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You know, at face value he's absolutely right. We shouldn't claim care that is unnecessary or maybe even harmful. But where we disagree is that I think that decision should be left to our medical professionals
Really what it should be is that if a doctor prescribes unnecessary care, they should go after the doctor, not the patient. Doctors have malpractice insurance. If the health insurance can't win a case of malpractice, then they should pay the bill. Why are patients in the midfle here at all.
This is still validating the profit incentive of private health insurance.
If the doctor prescribes unnecessary care, it should be none of these peoples' business, because they shouldn't be allowed any stake in the decision whatsoever.
It’s the same trick as rebranding bank robberies to identity theft. It puts the blame on the consumer who can’t afford to defend themselves.
Huh, I hadn't thought of that as a Crying Indian.
Really what it should be is that if a doctor prescribes unnecessary care
That's the core problem. The entity that defines unnecessary care is health insurance. And there are TONS of stories of them denying Diabetes medication for people with diabetes and anti-nausea meds to pediatric patients getting chemo.
If they were doing the right thing, no one would be pissed off. The "recent target" was the one to decided to run on AI driven denials that were denying 90% of care for months.
They are not fulfilling their duty to take the money from the subscribers and pay their righteous medical bills and instead using it as raw profit.
They are employing their own 'doctors' to prove stuff that is definitely necessary is labeled unnecessary.
Reminds me of the Tobacco Instrustry setting up the "Tobacco Institute", to disprove any links between smoking being addictive, and lung cancer.
They were constantly gaslighting the public, even tried to discredit the Surgeon General for his report on second hand smoke.
Not just meds. Patients with chronic pain are expected to take painkillers for treatment but omg if the doctor prescribes therapy deny that shit. Even though therapy helps faaaar better than medications for chronic pain sufferers.
It's the conflict of interest in the "decision maker"
Patients usually have the least amount of power. That's why.
My attitude is that if the doctor prescribes unnecessary care there's a professional board for that.
Though let's be real, the health insurance for profit industry is the problem and it's not going to get better until we get rid of it
Yeah, but the professional board is kinda like an HOA board. Should be more like a jury of all regular doctors or something.
Insurance claims are approved or denied by medical professionals. In the state of NY it's even required for a specialist to approve or deny specialist care.
Some doctors are just absolute scum.
They are done by medical professionals who have no obligation or incentive to serve the best interests of the patient. If your doctor fucks up, he can be found liable. If the insurance doctor fucks up, there is no liability whatsoever. Cases have been brought to court and then immediately thrown out because there is no legal basis for holding them accountable.
Except in this case, they used AI to help them make decisions. The lawsuit is still ongoing so I shouldn't speak in definitive terms, but considering the circumstances and evidence I think it's pretty clear than they have tried to automate some processes and didn't audit them properly.
Did it not work as intended, though?
I mean I'm pretty sure it wasn't meant to be a method of committing suicide
Medical professionals that spend an average of 6 seconds per case. And keep getting caught with revoked/expired licenses. And well outside their area of expertise (the classic example is failed dentists deciding on cancer treatments).
There is a lot of crap that they’re able to instantly deny through your plan’s terms and conditions.
It’s worth reading the plan summary of what won’t be covered, even if it’s prescribed treatment. Some of the shit that’s hidden in there is fucked up.
This year someone in my family started to have to pay out of pocket for their GLP1s because their diseases didn’t progress far enough for the treatment to be covered. They’d rather you hurry up and die than pay for expensive drugs that keep you alive for longer.
If they have cardiovascular disease or kidney disease, those are getting added as indications for the GLP-1's so they might be able to resubmit the authorization/claim with those diagnosis codes added to get it covered.
Yeah, but the problem is, if tests / labs show the precursor indicators for those diseases, and you have a family history, they’ll still deny until you actually have the something like a heart attack or stroke.
GLP-1s are the hot new thing, but it’s pretty common for insurance companies to deny expensive preventative care, even after all other avenues have been thoroughly explored.
In my family medicine rotation a couple months ago, we got it approved for someone with pre-diabetes, high blood pressure, and stage 2/3 kidney disease (which is not very advanced. A lot of people over the age of 35-40 can technically fall into stage 1/2.)
We just changed insurance and were able to get through with one provider that valued preventative care more, but our new insurance company is a complete pain in the ass. And the person in my family dealing with the insurance company actually works for the company and knows all the ins and outs.
They even give their own employees crap policies.
This is entirely unsurprising. Hopefully they can wrangle something functional out of the insurance at some point.
I don't have a source. But i've read they are incentivized to go through as many claims as they can, and not to approve too many.
Even if this were the case (it is not in any real sense, see your other replies), the fact that it is done by a for profit entity that will lose money by approving a claim all but ensures the process will not be neutral or correct.