With support from both sides of the aisle, Rep. Mark Green’s new bill would force insurers to let doctors — not algorithms — decide what care patients get.
As a patient advocate I am often hired to help people appeal the denials insurance companies give. I had a young man with a traumatic brain injury (TBI) have his services denied by a urologist from the insurance company. I was able to fight the decision based on that doctors lack of knowledge and using the letters from leading experts in the field of TBi.
How about the person who had lung nodules and needed a PET scan but insurance company told doctors, “no, you need a biopsy first.” Who are these suits making decisions?
It’s no wonder doctors are more and more refusing to work with insurance and only accepting private pay. Why would they want to go to school, become experts in their field only to be told they can’t practice as they know they should by an insurance company.
We must do everything possible to support this bill!
Insurance companies practice medicine without training or licenses all the time. As a certified patient advocate, and having done it for decades long before, the minute you ask for the person's license number, they tend to back down.
Given the full scope of our social, economic, political history and current reality, It is really hard to cheer on a white male republican elected from Tennessee.
Wendell, like everyone on both sides of the scalpel, I agree that prior authorizations are out of control. And of course, that the reasons given for deny and delay are medically ridiculous. But I don't think that this bill, if it passes and it's signed by the current president, will help patients as much as it will help doctors. Here's my logic.
It's a given that the real reasons for denying many charges are its cost and impact on profit. Even if the insurance employees are board certified physicians with appropriate backgrounds, they will be under the same relentless pressure to deny and delay. And ultimately, insurance companies will change their contracts to be like dental insurance contracts.
Meaning, that they'll just pay a much tinier percentage of expensive procedures. Right now, if you have a dying tooth, insurance will pay for it to be pulled out or they will pay a small percentage for an implant and nothing for the crown that's needed to cover the implant. Major insurance companies will change their contract terms so that if you need a PET scan, they'll pay 50% or less of what they deem to be appropriate costs.
That leaves patients holding the bag financially. And because the cost of these necessary procedures will be out of most Americans reach, They will have the difficult choice of going bankrupt or dying.
I agree with your comment, but also want to point out that some dental insurance companies will pay for the crown on the implant, but not pay towards the actual implant. Never underestimate the stupidity of dental insurance.
It’s about time! This IS an EVERYONE Bill for the better!both sides of the aisle have this issue.Insurance CEO’s have gotten out of control!Lost sight of Who they are supposed to be helping….Not collecting Bonuses and using Golden Parachutes as perks.
Having a true peer in your specialty review your pre-auth is clearly a step in the correct direction. However, the times that I have demanded a "peer to peer" appeal, my experience has been that the one I ended up speaking with is a person who is retired or who otherwise is not actively practicing medicine. Thinking logically, what doctor who loves their work and loves their specialty would work for an insurance company processing claims? I suppose this could be a surgeon involved in an accident who loses their ability to operate. Realistically, though, that is not the case.
Sure, but you find want government in ANYTHING. Look at the HITECH Act. Doctors jumping through hoops of bad (Epic) EHR systems, adding hours of documentation each day, plus administrators not having the ability to say "you coded that as X, but Y gets more insurance reimbursement.". Keep government out, and automate the entire health insurance industry out of existence. THAT is the answer.
As a patient advocate I am often hired to help people appeal the denials insurance companies give. I had a young man with a traumatic brain injury (TBI) have his services denied by a urologist from the insurance company. I was able to fight the decision based on that doctors lack of knowledge and using the letters from leading experts in the field of TBi.
How about the person who had lung nodules and needed a PET scan but insurance company told doctors, “no, you need a biopsy first.” Who are these suits making decisions?
It’s no wonder doctors are more and more refusing to work with insurance and only accepting private pay. Why would they want to go to school, become experts in their field only to be told they can’t practice as they know they should by an insurance company.
We must do everything possible to support this bill!
Insurance companies practice medicine without training or licenses all the time. As a certified patient advocate, and having done it for decades long before, the minute you ask for the person's license number, they tend to back down.
So careful even w the doctors...some play experts when not quite the case.
Given the full scope of our social, economic, political history and current reality, It is really hard to cheer on a white male republican elected from Tennessee.
That sounded a little racist to me. Substitute a different race/gender and you would be strung up.
This legislation would have to add "treating" in front of the specialist reviewing physician.
Mary McDevitt, MD
Wendell, like everyone on both sides of the scalpel, I agree that prior authorizations are out of control. And of course, that the reasons given for deny and delay are medically ridiculous. But I don't think that this bill, if it passes and it's signed by the current president, will help patients as much as it will help doctors. Here's my logic.
It's a given that the real reasons for denying many charges are its cost and impact on profit. Even if the insurance employees are board certified physicians with appropriate backgrounds, they will be under the same relentless pressure to deny and delay. And ultimately, insurance companies will change their contracts to be like dental insurance contracts.
Meaning, that they'll just pay a much tinier percentage of expensive procedures. Right now, if you have a dying tooth, insurance will pay for it to be pulled out or they will pay a small percentage for an implant and nothing for the crown that's needed to cover the implant. Major insurance companies will change their contract terms so that if you need a PET scan, they'll pay 50% or less of what they deem to be appropriate costs.
That leaves patients holding the bag financially. And because the cost of these necessary procedures will be out of most Americans reach, They will have the difficult choice of going bankrupt or dying.
I agree with your comment, but also want to point out that some dental insurance companies will pay for the crown on the implant, but not pay towards the actual implant. Never underestimate the stupidity of dental insurance.
‼️‼️
My logic is, yet the unconscionable profit of private health insurance corporations is acceptable to Congress.
It’s about time! This IS an EVERYONE Bill for the better!both sides of the aisle have this issue.Insurance CEO’s have gotten out of control!Lost sight of Who they are supposed to be helping….Not collecting Bonuses and using Golden Parachutes as perks.
When an issue is bipartisan, things happen!
Time to take on the Money too that propels our civil servants to 'overlook' abuse by the Medicare Advantage plans too.
Despite all the concerning data by these corps and their upcoding, etc., Congress is giving them a raise in 2026 of 5% to do more harm.
They are also penalizing sales agents who enroll seniors with multiple problems.
How much more are we going to allow them?
Having a true peer in your specialty review your pre-auth is clearly a step in the correct direction. However, the times that I have demanded a "peer to peer" appeal, my experience has been that the one I ended up speaking with is a person who is retired or who otherwise is not actively practicing medicine. Thinking logically, what doctor who loves their work and loves their specialty would work for an insurance company processing claims? I suppose this could be a surgeon involved in an accident who loses their ability to operate. Realistically, though, that is not the case.
https://christophermeestoerato.substack.com/p/if-democracy-survives-the-future?r=12utpl
At the same time this republican Doctor must support expanding and improving a comprehensive Medicare 4 all bill.
I wonder if Mike Johnson a Christian Nationalist and speaker of the house will do to support these ideas and relieve people from suffering.
Oh so necessary!
Sure, but you find want government in ANYTHING. Look at the HITECH Act. Doctors jumping through hoops of bad (Epic) EHR systems, adding hours of documentation each day, plus administrators not having the ability to say "you coded that as X, but Y gets more insurance reimbursement.". Keep government out, and automate the entire health insurance industry out of existence. THAT is the answer.
https://SentiaHealth.substack.com
They largely helped put us here by not allowing universal healthcare to move forward. It's LITERALLY the LEAST they can do.