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.
>> So, your doctor ordered a test or treatment and your insurance company denied it. That is a typical cost saving method.
OK, here is what you do:
1. Call the insurance company and tell them you want to speak with the "HIPAA Compliance/Privacy Officer" (By federal law, they have to have one)
2. Then ask them for the NAMES as well as CREDENTIALS of every person accessing your record to make that decision of denial.
By law you have a right to that information.
3. They will almost always reverse the decision very shortly rather than admit that the committee is made of low paid HS graduates, looking at "criteria words." making the medical decision to deny your care. Even in the rare case it is made by medical personnel, it is unlikely that it is made by a board certified doctor in that specialty and they DO NOT WANT YOU TO KNOW THIS!!
4. Any refusal should be reported to the US Office of Civil Rights (http://OCR.gov) as a HIPAA violation.
It certainly sounds like something that could work.
By deeming something not medically necessary they are (in my opinion) effectively practicing medicine. If they aren't qualified to practice that specialty, or aren't acting in the patients interest we should really be getting malpractice suits on them and stripping medical licenses.
https://healthlaw.org/wp-content/uploads/2025/11/Vanneman_Pr...
The overall situation is that the insurance company doesn't want to trust your doctor's judgement [0], so they insist on getting a second opinion about the care you might need to receive. That second opinion is still being performed by a licensed doctor who is supposed to be working in your interests - it's a straightforward practice of medicine the same as if you yourself were to go and seek out a second opinion.
[0] or really they want to play good cop / bad cop - remember "your" doctor themselves is essentially also an employee of the insurance company!
Feels like convenient lawcraft to wash the health plan employee’s hands of liability. I’m sure the prevailing popular opinion would be that this is practicing medicine.
Although on the words having meanings front, whatever is going on here is pretty clearly not insurance at this point; it'd be better just to honestly call it welfare rather than force people to redefine the word 'insurance'. It is hard to talk to people in the US about actual insurance now because they don't have a word for it any more. Politically redefining 'medicine' too would be a mistake, important conversations will become incoherent.
If I build you a house and tell you the roof trusses aren’t necessary, you’d be pretty peeved.
Maybe an even better analogy is that I live in a rented home and after I report some weird respiratory issues, an inspector finds black mold all over the place. The landlord refuses to fix the issue because "black mold is totally fine, bro" and I get really sick. I could maybe have moved out, but I kinda feel like the landlord is going to have a bad time here.
That might not be actually an option. Well the provider can do it for free, probably; but they may not be able to accept money for care that was denied coverage. A Medicare provider can charge patients for things outside the scope of Medicare, but generally can't charge for things in scope but deemed not medically necessary: ex if Medicare says 6 PT visits for whatever and you would like to have 8, you can't pay the provider for two more; you'd have to find a non medicare provider or come back with a fake moustache.
The reality is that this is the insurance companies trying to have their cake and eat it too. They actually want to be making a medical decision in denying coverage since it gives them a legitimate reason to do so, but want to avoid any liability if that decision was wrong.
It will never happen.
This is largely what at least half the country wants.
“If I need to take a drug test to earn a check you better take one to get welfare.”
I’ve heard a working class person say this. I guarantee you the people who own defense contractors, the real welfare queens don't need to take a drug test.
Likewise, the horrific thought that someone unworthy might get free healthcare is appalling to half this country. They’d rather go without just to ensure *those people don’t get free healthcare.
This country doesn’t want to be fixed. It wants RFK to tell you to treat Autism with raw milk and sunshine.
Nothing much to do but try to find a civilized place to live
2 questions:
* This time, is it paid? Is it billable? Is it part of the visit I pay for?
* What can I - as a patient - do to make this process easier?Depending on the issue, the patient may be needed to provide supporting paperwork, like previous diagnoses or treatment for providers. Other than that, not really, short of taking legal action.
Two, that book may be a good idea:D
Did they ding you for bad performance after a while? Your job was to maximize denials, not approvals.
Who decides this? You?
Should we allow everyone in the world who needs a procedure to receive one free and get ahead in line for Americans who need the same procedure? That's what the current climate looks like with unbridaled immigration under progressives.
These are hard questions. What's the answer?
Gating access to medical care is the job of the patient's PCP and or other doctor. If the care is truly, meaningfully rationed (like transplant organs and blood banks), there are triaged priority lists managed by medical organizations.
MAID is popular not because of lack of care but because Québécois values their autonomy and quality of life above being simply alive for the longest time possible.
And the scans are not scheduled months in advance. We complained that we were only informed of the date and time of the next scan a few days before it... The explanation was that they have a must not be done before and a must be done after dates but the actual scheduling is done just in time so urgent case are prioritized before routine care.
This claim is so outlandish that I'd like to see some sources for it.
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.
"Medicare Advantage" = HMO. All the usual HMO problems.
The best Medigap plan is Plan F, which is no longer available to new subscribers. "Discontinuation of Medicare Plan F was a strategic decision aimed at promoting responsible healthcare spending and ensuring the financial sustainability of the Medicare program." It covers just about everything Medicare doesn't pay, including the various deductibles Medicare has. If Medicare covered Medicare's part, the Plan F provider has to pay their part. They don't get to question it. I don't even see hospital bills, just statements that it's been paid for.
Plan G is one step down from that.
Not on Medicare, but I switched to an HMO over 10 years ago at work, and have never been happier.
There are fantastic and crappy PPOs, and fantastic and crappy HMOs.
After years on Kaiser because of familiarity, when I became eligible for Medicare, I had to make a choice between original Medicare or Medicare Advantage.
It’s incredible expensive to buy into adequate coverage if you’re under 65 and on disability and want original Medicare, but after the mixed experience I had with Kaiser, I wouldn’t have it any other way.
As I have some serious health conditions, I signed up with Plan G Extra and a high coverage tier for Part D. It’s going to cost about $1300/mo plus an additional $202.90/mo for part B, but it’s better than having to worry about future health issues putting me in financial ruin.
Nice to preserve choice being responsible for at most a $283 deductible per year on top of the monthly cost.
I had a 3 day hospital stay in December 2024 that was $75,000 and I didn’t have to pay for it, so it was worth it to have good coverage.
https://www.kff.org/medicare/higher-and-faster-growing-spend...
Insurance is brutally simple. Money in, money out. Trying to make your back office more lean with tech and automation has extremely limited returns, because the back office is such a small portion of the total cost structure. 95-100% of costs in any given insurance operation are claims. So everything to do making things more efficient and reducing costs has to do with reducing claims.
The insurers are such behemoths and so largely vertically integrated it is controlling the system instead of improving it.
Notice how there is rarely ever any new competition in the health insurance space to drive down pricing.
Who are the people who sleep at night after designing these policies?
There is an unlimited pool of people without empathy. Never forget that.
https://commons.wikimedia.org/wiki/File:OECD_health_expendit...
(And we’re middling in outcomes!)
Americans are not inherently three times as sick as Australians.
Side note: I'm an Australian citizen, living in the States.
An Australian hospital doesn't need a billing/collections department and the docs don't sit on appeals calls with insurance; when my wife broke her foot visiting, they basically didn't know how to bill her (for surgery and three days in a ward!). My son needed a badly ingrown toenail treated on a separate visit there last year; they just treated it and sent us on our way, no charge, despite his being a tourist.
I straight up don’t believe the drug use one, we have way more fentalyl deaths than you and it’s not even close.
You didn’t address crime. We have much more of it. More gun ownership and gun usage as well.
I’m not quite sure what this anecdote has to do with my comment.
Australians eat a substantially similar diet to Americans, and have similar health issues (obesity, heart disease, etc.) as a result. They are deeply related things.
> I straight up don’t believe the drug use one, we have way more fentalyl deaths than you and it’s not even close.
Gee, I wonder if not having healthcare (including access to things like therapy and rehab) might drive up drug death rates.
> You didn’t address crime.
Sure; you didn't address how it's responsible for 3x the healthcare costs.
Sorry I don't believe this
> Gee, I wonder if not having healthcare (including access to things like therapy and rehab) might drive up drug death rates
Lol, yeah that's why we have so many fentanyl addicts, the lack of therapy, I'm sure that's it
> Sure; you didn't address how it's responsible for 3x the healthcare costs.
Gunshot wounds obviously, we have way more guns and gun crime than Australia
It doesn't help that our healthcare billing systems are so outdated and broken. I once had a doctor visit denied with the reason code that it should charge the other insurance (for people on multiple plans). I was only on one plan, but my wife was on two. The doctor and I went through all the paperwork - my name was right, my birthday was right, my policy number was right and when I got notice of the rejection it had my name on it. Eventually we traced it to an error - not in my insurance company, not in the company that handles claims in this areas for my insurance, but instead in some middle-man company that was responsible for transferring claims between the two. Nevermind that all three companies claimed to be BlueCross BlueShield. This took over a year to resolve.
The numbers here are not close. They're stark.
> A new study finds that the extra time and labor physician practices spend on interacting with insurance companies and government entities cost U.S. physicians $82,975 each per year, while doctors in Ontario spent $22,205.
> Canadian physicians follow a single set of rules, but U.S. doctors grapple with different sets of regulations, procedures, requirements, formularies and forms mandated by each health insurance plan or payer. The average U.S. doctor spent 3.4 hours per week interacting with health plans; Ontario doctors spent 2.2 hours. The bureaucratic burden falls heavily on U.S. nurses and medical practice staff, who spent 20.6 hours per physician per week on administrative duties; their Canadian counterparts spent only 2.5 hours on paperwork.
All that falls in your $2.5T bucket. And their cleaners, HR, etc. And insurers have had 15 years of innovation since that study.
My local grocery store wouldn't even bother issuing a coupon for that small a discount.
This isn’t seventh grade math. This is kindergarten level cause and effect.
I said earlier we'd gone round-and-round on this topic before, and I was a little burned out on it, but I didn't expect you to refute your own argument like this. I'm glad we gave it another run this time! This is a great statistic; I'll be using it elsewhere. Thank you.
> I was a little burned out on it
I just did my taxes and am a little burned out by the $49k in healthcare expenses I got to deduct on them.
later
Fun fact: given your background and field, you probably come out significantly ahead of where you'd be in countries with single-payer health care. That's despite the fact that those countries have significantly healthier systems where doctors don't make 3-5x the G20 average and where overprescription and overdelivery isn't as rampant as it is here.
The numbers really do a number on a lot of the narratives people bring to these discussions.
Oh, absolutely not. I’ve done the math on that, for sure. Unfortunately, one family member has a condition that makes emigration infeasible.
> Today, many of those practices have been bought up by large corporations, including hospitals, private-equity firms and even health-insurance companies. It’s a shift that not only has changed how money moves through the health care system, but may also be helping some insurers boost their profits, according to new research published in Health Affairs.
> A study from researchers at Brown University’s Center for Advancing Health Policy through Research and the University of California Berkeley found that UnitedHealthcare, the nation’s largest health insurer, pays doctors who work for its own physician network, Optum, more than it pays independent practices for the same care.
(And the independent practicioners are having to use a significant portion of the money they take in to… fight the insurers!)
The idea that the problem with our system is health insurers is just slopulism. We have grave problems with our system! But they start with the providers, where the majority of all the funding in our system goes, not to the scapegoats they've stoop up in our insurers. The distinction is vitally important, because the most popular answer to this problem is to extend Medicare to everybody, and Medicare is just as victimized by this as everything else is!
We pay doctors too much, and we artificially restrict the supply of practitioners. Those doctors routinely overprescribe. Every other problem in the system is marginal.
And by inflating that amount...
> Using newly available federal price transparency data, the researchers found that UnitedHealthcare pays Optum physician practices about 17% more than non-Optum practices in the same region. In markets where UnitedHealthcare holds a large share of the insurance business, that difference was even larger, up to 61%.
their capped-by-law 20% cut of premiums goes up, too. "Oh, those mean old providers we own charge so much! We have to raise premiums again!"
Fun thing about the NHE: you can project it as far back as you want. The data is there.
What? Insurers have been playing this game far further back than 2023.
If an insurer doubles the time a doc has to fight over denials and has to hire extra billing staff to assist, where do you imagine that cost shows up?
Again: how will the “insurers force provider costs up” show up in said tables?
It’s caused by the insurer. It shows as a provider’s cost. But it doesn’t mean said doc is making any more money at the end of the day.
The insurer does, though! Their 20% cut got bigger, and the "computer says no" denials are cheap!
TL;DR: Where in your link does "doc spends needless hours on phone fighting insurer" show up as a cost?
But it's not a "Cost of Health Insurance" item. It's an expense at the practicioner level! They have to factor that non-billable time into what they charge for the procedure!
Read their definitions: https://www.cms.gov/files/document/quick-definitions-nationa...
"Administration" is the insurer's side of it.
If an insurer manages to double a doctor's administrative costs for billing/appeals/etc., where does it show up in your tables, per your link's PDF of definitions?
> Insurers are almost literally a rounding error.
Again, the argument is that the raw cost of health insurance does not reflect its externalities imposed on the other items in your list; that insurers drive up hospital and practice costs, as they have to staff up enormous amounts of staff and expensive physician time to deal with the insurer.
Some of which is those practicioners' admin cost from dealing with the insurers. (And, you know, doing the actual work.)
Denials are nice and cheap. Fighting them is not.
And as noted in that other conversation, this is one aspect of many. UHC isn’t pursuing vertical integration for funsies.
Again, I want to be clear: I'm not here to defend the American health system. It's a disaster. It's just clear to me you don't have a bead on why that is. (The answer is artificial scarcity of practitioners, overprescription, and lack of price transparency).
So is “insurance doesn’t have any externalities that might hide in my very broadly categorized numbers”.
https://www.cms.gov/priorities/burden-reduction/overview/int...
I had the insurance written approval in my hand while the pharmacist told me it was being rejected for needing prior approval. The insurance phone rep said they could find no record of any REQUEST, let alone approval, for the drug.
So I go to the state insurance regulator. That does at least light a fire under their arse. They can't claim it's not medically necessary when I already have their approval.
During the complaint process I learn: - Front line reps don't have any access to any pre-auths. You need to talk to a supervisor. They ADMITTED the system is by design obstructive. - The person who entered my approval did it wrong and did not follow the SOP to run a test transaction that would have caught the error.
They then submit their reply to the regulator leaving out all of the above and blaming the pharmacy instead. I follow up with the regulator pointing this out. I have voice recordings.
Regulator closed it as resolved.
I'd class action their butts if I wasn't still exhausted by the experience two years later.
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.
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.
When they can't completely deny they delay and/or set up burdensome hoops for the patient to jump through before they will qualify for treatment. It's literally their business model.
They even brag about it on their website! > Reduced inpatient hospital admissions by 15% > Reduced use of skilled nursing facilities by 15% (because we won't approve them for nursing care!) > MedExpert clearly reduces rates of unnecessary elective surgery.
If you want entertainment go to their glassdoor reviews and sort by lowest ratings: https://www.glassdoor.com/Reviews/MedExpert-Reviews-E777566....
> 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
State politicians are much cheaper, and no one from the New York Times pokes around when you buy off the state representative of East Bumfuck, Montana.
Slavery was estimated at ~12% and "hey, you need to lose a few % of your margin and actually pay those people" started a war.
Now, there's an argument to be made about ideology, geographic concentration of industry, etc. doing a fair bit of lifting kicking that off (their own neighbors telling them to stop surely would have gone over better than a bunch of smarmy northerners in their ivory towers telling them the same thing). But the fact remains that you cannot make a large fraction of the country take a haircut without causing strife.
The only way to fix this "nicely" at this point is to boil the frog over decades.
Most people would consider money a resource, and quite a few rural hospitals are closing because of a lack of that specific resource.
> you'll discover how you really DONT want the government to tell you which patients to serve
Yeah, wait until you hear about private for-profit insurers doing that instead.
It's a money problem because the medicare doesn't pay enough to hosptals, and boomers are all on medicare.
So your government run healthcare is destorying rural hospitals.
Sure you have. Copays and deductibles are still a thing. I wish my kids didn't have medical bills!
Problem is you’ll go right to the emergency room when you have a heart attack.
Yes, the patient needs skin in the game. People need to take care of their own health. Most procedures are given to grossly unhealthy people.
Yes, completely privatize it. Make people pay for their care so their daily decisions are weighed against what affect it will have on their overall health.
The hint here is that the random pricing needs to stop. Same procedure for the same price. No market can work if participants don’t know the actual price. Insurance and hospitals probably have a very good idea but patients are being kept totally in the dark. You are expected to just accept what this opaque machinery comes up with.
Well, yeah. That's the idea behind "medically necessary". We don't do elective heart transplants on healthy people for funsies.
They just get to die, or what?
Totally unrelated. In traditional stories, as anyone ever been upset when the knight slays the dragon at the end because the dragon was hoarding all the gold and killing the townspeople? I was never upset when the dragon got slayed.
EDIT: Yeesh. I guess people here really like it when the dragon wins. Oh well. I guess people have to die so the dragon can hoard the wealth.
This applies to just about everything, not just medical.
The suffering in society always reaches equilibrium with the pushback and modern people are very, very, very docile so we're made to suffer a lot.
The more care that's allowed, the more dollars they can keep. It's a complex optimization though; people like to pay less premiums, so an insurance company wants to price coverage low enough to attract customers and then allow enough care to keep the premiums without allowing so much as to reduce their margin.
TLDR is that it’s a job that can pay enough to keep one housed, and sometimes there are no alternatives.
I’d redirect the outrage away from the grunts denying care, and towards the leadership that set up those incentives. And even further, when the shareholders demand more profit because the line must go up, what to do?
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".
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.
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.
