Sure, I won't go as far as calling it outright fraud. But, it certainly is part of the business. And as the consumer, at the time of service, I really don't care why it happens, only that it does and that it costs me time and money and delays treatment.
As far as I can tell, it's a byproduct of an adversarial relationship between the 3 parties (consumer, doctor, insurer). Insurance doesn't trust the MD to do his job, so hires their own MDs to second guess. And on anything that costs more than $100, that second guessing is the default action - the insurance company's own MDs are only there to provide legitimacy to the initial denial. I say this because in ALL cases, my medical needs have eventually been covered, but not before committing more time and energy than should be necessary.
At the end of the day, we pay more money (and time) for worse outcomes than most of Western Europe and the wealthier nations in Asia.
>the insurance company's own MDs are only there to provide legitimacy to the initial denial.
I have first hand knowledge that this is false. Especially if the insurer is just acting as an administrator for a state Medicaid or federal Medicare or other payer, since there are big penalties for denying coverage just to save money. The insurers even have MDs and PharmDs to audit their own MDs and PharmDs to see if they are appropriately approving or denying treatment.
A lot of the problem is probably coming from lack of proper EMR and supporting documentation justifying treatment, and subjectivity in justifying treatment because there are many gray areas.
This same approval denial situation happens under taxpayer funded healthcare also, since no one has unlimited resources. But yes, the US implementation of it with myriad payers and rules certainly makes for an unpleasant experience and results in subpar healthcare.
I guess, but if so, that's a massive amount of cost to the insurer (and eventually falls back on the consumer) around paperwork/review/approval for something they're going to approve eventually. I really don't understand it. Certainly in my experience, the insurer could get rid of their internal review process and people, just rubber-stamp whatever our MDs are prescribing, and save us all a lot of money and headache.
>the insurer could get rid of their internal review process and people, just rubber-stamp whatever our MDs are prescribing, and save us all a lot of money and headache.
If that was true, there would be an insurer doing that and offering lower premiums on healthcare.gov
But it's not true, and the review processes do control costs (even if wrongly at times). I think the government farms this task out to insurers specifically so the insurer can take the heat for the denials, when it's actually the government's rules and standards for the requested therapies that is resulting in denial of coverage.
I've personally seen this with Medicaid or CMS penalizing for erroneously approving payment for treatments and also erroneously denying payment for treatments. And it gets very fun when the rules are not clear and there is a lot of gray area.
As far as I can tell, it's a byproduct of an adversarial relationship between the 3 parties (consumer, doctor, insurer). Insurance doesn't trust the MD to do his job, so hires their own MDs to second guess. And on anything that costs more than $100, that second guessing is the default action - the insurance company's own MDs are only there to provide legitimacy to the initial denial. I say this because in ALL cases, my medical needs have eventually been covered, but not before committing more time and energy than should be necessary.
At the end of the day, we pay more money (and time) for worse outcomes than most of Western Europe and the wealthier nations in Asia.