y ago
    I think you're a little confused about causality. All healthcare systems, including fully socialized ones, perform similar types of case review to ration care and hold down costs. US healthcare costs might be high now but would be even higher if the payers (including the Medicare / Medicaid government payers) paid every claim that came in without denying those that fail to mean plan coverage rules. If we want to hold down costs then we'll have to put a greater focus on preventative care, stop expensive treatments for terminal patients, impose price controls on providers, and stop subsidizing drug development for the rest of the world. None of those measures are politically popular.
    - WalterBright 2y ago
      Price controls always result in shortages.
      - nradov 2y ago
        Yes, exactly. Since demand for healthcare services is essentially unlimited, creating artificial shortages is one way to ration care and hold down public spending. The US government already creates healthcare shortages in other ways, such as constraining the number of residency slots to limit Medicare spending. (I don't support this, but it is somewhat effective from a fiscal policy perspective.)
nradov 2y ago
Legally speaking the insurance company isn't overruling medical professionals. They're simply refusing to pay. Patients still have the option of paying for treatments out of pocket. (I do understand that for poor patients this is a distinction without a difference, I'm just clarifying the legal issue.) Some states have recently passed laws which limit the authority of health plans to conduct medical reviews or deny payment for services that providers deem medically necessary. This will reduce hassles and expenses for some patients, but it will also accelerate the inflation of insurance premiums paid by everyone else.

gruez 2y ago

AFAIK the overruling is done by a "medical professional" as well, albeit one that's on the insurance company's payroll.

jandrese 2y ago
That "medical professional" has literally 90 seconds to review your case and say yes/no. They've never met you. They don't know your doctor. All they have are some notes on the case, a billing code, and a quota to reach every day. They get bonuses based on how much money they save the insurance company. All of that cost savings makes US healthcare cost double what it does anywhere else in the world.
- nradov 2y ago
  I think you're a little confused about causality. All healthcare systems, including fully socialized ones, perform similar types of case review to ration care and hold down costs. US healthcare costs might be high now but would be even higher if the payers (including the Medicare / Medicaid government payers) paid every claim that came in without denying those that fail to mean plan coverage rules. If we want to hold down costs then we'll have to put a greater focus on preventative care, stop expensive treatments for terminal patients, impose price controls on providers, and stop subsidizing drug development for the rest of the world. None of those measures are politically popular.
  - WalterBright 2y ago
    Price controls always result in shortages.
    - nradov 2y ago
      Yes, exactly. Since demand for healthcare services is essentially unlimited, creating artificial shortages is one way to ration care and hold down public spending. The US government already creates healthcare shortages in other ways, such as constraining the number of residency slots to limit Medicare spending. (I don't support this, but it is somewhat effective from a fiscal policy perspective.)

nradov 2y ago

Legally speaking the insurance company isn't overruling medical professionals. They're simply refusing to pay. Patients still have the option of paying for treatments out of pocket. (I do understand that for poor patients this is a distinction without a difference, I'm just clarifying the legal issue.) Some states have recently passed laws which limit the authority of health plans to conduct medical reviews or deny payment for services that providers deem medically necessary. This will reduce hassles and expenses for some patients, but it will also accelerate the inflation of insurance premiums paid by everyone else.