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They'd most likely go bankrupt. There is already an incentive for them to spend on medical care due to the Medical Loss Ratio (MLR) which caps their profits on
by hypeatei 1y ago
They'd most likely go bankrupt. There is already an incentive for them to spend on medical care due to the Medical Loss Ratio (MLR) which caps their profits on collected premiums.
If you're saying they need to be forced to pay whatever invoice comes to them and start legal battles for each suspect case then yeah... that doesn't seem feasible.
- djoldman 1y agoHealth insurance companies are not immediately insolvent because they 1. pay out claims slowly and/or 2. deny or downcode claims outright? Really? That to me would imply that doctors/patients are submitting a huge amount of incorrect claims.
- hypeatei 1y agoDoctors/patients are human too and your proposed system would be ripe for abuse. If you're well versed in submitting claims, and you know they have to pay out, then you could inundate them with fraudulent ones. > That to me would imply that doctors/patients are submitting a huge amount of incorrect claims UnitedHealthcare says that 10% of claims go through additional review for various reasons[0]. I don't know if there are stats for the industry as a whole, but my guess is that they deal with a lot of errors. 0: https://www.uhc.com/news-articles/newsroom/how-many-claims-are-denied https://www.uhc.com/news-articles/newsroom/how-many-claims-a...
- djoldman 1y agoI'm not proposing that all guardrail responsibilities be shifted to the insurer. Just the "medically necessary" provision. Doctors would still have a Duty to Code Services Accurately and a Duty to Maintain the Medical Record (which would clearly enable an insurer to prove a non-medically necessary therapies). There would be plenty plenty of evidence for an insurer to immediately respond. So claims could be rejected on the basis of failing to code accurately or lack of record.