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Yes, of course you're right. That's why my surgeon friend who works in oncology has to frequently waste his time calling insurance over denied claims regarding fucking treatments for cancer patients. Truly medically unnecessary, which is why they're pretty much always reversed and when they're not, he gets to tell the patient they are going to die because someone who has never met them denied their claim as medically unnecessary. Same goes for my friend in the PICU, except she gets the added bonus of telling a little kid's parents.
And my guess is it would have literally been cheaper for everyone involved for insurance to just pay for the $200 seat cover. Modern American insurance companies are capitalist enterprises providing a socialist benefit. And the doctors denying claims on behalf of the insurance companies are not seeing the patients in question so are basing their decision on questionable documentation and "industry standards" that are based on heavy insurance influence. All to maximize value for the company rather than ensure patient welfare, which is the fucking point of insurance.
There is plenty of abuse of the system through over billing, but somehow fucking Medicare is the most efficient health insurance system in America. If private insurance is so great, why are they more inefficient with worse outcomes?
Medicare is the most efficient health insurance system in America.
Are you under the impression that medicare does not do chart review nor deny claims? I assure you this is incorrect because, the irony being, my wife works on the medicare side of chart review.
As I've been saying, this doesn't go away, nor should it, if we move to universal health care. Something I strongly support, btw, I dislike insurance companies as much as you do. The difference between you and me is that I recognize that doctors are not infallible and omniscient and can make mistakes.
If private insurance is so great, why are they more inefficient with worse outcomes?
I started off very clearly and explicitly saying Im a strong supporter of universal healthcare. Why do you think you came to the conclusion that I think private insurance is so great?
Medicare or Medicare Advantage? Because Advantage is private. Medicare has like 5 levels of appeal, including to a federal court, most of which is free. There are systems in place to allow challenges to the reviewing doctor's denial. Private insurance typically forces arbitration.
I have problems with Medicare's system too, especially when it comes to claims denials. If it is a covered item or procedure, the claim is not fraudulent, and the insurance provider has not met the patient to perform any exam, then going off of notes and comparing with best practices is insufficient to deny a claim. This may surprise you, but the doctors hired by insurance are not magically better than the ones treating the patient.
Medicare or Medicare Advantage?
It's Medicare. She has a friend who works on the private insurance side of the company and she always makes fun of him for it.
If it is a covered item or procedure, the claim is not fraudulent, and the insurance provider has not met the patient to perform any exam, then going off of notes and comparing with best practices is insufficient to deny a claim.
The metric is based on medical necessity, and it's standard for Medicare to deny claims for things that are not medically necessary. Again, if the doctor thinks it is medically necessary, they can appeal the decision and make their case, and that happens frequently.
This may surprise you, but the doctors hired by insurance are not magically better than the ones treating the patient.
I've already stated that I know doctors are not perfect and omniscient, so I'm not sure why you would imply I think otherwise. Although, this isn't the first time you've implied I think the opposite of what I've explicitly stated. Is this going to be a trend?
Then fair enough, I apologize for assuming she works in private insurance. Your initial framing and argument made it seem otherwise. I still think you and I disagree on the need for widespread chart reviews for medical necessity.
When you said doctors are not infallible, you said it in response to my claim that, in essence, the treating doctor should always get deference. It is natural to assume that you did not believe the same standard applied to reviewing doctors at Medicare since you've been arguing the same.
As you note, treating doctors frequently appeal Medicare denials. That's a lot of wasted time and money. I see no evidence that these denials are saving more money than is being wasted fighting them. I'm having trouble finding data for traditional Medicare, but for Medicare Advantage, appeals routinely get overturned to such a degree that Congress investigated it.
You stated earlier that doctors are required to take notes and your wife relies on these notes when making a recommendation. Doctors are notoriously bad at documentation. It's why relying on their notes to make a judgment as to medical necessity is a terrible idea. I firmly believe no one should be denied coverage because their doctor sucks at writing a report.
Your initial framing and argument made it seem otherwise.
Understandable because I said she works for an insurance company. But it was not my intent. No need to apologize for this.
It is natural to assume that you did not believe the same standard applied to reviewing doctors at Medicare since you’ve been arguing the same.
I disagree that it's natural. I said doctors, not just doctors providing care (which my wife is still one of, btw). I suspect that this is an issue of viewing it as too black and white ... so because I said one "side" is not perfect...well I must then think the other "side" is perfect.
I see no evidence that these denials are saving more money than is being wasted fighting them.
This is a different question than the one I'm trying to answer. I haven't seen the books or analysis, so I don't know whether it is more efficient. However, just peripherally, even i can see how much waste there is an even as a laymen it's easy for me to understand that so many of the things she sees are just blatantly not medically necessary.
Doctors are notoriously bad at documentation.
Times they are a changing. Them not justifying why they are doing something is no longer adequate, and wont be adequate even if (maybe even especially if) we move to universal health care.