"Not Medically Necessary": Helping America's Health Insurers Deny Coverage

“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.

Medicare has a similar issue. When you sign up at 65, you have to make a first big decision, Traditional Medicare (yay!) or private Medicare Advantage (boo!).

Traditional Medicare consists of Part A (hospitals), Part B (doctors) and Part D (drugs). Part A+B don't cover everything so you have a Medigap plan. I have Plan G which has very little paperwork. All up, I spend about $400/mo and I'm very happy with A+B+G+D.

With Medicare Advantage you sign over your Medicare rights+benefits to a private insurer. This may save you some money, especially early on. In fairness, not really a lot and the $0/mo plans are a scam. With Medicare Advantage, you will then have to argue with an insurance company for the rest of your life. You'll have to deal with preauthorizations and a restricted network.

With Traditional Medicare, what's covered is spelled out pretty clearly ahead of time. Docs know it. You know it. There's literally an app for that. With Medicare Advantage, medically necessary is at the discretion of the private insurance company.

Here is the scenario from a relative: he had a heart event which ended up needing a stent. He had to argue with Kaiser while this was going on. Kaiser is 240,000 people. He is one.

Medicare Advantage is very profitable.

It is possible to switch back from MA to TM which really revolves around your Medigap plan. You are guaranteed issue for Medigap plans for about 3 months before/after you turn 65. After that, you will have to undergo medical underwriting.

If insurance companies are for profit then they are incentivized to deny coverage. This fucking sucks.

> In 2022, Carelon settled a lawsuit for $13 million that alleged the company, then called AIM, had used a variety of techniques to avoid approving coverage requests. Among them: The company set its fax machines to receive only 5 to 10 pages.

Who are the people who sleep at night after designing these policies?

The worst part, simultaneously soul crushing and apocalyptic rage inducing is that we get these outcomes after spending more per capita on healthcare than pretty much any country on the planet.

Evilcore is a fitting name.

> Connecticut’s Insurance Department recently reviewed EviCore and Carelon. It found no problems with Carelon. EviCore was fined $16,000 this year for more than 77 violations found in a review of 196 files.

$16k is such a low fine that it’d be funny if it wasn’t so sad. fines should be increased to actually represent a threat to the company - maybe as a % of yearly profit?

our system is so fucked dude

I am a member of a community that had an extremely high rate of HIV infection, and watched dozens of people die, in the 1990s. It was pretty awful.

I found out that many insurance companies deliberately delayed approving procedures, in the hope that it would kill the patient.

back then, there was no AI. The decisions were made by humans.

Sometimes, people suck.

Medically speak, I'm sure we can all find several businesses that arn't necessary.

Geiz-ist-geil-healthcare is, according to many election results anyway, what most US citizens want; everything else is communism/socialism/woke/leftist/[...].

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