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

cyanydeez

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

vanc_cefepime

“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.

d_burfoot

America cannot, as a country, discover a reasonable approach to managing health care costs because Americans do not have a sufficient core set of shared political values. The solution is to end regulation at the federal level, and allow the states to determine what regulations they may deem appropriate. As a New Hampshire libertarian, I do not want Californian progressives telling me how our state must manage health care spending, and I am sure they feel the same way about me.

CalChris

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.

khriss

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.

spankibalt

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

jmux

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

ro_bit

> 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?

ChrisMarshallNY

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.

lewdev

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

LorenPechtel

The problem here is one of balance. As with so many situations where you have unreasonable corporate behavior the problem is the economics favors making wrong decisions. Thus there will be little attempt to prevent those wrong decisions. The only real fix is to make wrong decisions cost--look at airlines. You end up with more passengers that seats, you pay. It went a long way towards addressing the problem. (But it should have been higher and it should be indexed to inflation.) But note the insurance is not always the bad guy. Patients want things that aren't medically warranted, especially when the right answer is "do nothing". And doctors like to run up the bill. And note this article is focusing on things other than medical decisions--but describing a system that could only be a problem if they are making wrong medical decisions. How they decide what claims to examine is irrelevant, what matters is if they are making wrong medical decisions. It very much needs to be considered the practice of medicine and a denial should only come from someone of at least the same specialization as the doctor making the request. And "not medically necessary" should require an evaluation of why, you don't get to just say "no".

JohnMakin

I am perplexed by the type of people that are able to stomach working in these kind of positions - how do they rationalize it? Do they really just not care? Like, in some industries that are not doing great things, or bordering on evil things, I can see sometimes how one could convince themselves they were actually doing good. But this denial stuff is nearly like, "press this button to make money, knowing you may be denying someone critical care that could kill them or cause them harm" and you're comfortable just mashing that button? How do they sleep at night? Or are there just a lot of really gung ho believers that hate provider billing with a passion and believe most of it is waste and they truly know better? Is it a bunch of sociopaths? How this can exist as an industry is crazy to me, I wouldn't even know how to hire, I'd expect the vast majority of applicants upon finding out would say "ew, no" but I guess I have a rosier view of humanity that does not align with reality.

delfinom

EviCore looks like EvilCore and knowing some richfucks that got into various businesses, that may be more intentional than coincidence.

eaf7e281

When life is controlled by algorithms.

thatmf

The world needs more Luigis.

righthand

My IT guy spends his days pushing problems that come across his desk into an LLM and generating reports/responses. He then pushes the generated material out to people in slack channels and says “hey this is what we need to do”. New AI tool? “Lets integrate, this AI report says it’s a good idea”. The C-Suite are so brain dead and unskilled at leadership that they just rubber stamp anything. When asking questions and poking holes in the generated material in order to establish some sort of vetted guidance and leadership direction, the IT and Leadership push back “Well what does your team think we should do?” Yo! I’m literally asking you that question. I’m the implementer employee you’re the specialists and leaders. Did you read the report? Does it make sense? Did you see anything that seems off? “What do you think we should do?” This is how this stuff devovles. All nepotist C-Suites should be hollowed out and fired and we should rebuild our institutions without these useless people that can’t even remember how to run a business or make a decision 6 years into LLMs.

anarticle

I think in the case of Optum + UnitedHealthCare being the Scylla and Charybdis of a healthcare situation, we should break up this style of business. Owning both sides of the equation means there is no competition if you are unlucky enough to find this combination. Feels like two wolves negotiating on how much of the sheep (the sheep is you) they get to eat. Dare I ask, who is for the "consumer"? If we should even use those words in this system, which in my mind should be for a nation keeping its citizens alive and well both of their own sake and the state's sake.

pumanoir

Mark Cuban has a neat startup to appeal health insurance denials www.getclaimable.com/

nradov

The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) is driving some industry improvements in this area and there's a lot of opportunity for technologists to help implement it. While the rule mostly only applies to Medicare Advantage health plans, many payers are voluntarily implementing the same HL7 Da Vinci Project Prior Authorization Burden Reduction APIs across all lines of business. These APIs give providers standard ways to check whether prior authorization is required for a plan of treatment, find out exactly what documentation the health plan requires, and then submit the prior auth request. This won't solve the problem of improper denials but will at least reduce delays and errors. https://www.cms.gov/priorities/burden-reduction/overview/int...

bparsons

Thought I would remind people here of this simple, but mostly unknown fact about American healthcare: American taxpayers invest more public dollars per capita in healthcare than anyone in the world. This before a single cent is paid into the private insurance system. Through Medicare, Medicaid, VA and other public health programs, you pay about 40% more public dollars per-capita than the most socialist, gold plated single payer system anywhere else. You are not only getting ripped off by your insurer, but you are getting ripped off a public system, which has more than enough money to provide every man, woman and child with a lifetime of world-class, free at the point of service universal healthcare.