How about getting rid of these middlemen who have nothing whatsoever to do with health care? Why are we trying to work around multi billion dollar grifters? Just get rid of them and develop a strong single payer system without any form of managed care with its upfront capitated payments that turn the physician into a risk bearing entity with incentives to deny care? Lets do either Fee For Service or Fee for Time for individual practitioners and strict global operating budgets for each individual institution (ie hospitals,nursing homes, dialysis centers, etc.)
author is a “Health Care executive”. he clearly can’t confront the reality that there is no “good” side in the corporate practice of medicine (i think he helps physicians negotiate contracts with insurers). if he thought health care was a good or noble field to pursue, he should have gone to medical school (or done anything on the clinical side). ban the corporate practice and corporatization of medicine (it really isn’t a matter of outlawing it, it is a matter of overhauling our government, as Congress & federal judges have been responsible for all of this criminal highway robbery from taxpayers).
As a standard Medicare participant I've been insulated from the excesses of prior approval. But with the trial implementation of the WIsER program for pre-authorization I think it's coming for standard Medicare participants as well. Only in six states at the moment and for a handful of conditions, but if you ask me it's just another scheme to push more retirees into Medicare Advantage plans.
Actually, “medical necessity” is strictly a legal term. Is it not a co-opted clinical term.
Clinicians are trained in standards of care, not in “medical necessity.”
And insurers may use proprietary “standards” of care developed by for-profit entities (in some cases, entities that they own), instead of the clinical standards of care developed by clinicians and approved by no-profit clinical groups.
And too often the insurers do not disclose their proprietary standards and their use in denial of care.
Did I mention that insurers may have a bias for covering claims for crisis stabilization, not for a patient’s recovery. Such a limitation is absurd; think of a cancer or cardiovascular intervention that stops with crisis stabilization.
More often, clinicians are supplanted by an AI bot applying a mathematical formula (algorithm) to approve/delay/deny claims. The bot has no medical training nor does it have access to full medical records.
Most use these only for approvals and all denials go to the MD. RNs also can approve but not deny. Only an MD can do denials... at least in Medicaid Managed care.
The entire problem boils down to only one thing.... the huge mistake in allowing any profit or profit motive to be part of our healthcare system in any way! We need a completely and exclusively publicly funded national healthcare system that will cover everyone residing in the US for life... one that is government-run and eliminates all middlemen (health insurance companies). That is the ONLY way to cure our terminally ill current system, which has been transformed into a system of "wealthcare" for wealthy investors!
The IDEAL system would also make every medical practitioner and healthcare worker a salaried employee in a government-run system. This would eliminate all profit motive. Every employee's salary would be based on the difficulty, education, and training needed for that particular position.
The second best system (Medicare for All) would be one where, instead of becoming government employees, physicians (medical practices) would remain privately owned. However, there would still be no health insurance companies, and the government would cover all medical costs for everyone.
Either of these models would be paid for via a very progressive tax, so that the wealthiest would be shouldering far more of the cost, in order for those who cannot afford to be taxed to still be covered the same as everyone else. There is a Medicare For All bill in the House introduced by Representatives Jayapal and Dingell, which would implement the Medicare for All system. It is HR 3069. We need to demand immediate passage of this bill!
How about defunding these cheating health insurance companies who are abusing the “medical necessity” phrase to deny and delay care. I personally experienced this when I had an eye infection and could not see a specialist until my primary doctor intervened and by then my infection has become chronic. It is time to end this monopoly of insurance companies who are only interested in profiting off of patients and taxpayers. Medicare Advantage should be banned and we should insist that more control over administration fees be enacted to protect consumers—the American public.
Thanks for this and I will share it with our state association who often talks about this. I’m a psychologist and owner of a midsize practice. I’ve been looking for someone with expertise in mental health audits. Preferably someone who has worked as an auditor at an insurance company in the past. Any ideas how to locate someone with this experience?
Yes! In particular, establishing the principle that medical decision making by the company must meet legal standards for the practice of medicine would be most welcome.
When you say that you have negotiated these contracts, you are talking about negotiating the prices which are attache to the back of a Provider Contract. The terms and conditions don't change and the Hold Harmless language can't change because it's mandated by the laws of every state in the country. The T and C's simply aren't up for negotiation. So don't tell me a person can simply pay for care when coverage is denied. I have read the Contracts and they absolutely bar a provider from billing or accepting any form of compensation when coverage is denied. - - - I've also had two VPs of Legal and several hospital presidents acknowlrdge what I am saying. And, I tried to pay three separate hospitals for the care that my wife needed when coverage was denied and was refused in what were very hot arguements. - - - So, if you want to promote discussion, let's start with the actual language of the insurance industry's SECTRE Provider Contracts. And, please don't try to tell me they aren't secret. It's simplt too easy to prove that they most certainly are. - - - Please forgive my bluntness, but discussion isn't what we need. What we need is disclosure. Beacuse, these same Contracts require the provider to rtender the car REGARDLESS of their ability to receive compensation.
Ron. Many thanks for your comment. But we need to put another layer on this fraudulent cake. The health insurer's Provider Contracts BARR all billing and payment whenever the insurer denies coverage. So you can't even pay for your own healthcare when coverage is denied, because the Provider is contractually BARRED from billing you or accepting your money when coverage is denied. - - - This very situation caused the death of my wife and is the reason I understand the details of their Provider Contracts. Read my book at <www.killAbill.com> and you will understand what's in these Provider Contracts, as well as know how to turn what's in them to your advantage.
First of all, thank you for the discussion. We need more discussion on this topic, even when the parties don't fully agree. I completely understand the issue you bring up. I have been negotiating these contracts, first on the payer side for 18 years and now on the provider side for the last 21 years. I understand the issue. However, at any point the insured can choose not to use their insurance and pay for the service. The problem is most people can't afford that option so it's not much of an option. Thanks again for your comments.
Ron Howrigon's article misses the entire point of Medinally Necessary Care. It's by LAW a determination that can only be made by the attending doctor - PERIOD. An insurance company has ZERO legal standing to determine Medical Necessary Care for a patient it has never even seen. What an insurer does have is the right to deny COVERAGE in order to "induce" lower cost healthcare per the U. S. Supreme Court in a 1990 ruling. However, the Provider Contract that every in-network provider signs makes it absolutely clear that the Provider MUST render the care determined to be Medically Necessary regardles of the ability to be compensated for the rendering of the care.
CONCEQUENTLY, there is ZERO need to change the law or policy on the denial of coverage for Medically Necessary Care. We just need to inform the public on what the current law actually IS !!!!!!!!!!
Please, try to tell me where I'm wrong. I'm sure the silence will be deffining!
Having worked for insurance companies for the first 18 years of my career I understand and used the statement, "We are not denying care we are only denying coverage". However, denying coverage, especially when the rational is that the care is not "medically necessary" is really denying care because people can't afford the care without insurance. My point is that if the Medical Director that signs off on this denial of coverage by saying that the care recommended by the treating physician had to follow the same rules, responsibilities and accountabilities this problem would go away and people would get the care they need.
"If only there was a group of doctors that represented every specialty, we could get them to meet and determine universal coverage policies that could be mandated for all health insurance, both government and commercial."
Works for me in terms of defining Medical Necessity. Reduce them to writing, publish widely. Mandate insurers and self-insured health plans specifically agree OR disagree to follow those requirements.
The tradeoff?
Let the insurers and self-insured, employer-sponsored plans define in writing what risks they want to take on (illnesses, injuries, etc. - one by one, yes or no, for each CPT) - eliminating all state and federal insurance and other coverage mandates.
That way, every individual has certainty over what any insurance policy of employer sponsored health plan covers and does not cover, and the insurance companies and self-insured health plans can properly price the risk being transferred.
How about getting rid of these middlemen who have nothing whatsoever to do with health care? Why are we trying to work around multi billion dollar grifters? Just get rid of them and develop a strong single payer system without any form of managed care with its upfront capitated payments that turn the physician into a risk bearing entity with incentives to deny care? Lets do either Fee For Service or Fee for Time for individual practitioners and strict global operating budgets for each individual institution (ie hospitals,nursing homes, dialysis centers, etc.)
author is a “Health Care executive”. he clearly can’t confront the reality that there is no “good” side in the corporate practice of medicine (i think he helps physicians negotiate contracts with insurers). if he thought health care was a good or noble field to pursue, he should have gone to medical school (or done anything on the clinical side). ban the corporate practice and corporatization of medicine (it really isn’t a matter of outlawing it, it is a matter of overhauling our government, as Congress & federal judges have been responsible for all of this criminal highway robbery from taxpayers).
As a standard Medicare participant I've been insulated from the excesses of prior approval. But with the trial implementation of the WIsER program for pre-authorization I think it's coming for standard Medicare participants as well. Only in six states at the moment and for a handful of conditions, but if you ask me it's just another scheme to push more retirees into Medicare Advantage plans.
Most doctors participate in traditional Medicare. You can see any doctor anywhere in the U.S.
No referrals required to see a specialist.
Please fight for, support, and ask ALL members of Congress to co-sponsor Medicare for all acts. The congressional switchboard 202 224–3121.
Nice work Ron.
Actually, “medical necessity” is strictly a legal term. Is it not a co-opted clinical term.
Clinicians are trained in standards of care, not in “medical necessity.”
And insurers may use proprietary “standards” of care developed by for-profit entities (in some cases, entities that they own), instead of the clinical standards of care developed by clinicians and approved by no-profit clinical groups.
And too often the insurers do not disclose their proprietary standards and their use in denial of care.
Did I mention that insurers may have a bias for covering claims for crisis stabilization, not for a patient’s recovery. Such a limitation is absurd; think of a cancer or cardiovascular intervention that stops with crisis stabilization.
www.governmental health.com
More often, clinicians are supplanted by an AI bot applying a mathematical formula (algorithm) to approve/delay/deny claims. The bot has no medical training nor does it have access to full medical records.
Most use these only for approvals and all denials go to the MD. RNs also can approve but not deny. Only an MD can do denials... at least in Medicaid Managed care.
The entire problem boils down to only one thing.... the huge mistake in allowing any profit or profit motive to be part of our healthcare system in any way! We need a completely and exclusively publicly funded national healthcare system that will cover everyone residing in the US for life... one that is government-run and eliminates all middlemen (health insurance companies). That is the ONLY way to cure our terminally ill current system, which has been transformed into a system of "wealthcare" for wealthy investors!
The IDEAL system would also make every medical practitioner and healthcare worker a salaried employee in a government-run system. This would eliminate all profit motive. Every employee's salary would be based on the difficulty, education, and training needed for that particular position.
The second best system (Medicare for All) would be one where, instead of becoming government employees, physicians (medical practices) would remain privately owned. However, there would still be no health insurance companies, and the government would cover all medical costs for everyone.
Either of these models would be paid for via a very progressive tax, so that the wealthiest would be shouldering far more of the cost, in order for those who cannot afford to be taxed to still be covered the same as everyone else. There is a Medicare For All bill in the House introduced by Representatives Jayapal and Dingell, which would implement the Medicare for All system. It is HR 3069. We need to demand immediate passage of this bill!
There needs to be a special place in hell for those who take a patient’s money and then deny them medical care.
How about defunding these cheating health insurance companies who are abusing the “medical necessity” phrase to deny and delay care. I personally experienced this when I had an eye infection and could not see a specialist until my primary doctor intervened and by then my infection has become chronic. It is time to end this monopoly of insurance companies who are only interested in profiting off of patients and taxpayers. Medicare Advantage should be banned and we should insist that more control over administration fees be enacted to protect consumers—the American public.
"Medicare Advantage should be banned" ---as should all Medicaid "managed care"
All the administrators, directors and secretaries in our current cabinet are pretty much medically unnecessary.
Thanks for this and I will share it with our state association who often talks about this. I’m a psychologist and owner of a midsize practice. I’ve been looking for someone with expertise in mental health audits. Preferably someone who has worked as an auditor at an insurance company in the past. Any ideas how to locate someone with this experience?
Yes! In particular, establishing the principle that medical decision making by the company must meet legal standards for the practice of medicine would be most welcome.
Ron,
When you say that you have negotiated these contracts, you are talking about negotiating the prices which are attache to the back of a Provider Contract. The terms and conditions don't change and the Hold Harmless language can't change because it's mandated by the laws of every state in the country. The T and C's simply aren't up for negotiation. So don't tell me a person can simply pay for care when coverage is denied. I have read the Contracts and they absolutely bar a provider from billing or accepting any form of compensation when coverage is denied. - - - I've also had two VPs of Legal and several hospital presidents acknowlrdge what I am saying. And, I tried to pay three separate hospitals for the care that my wife needed when coverage was denied and was refused in what were very hot arguements. - - - So, if you want to promote discussion, let's start with the actual language of the insurance industry's SECTRE Provider Contracts. And, please don't try to tell me they aren't secret. It's simplt too easy to prove that they most certainly are. - - - Please forgive my bluntness, but discussion isn't what we need. What we need is disclosure. Beacuse, these same Contracts require the provider to rtender the car REGARDLESS of their ability to receive compensation.
Ron. Many thanks for your comment. But we need to put another layer on this fraudulent cake. The health insurer's Provider Contracts BARR all billing and payment whenever the insurer denies coverage. So you can't even pay for your own healthcare when coverage is denied, because the Provider is contractually BARRED from billing you or accepting your money when coverage is denied. - - - This very situation caused the death of my wife and is the reason I understand the details of their Provider Contracts. Read my book at <www.killAbill.com> and you will understand what's in these Provider Contracts, as well as know how to turn what's in them to your advantage.
First of all, thank you for the discussion. We need more discussion on this topic, even when the parties don't fully agree. I completely understand the issue you bring up. I have been negotiating these contracts, first on the payer side for 18 years and now on the provider side for the last 21 years. I understand the issue. However, at any point the insured can choose not to use their insurance and pay for the service. The problem is most people can't afford that option so it's not much of an option. Thanks again for your comments.
“This is where things go off the rails.” So true. The debate and definition depends on who is talking, as you stated; Insurers or Physicians.
Insurers have usurped the role of Physicians. A conundrum at best.
The debate is
Ron Howrigon's article misses the entire point of Medinally Necessary Care. It's by LAW a determination that can only be made by the attending doctor - PERIOD. An insurance company has ZERO legal standing to determine Medical Necessary Care for a patient it has never even seen. What an insurer does have is the right to deny COVERAGE in order to "induce" lower cost healthcare per the U. S. Supreme Court in a 1990 ruling. However, the Provider Contract that every in-network provider signs makes it absolutely clear that the Provider MUST render the care determined to be Medically Necessary regardles of the ability to be compensated for the rendering of the care.
CONCEQUENTLY, there is ZERO need to change the law or policy on the denial of coverage for Medically Necessary Care. We just need to inform the public on what the current law actually IS !!!!!!!!!!
Please, try to tell me where I'm wrong. I'm sure the silence will be deffining!
Having worked for insurance companies for the first 18 years of my career I understand and used the statement, "We are not denying care we are only denying coverage". However, denying coverage, especially when the rational is that the care is not "medically necessary" is really denying care because people can't afford the care without insurance. My point is that if the Medical Director that signs off on this denial of coverage by saying that the care recommended by the treating physician had to follow the same rules, responsibilities and accountabilities this problem would go away and people would get the care they need.
"If only there was a group of doctors that represented every specialty, we could get them to meet and determine universal coverage policies that could be mandated for all health insurance, both government and commercial."
Works for me in terms of defining Medical Necessity. Reduce them to writing, publish widely. Mandate insurers and self-insured health plans specifically agree OR disagree to follow those requirements.
The tradeoff?
Let the insurers and self-insured, employer-sponsored plans define in writing what risks they want to take on (illnesses, injuries, etc. - one by one, yes or no, for each CPT) - eliminating all state and federal insurance and other coverage mandates.
That way, every individual has certainty over what any insurance policy of employer sponsored health plan covers and does not cover, and the insurance companies and self-insured health plans can properly price the risk being transferred.