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> What a poorly designed system. If the insurer truly prioritizes client care as they claim, why on earth would the doctors contracted to review the treatments

> What a poorly designed system. If the insurer truly prioritizes client care as they claim, why on earth would the doctors contracted to review the treatments of the insured, have access to the insurance policies? Shouldn't the output of their review simply be whether or not the treatment seems appropriate, period? Why are the doctors weighing their review against the insurers policies? All healthcare systems ultimately have to make cost-benefit tradeoffs, and in the US system those tradeoffs are generally represented as insurer coverage policies. I don't mean to suggest that this justifies the story in the article, where it really sounds like the treatment did fit the policy and UHC worked hard to avoid seeing that. But there's no system where a doctor dreams up an arbitrarily expensive treatment protocol and a patient gets it with low out-of-pocket costs and no questions asked.

lijok 2y ago
So are you saying the doctors contracted to review the treatments need access to the clients insurance policies in order to make a decision on whether the treatment is appropriate? For what purpose? My, arguably naive, understanding is that the reviewer should only need to provide two things for the adjuster to take it from there; whether the treatment is appropriate, and alternative potentially cheaper treatment options. If there are alternative potentially cheaper treatment options available, those should be discussed with the care provider and ruled out. I just don't understand why the reviewing doctors report is required to take into account the policies of the contracting insurance firm?
- SpicyLemonZest 2y ago
  The policies consist largely of guidelines regarding what the most cost-effective treatment option for a condition is likely to be. Good insurance companies do try and discuss with providers rather than firing off denial letters willy-nilly, but of course that still ends up being a conflict where your insurance might not let you have the treatment your doctor thinks is best. This conflict is why I've always subscribed to Kaiser when I have the option. It's much less headache for me if there's no distinction between what a doctor wants to prescribe me and what they're allowed to prescribe. (Would I feel differently if I needed some crazy custom treatment protocol? Perhaps.)
  - lijok 2y ago
    That sounds very strange to me. If the adjuster has this information, why the need for a review from a consulting doctor? And why would the consulting doctor not be expected to know the costs of these treatment options, at least in relation to alternative options?
    - SpicyLemonZest 2y ago
      In most states (I think all?) insurance companies are required by law to get review from a consulting doctor if they're going to challenge a claim. I don't really think we could expect a doctor to know offhand the relative costs of every treatment for every potential condition in their specialty.

lijok 2y ago

So are you saying the doctors contracted to review the treatments need access to the clients insurance policies in order to make a decision on whether the treatment is appropriate? For what purpose? My, arguably naive, understanding is that the reviewer should only need to provide two things for the adjuster to take it from there; whether the treatment is appropriate, and alternative potentially cheaper treatment options. If there are alternative potentially cheaper treatment options available, those should be discussed with the care provider and ruled out. I just don't understand why the reviewing doctors report is required to take into account the policies of the contracting insurance firm?

SpicyLemonZest 2y ago
The policies consist largely of guidelines regarding what the most cost-effective treatment option for a condition is likely to be. Good insurance companies do try and discuss with providers rather than firing off denial letters willy-nilly, but of course that still ends up being a conflict where your insurance might not let you have the treatment your doctor thinks is best. This conflict is why I've always subscribed to Kaiser when I have the option. It's much less headache for me if there's no distinction between what a doctor wants to prescribe me and what they're allowed to prescribe. (Would I feel differently if I needed some crazy custom treatment protocol? Perhaps.)
- lijok 2y ago
  That sounds very strange to me. If the adjuster has this information, why the need for a review from a consulting doctor? And why would the consulting doctor not be expected to know the costs of these treatment options, at least in relation to alternative options?
  - SpicyLemonZest 2y ago
    In most states (I think all?) insurance companies are required by law to get review from a consulting doctor if they're going to challenge a claim. I don't really think we could expect a doctor to know offhand the relative costs of every treatment for every potential condition in their specialty.