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“The algorithm cannot say no, however. If it finds problems, it sends the request for review to a team of in-house nurses and doctors who consult company medica
by vanc_cefepime 5mo ago
“The algorithm cannot say no, however. If it finds problems, it sends the request for review to a team of in-house nurses and doctors who consult company medical guidelines. Only doctors can issue a final denial.”
As a physician, I’ve had to speak to these so called “peers” in a peer to peer denials with both my clinic and hospital setting. They are usually people who aren’t physicians as a first line of their defense, ie therapist, nurses, etc. This weeds out the providers who either don’t care about the patient denial and blindly accept the denial, or patient has to take matters in their own hands just to get the care they need/deserve. Or worse, in the hospital that means the patient gets hit with a huge bill (already an insane number in the US even with insurance, so don’t get me started on this) or it gets delegated to another provider who has to deal with it. Quite often patients get denied medical and rehab services, esp after something debilitating like a stroke, trauma/accident, etc. and at that point the peer to peer is to weed the provider out. Usually someone will tell the patient you’ve been denied, either go home without the services they need or you fight it.
I fight it. Can’t count the number of times I’ve spoken to someone not in the field of medicine or if they are, not my field of medicine (both Family/Hospital Medicine). Often I’m fighting with an MD or “practitioner” who is some other field like a gynecologist about hospital medicine services or rehab. I’ve even had the pleasure of talking to a physical therapist and didn’t let me get a word in as we began the peer to peer. I now start of by asking for their credentials and field of speciality and demand a peer of my field to do the denying if they are so adamant about it “not being medically necessary”.
I have so much to say and could write a book about it. I just wish I had the money and connections to actually change the state of US of Corporate Medicine.
- OptionOfT 5mo agoAs someone who needs expensive medication, thank you. I appreciate it. 2 questions: * This time, is it paid? Is it billable? Is it part of the visit I pay for? * What can I - as a patient - do to make this process easier?
- ceejayoz 5mo agoIt's unpaid time, but that'll just get factored into the rates charged for billable things like appointments and procedures.
- paulddraper 5mo agoIt's like any time spend on billing or administrative work, it's baked into the costs. (Administrative costs is a big component of rising healthcare costs.) Depending on the issue, the patient may be needed to provide supporting paperwork, like previous diagnoses or treatment for providers. Other than that, not really, short of taking legal action.
- vanc_cefepime 5mo ago1. It’s unpaid, short answer. Not part of your visit, usually a visit code is just one time based code for everything you provided and maybe a procedure if you did something like ear flushes, wart burning, quick wound fixes, etc. Long answer below. If there’s a billing code for it, I’m not aware of it and frankly I shouldn’t have to use it. For providers, it’s part of their “administrative time” which used to be a full day of catching up. In most hospital or insurance-owned clinics, that admin day is gone. You now do this during your lunch break and anytime you can squeeze a phone call. Fun fact, in the hospital, these peer to peers are at the mercy of the insurance company and only give you 24-48hrs to do it, so the hell to the overworked provider and their schedule, again this is exactly what they want. A overworked provider who doesn’t have the energy to fight. Providers are so overworked, they no longer can you catch up on charts and hence why the patient-provider relationship has eroded and become so cold when you see your provider just typing away instead of focusing on you. 2. Fight. Appeal your denial. Make sure your provider does the same. Follow this: https://news.ycombinator.com/item?id=48126000#48128288 https://news.ycombinator.com/item?id=48126000#48128288 Can’t speak to all providers, but most of us are good people trying to do their best to help people. Few bad actors out there give us a bad name, but every field has good vs bad. It’s not right to make hasty decisions based on legitimately a few bad providers out there because of their greed, corruption, fraud, etc and lump everyone to prove they’re not fraudsters. Your basic primary care physician/NP/PA or surgeon isn’t the problem. It’s the conflict of interests of the health care industry, private equity groups, etc who create these issues, exploit the system and make it a breeding-ground for fraud/etc then complain that it needs to be fixed with more middle men.
- tempaccount5050 5mo agoIn the early 2000s I got a job right out of highschool working at a Blue Cross Blue Shields call center. I thought it was going to be customer service but it was insurance claims. Training was supposed to be 6 weeks but they pushed me live after just 2. I had no idea what I was doing. After floundering for a couple weeks trying to learn to basically be a fuckin doctor, I just started approving everything. "Patient needs emergency surgery for X" "Approved". The whole experience was completely insane.
- evulhotdog 5mo agoThank you for your service!
- kjs3 5mo agoThat was the correct course of action.
- vjvjvjvjghv 5mo ago“ I just started approving everything. "Patient needs emergency surgery for X" "Approved".” Did they ding you for bad performance after a while? Your job was to maximize denials, not approvals.
- tempaccount5050 5mo agoI didn't stay long enough to find out, but yeah, they probably would have. The pressure was definitely to default to deny it. That's what the run books (very few) were defaulted to. It was really just a bunch of expendable people to deny claims. The turnover was wild for obvious reasons.
- jmspamerton 5mo agoPhysician and Hospital resources is a real zero sum game, how do you fairly regulate the medical landscape so those who's lives will benefit most from a procedure will receive the procedure? Who decides this? You? Should we allow everyone in the world who needs a procedure to receive one free and get ahead in line for Americans who need the same procedure? That's what the current climate looks like with unbridaled immigration under progressives. These are hard questions. What's the answer?
- singleshot_ 5mo ago[flagged]
- ben-johnson 5mo agoAre they? I would love to hear how you would solve those problems rather than make a blythe, thoughtless remark
- singleshot_ 5mo agoDid you know you spelled "unbridled" wrong because you are an idiot?
- tt24 5mo agoDang, can we take a look at this one please? It’s not a productive, helpful, or interesting comment. Thanks!
- hdgvhicv 5mo agoEvery other country seems to solve it
- ben-johnson 5mo ago[flagged]
- 5mo ago
- zardo 5mo agoI feel like this should really be something people should lose their license over. By deeming something not medically necessary they are (in my opinion) effectively practicing medicine. If they aren't qualified to practice that specialty, or aren't acting in the patients interest we should really be getting malpractice suits on them and stripping medical licenses.
- nradov 5mo agoLegally speaking the health plan employee isn't practicing medicine in that circumstance. The requesting provider is still free to treat the patient, they just won't be reimbursed by the health plan. The requesting provider can do it for free, or the patient can pay cash. I do understand that those aren't realistic options in most cases, I'm just explaining the legal distinction.
- teeray 5mo ago> Legally speaking the health plan employee isn't practicing medicine in that circumstance Feels like convenient lawcraft to wash the health plan employee’s hands of liability. I’m sure the prevailing popular opinion would be that this is practicing medicine.
- roenxi 5mo agoIf "convenient lawcraft" is the new slang for "words have meanings" then absolutely. Insurance company employees talking about insurance is practising insurance. Nobody wants them to practice medicine, the question is whether they are they going to hand over the money or not. Money is not a form of medicine, even if the person deciding where it gets sent is medically qualified. Although on the words having meanings front, whatever is going on here is pretty clearly not insurance at this point; it'd be better just to honestly call it welfare rather than force people to redefine the word 'insurance'. It is hard to talk to people in the US about actual insurance now because they don't have a word for it any more. Politically redefining 'medicine' too would be a mistake, important conversations will become incoherent.
- throwanem 5mo ago[flagged]
- rocketpastsix 5mo agoseriously consider that book if you can fill it up with these types of stories. A book like this could be a huge hit, get this issue even more spotlight and maybe some fixes.
- iugtmkbdfil834 5mo agoFirst off, thank you for taking the time to do it. I know most people don't agree on many things today, but most Americans agree the current system is stacked against them. Not to search very far, I have good insurance and I still have to deal with things that border on criminal. Two, that book may be a good idea:D
- hydrogen7800 5mo agoThis is good to hear. My mother was a PA for a private practice and also would often call the insurance providers to challenge denials, often from people far from the relevant specialty. By her accounts she was usually able to reverse the denials.
- wingspar 5mo agoI’ve saved a message that was reposted by Bill Ackman on dealing with denials. Thankfully, never had occasion to use it yet: >> So, your doctor ordered a test or treatment and your insurance company denied it. That is a typical cost saving method. OK, here is what you do: 1. Call the insurance company and tell them you want to speak with the "HIPAA Compliance/Privacy Officer" (By federal law, they have to have one) 2. Then ask them for the NAMES as well as CREDENTIALS of every person accessing your record to make that decision of denial. By law you have a right to that information. 3. They will almost always reverse the decision very shortly rather than admit that the committee is made of low paid HS graduates, looking at "criteria words." making the medical decision to deny your care. Even in the rare case it is made by medical personnel, it is unlikely that it is made by a board certified doctor in that specialty and they DO NOT WANT YOU TO KNOW THIS!! 4. Any refusal should be reported to the US Office of Civil Rights (http://OCR.gov http://OCR.gov) as a HIPAA violation.
- js2 5mo agoOCR is https://www.hhs.gov/ocr/index.html https://www.hhs.gov/ocr/index.html
- cj 5mo agoAnyone looking for a startup idea? Here you go.
- AIorNot 5mo agoInteresting
- enaaem 5mo agoImagine this: patients buy an AI service to get approval. Insures build an AI to deny claims. 21st century AI wars..
- autoexec 5mo agoIt'd be pretty dystopian if in order to get medical care Americans had to pay some middle man app/service so that it can fight with the middle man the private insurance company they were paying had already inserted between them and their doctor. All if it just raises the total cost of care for the American and absolutely none of it is necessary. The actual fix is to just get rid of the private insurance company and cover everyone's medical needs under a single payer plan.
- forshaper 5mo agoAs a random person, I'm becoming convinced that the first stone to get things rolling is full price transparency at all scales.
- 999900000999 5mo ago> I just wish I had the money and connections to actually change the state of US of Corporate Medicine. It will never happen. This is largely what at least half the country wants. “If I need to take a drug test to earn a check you better take one to get welfare.” I’ve heard a working class person say this. I guarantee you the people who own defense contractors, the real welfare queens don't need to take a drug test. Likewise, the horrific thought that someone unworthy might get free healthcare is appalling to half this country. They’d rather go without just to ensure *those people don’t get free healthcare. This country doesn’t want to be fixed. It wants RFK to tell you to treat Autism with raw milk and sunshine. Nothing much to do but try to find a civilized place to live
- mancerayder 5mo agoDefinitely write to NYT or Guardian or Atlantic about this stuff! Journalists probably have a ton of info on how messed up the system is, but if feels like you have data-backed opinions and documentation to remind yourself of examples!
- mancerayder 5mo agoAnother idea: why can't these claim reviewers pass some sort of government or medically-licensed authorization to do this work?