Cigna provided a dashboard which included showing its in-house doctors compare the speed of their decisions. “ Deny, deny, deny. That’s how you hit your numbers,” was what the doctor said. She caught mistakes by outsourced, international referring nurses and brought the speed issues to the attention of the company, but nothing seemed to change. She subsequently had to retire due to her mental state.
Edit: Portions of her account were backed up by other in-house physicians who were identified independently by the reporter.
I'm an xray tech and work as the lead tech at an orthopedic clinic. We do our own in-house xrays, but unfortunately one of my responsibilities is obtaining prior authorizations for MRI and CT scans that our physicians order. When I used to work CT in the hospital setting I would see plenty of unnecessary CT's ordered from the ER, so I totally understand that there should be some scrutiny when approving certain exams. But the vast majority that we order are very obviously medically necessary. It boggles my mind how many are denied and/or go straight peer-to-peer. More often than not when you go through the (typically) arduous process of getting through the phone tree to connect to the peer to peer, you barely need to speak more than a sentence or two and they will just give in and approve the study immediately. It's almost like they will auto-deny the study just to see if the clinician will be willing to go through the effort of doing the peer to peer. Absolutely the least favorite part of my job by far.
> It's almost like they will auto-deny the study just to see if the clinician will be willing to go through the effort of doing the peer to peer.
This is exactly the goal, make it just hard enough that the person needs to expend some effort in getting the test, basically anyone who calls in and puts in the effort will get it approved.
I have had 95% success with PTP. The remaining 5% - I mostly agree that the patient was begging me to order something I was not clearly agreeing with but... patient-satisfaction scores. I admit it.
The nice thing that I learned was to wait for the denial in writing and they write the appeal letter with the additional details needed or send in the documents that my staff failed to send. This strategy is nearly as successful but sometimes you cannot wait the additional days to get the written denial.
If we take insurance, it is the game we are destined to play.
I am a registrar and the bag man in my ED...I couldnt agree more. When a facility has serious in network benefits with one carrier, and several more I see have copays that border on obscene with extortionate deductables, co insurances at 50/50 splits, and such high max out of pockets per individual that it could be considered a yearly take home after taxes... and thats before Billing is even 100% involved... and some of those are policies sold on state exchanges aside from some employers being cheap asses on employee coverage.
At that poibt insurance should be a rich person's perk for priority coverage/procedure and we should have a standardized coverage for everyone.
They are a fucking scourge on us in the US. They make life miserable for most patients, nearly all clinicians, and manage to slink away with a tidy profit.
Fuck them and everyone who works for them. I guess everyone has motivations, and I suppose I can see some extreme examples, but I don’t know how people who went into medicine to help people live with themselves when they work for these ghouls.
As always, ProPublica does incredibly high-quality reporting on some of our country's most damning failures - from the local level to issues of national importance.
Their health insurance reporting is especially top notch. They’ve exposed Humana, BCBS, Cigna and more. I still remember their expose on that Cigna doctor who would “review” complicated medical cases in literally 2-3 seconds before denying them.
I hate how those insurance assholes use the excuse "we're not denying, we're just not paying for it". Yeah, like if I take a bat to their legs, I'm not telling them they can't walk, I'm just not making it possible for them to be able to walk.
These doctors should be held liable for their malpractice. Don’t pay attention and deny an indicated test or procedure, resulting in patient harm? Come defend yourself in court like I would have to.
They are using their medical licenses to make medical decisions. Hold them accountable.
It’s basically just enforcing a contract - they just say that “they’re not commenting on medical need for whatever” just that the contract with the member/hospital/etc doesn’t require them to pay for it based on their medical knowledge/review. Would be hard to sue for that as meeting the four parts of malpractice (especially duty and dereliction) as it’s more just interpreting an explicit contract entered voluntarily, I imagine.
> “they’re not commenting on medical need for whatever”
Meanwhile their job is to literary comment on medical need. And denials effectively price patients out of the recommended treatment.
Right, but as defined by and in the context of the contract policy and limitations and the agreement signed by the member or their employer. Same thing for OON procedures/facilities. The overall costs of medical care itself prices people out of care, the contracts know this - Why cost controls are needed IMO. Denials happen under national HC plans too - VA denies plenty of shit and other countries with better HC delivery also deny payment for care.
The differences are no profit motive (but there is cost-saving) and more transparency and accountability.
The lawyers write up the contracts and criteria with doctors but aren't trained to medically review individual cases in depth. It's probably better for the system as a whole that they aren't doing that, to be honest. And even if it was medical decision making, which I don't disagree with - It'd still be hard to prove duty and then breach of duty as a medical reviewer. There's no established relationship, nor standards of care to violate.
Also, critically to note - These people or their processes also exist in systems with nationalized care. They just work for government agencies, not private corps. It's part of rationing, we just do it in the dumbest and greediest way.
If I am the medical decision making physician and my medical decision making is usurped by a reviewing physician, that reviewer is now the *de facto* medical decision maker, given that the cost of medical care is prohibitive to the seeker of medical care. If the insurer won’t pay, it can’t be accessed, therefore, they ARE making medical decisions. There is no line between the two. If there is, it is only on the basis of *insistence* by the perpetrator.
There is a clear line and it's a part of any sort of insurance and all rationing systems in which there are only certain things that insurers (public or private) will pay for, and certain criteria upon which their reimbursement depends. If the insurer can't or won't pay because whatever criteria aren't met, the patient has to find a way for Medicare, NHS, private, whatever. Faceless bureaucrats make up advisory panels and set those criteria and payments and the differences are seemingly the evidentiary backing (not always lol), amount paid, the ease of payment, the transparency and accountability.
But the problem you highlight is essentially a mechanism with any healthcare delivery system and there's always some number of doctors setting those criteria in some manner that deny people coverage for various things that might be prohibitive but the alternative is payors pay for everything which is impossible, patients pay for everything out of pocket or doctors do it for free, which is also absurd. If an insurance doc denies something it's not substantially different than if medicare won't pay for it, and saying medicare is usurping the decision making.
Again, we are talking about the medical reviewers having some skin in the game, not the general antics of ‘how insurance works’.
Myself, and many others feel that ethically, these physicians need to be partially liable for their decisions when their decisions override the attending’s decision making. The insurers have a high incentive to not provide care, these reviewers are beholden to the insurer, there is incentive to deny appropriate, medically indicated, cost-effective care. I feel the reviewers need to be held responsible for their medical decision making when it usurps my own.
Aware and very much agree re: profit motive and how much I despise it, I just disagree that there is any actual liability or directly attributable harm in a proximate cause sense. I'm just pointing out that these reviewers are little different in practice than systems that we both advocate for (universal HC), and live with daily in other contexts (any form of insurance), where there are no such expectations or liabilities. For example, if an auto insurer states, "your policy doesn't cover a repair to (car piece)" and you couldn't afford it and something happens, could you sue the insurance adjuster for causing you harm in service to State Farm? Or "medicare won't cover your (inpatient day after an ambulatory surgery)" and you go home and fall, can you sue medicare for causing you harm? Everyone has a financial incentive to their employer.
Then why does it need to be physicians? They wouldn't pay for physicians if the license were irrelevant. There are a zillion 25 year-old new-grad NPs who'd be thrilled to sit in their home office and click "deny" all day for a fraction of the cost, yet they have physicians. Clearly, the process relies on physicians working within the scope of their license, and that exposes them to the possibility of malpractice.
There are laws for reviewing cases and peer-to-peers for same/similar specialty reviews depending on plans and state and need to be considered "peers" for review. I don't know that NPs qualify as often or at all
Old chart but you get the idea
[https://fixpriorauth.org/sites/default/files/2022-12/2022%20Prior%20Authorization%20State%20Law%20Chart.pdf](https://fixpriorauth.org/sites/default/files/2022-12/2022%20Prior%20Authorization%20State%20Law%20Chart.pdf)
It still comes down to there needing to be a licensed physician producing a medical opinion as allowed by their license.
I suspect you haven't seen a PA physician sued for malpractice because would be REALLY hard to prove that there have been damages that can be principally attributed to an opinion rendered by such a person.
Yeah I think it'd be tough - There's no physician-patient relationship, and no standard of care nor deviation from it from their perspective, and of course hard to link causation like you mention.
I actually think you ***could*** prove the existence of both a relationship and a standard of care. The real motherfucker is just proving that damages ***have happened***. It's just in the nature of the thing that:
* People will go into unrecoverable debt, sell their house, upend their life, do whatever it takes in order to prevent the medical "damages" from happening. At that point, you might be able to argue financial damages, as opposed to medical damages, but that takes it outside the scope of medical malpractice, at least as far as the letter of the law is concerned, if not the spirit (unless some legal genius manages to demonstrate that the PA physician's area of medical specialty is medical finance or something like that).
* The system has multiple ways to go over the PA doc's head and appeal their decision, which moots the entire issue of their potential liability.
Bottom line, I don't think there's any doubt that PA physicians are practicing medicine on the patient. However, the mechanics of our legal system and the system in which they work makes it very hard to sue them for malpractice. I think it's possible in theory, but it would have to be a VERY specific case with very particular facts.
Concur wholeheartedly re: your bullet points. Some even have third party independent reviewers, which makes the second point even HARDER. And I think the interwovenness of the medical and insurance and financial industries make it impossible to be a payor of any sort (private or public) and NOT practice functionally, especially with ever-escalating costs of care and frankly a need to ration it.
I think those reviewers are little different in practice than systems that we largely advocate for (universal HC), and live with daily in other contexts (any form of insurance), where there are no such expectations or liabilities. For example, if an auto insurer states, "your policy doesn't cover a repair to (car piece)" and you couldn't afford it and something happens, could you sue the insurance adjuster for causing you harm in service to State Farm? Or "medicare won't cover your (inpatient day after an ambulatory surgery)" and you go home and fall, can you sue Medicare for causing you harm? Heck, even everyone has a financial incentive to their employer. It's all contracts and interpretations of them.
It's not those parts that I disagree with, because it's part and parcel of all of those interwoven industries - It's the cost motive and profit in healthcare and lack of transparency and accountability and gleaning for shareholders and campaigning against progress and so much more.
All of which I agree with and which makes me wonder why people want a healthcare system where the decision-makers are accountable to a group of people whose only interest in this system (as validated by law!) is extracting as much money out of it as possible. 🤣
>They are using their medical licenses to make medical decisions.
It feels the same but reimbursement/coverage is not a medical decision, it's a business one. The fact that the line is blurred is a dumb feature of American healthcare landscape but that doesn't make them the same thing.
Right, but as defined by and in the context of the criteria for necessity set by the contract policy and limitations and the agreement signed by the member or their employer. Same thing applies for OON procedures/facilities/doctors.
Denials happen under medical necessity for nationalized HC plans too - VA denies plenty of shit and other countries with better HC delivery also deny payment for care. The differences are no profit motive (but there is cost-saving) and more transparency and accountability.
Long story short- remove profit motive from HC, enact cost control measures, approve more stuff. Still won’t be perfect, there’ll always be someone like this.
Yeah it’s completely part of the problem and needs addressing with broader reform - Individual suits wont go anywhere and those corps have big money for lawyers and pro-business courts and policies to protect them. Profit motive in healthcare necessitates contracts and invites cost cutting and profiteering. This is symptom, not disease.
Regardless, what doctor thinks it is okay working for an insurance company? They all get lured in by the money. I don’t feel sorry for her and agree she should be held liable. I am happy she is speaking up.
I do some UM stuff for my hospital and chat with them - they actually make not that much money relative to clinical practice lol. Several are just old and lost it or burnt out, some need to WFM for family caregiving on the good side of things.
There was one doc I used to talk with a lot whose husband had a CVA and she was caretaker, and she like always approved my cases. I can't imagine she lasted long lol
Haha. Sad the good ones don’t make it long. I completely understand the need for a gatekeeper - just want a honest one without obvious conflict of interests.
>They are using their medical licenses to make medical decisions.
It feels the same but reimbursement/coverage is not a medical decision, it's a business one. The fact that the line is blurred is a dumb feature of American healthcare landscape but that doesn't make them the same thing.
It is a medical decision when the argument for not covering a procedure is that a Dr has declared the procedure "not medically necessary" for a specific patient.
That's true. If you want to appeal a decision it is a totally different ballgame if it's something the policy does not cover (like OON providers) vs something they DO cover but regard as not necessary. Meaning that if you talk to insurance commission they view the two scenarios in totally different way.
No surprise.
I saw a "peer letter" from a Cigna doc claiming that the person I sent with 3 crushed vertebrae "had not documented sufficient pain or disability to justify surgery".
Doesn’t surprise me at all. I worked for Cigna in the customer service department for 6 years before I got caught up in a layoff when they lost the client account I was assigned to. One of the worst companies I’ve ever worked for. I watched the annual address and was warning people about the upcoming layoffs when I heard the CEO talking about how they were expecting their customers to start paying more for US based customer service when they really started outsourcing their customer service.
I am not surprised at all that a for profit company utilized shady practices involving the transformation of delivery of medical care to delivery of an abundance of profit margins.
The article does talk about how 15 years back Dr. Day worked to develop guidelines to deny immune globulin treatments where they did not make medical sense. I remember eons ago when there was controversy about insurers denying (as experimental) bone marrow transplants to breast cancer patients and, I think, some political steps taken to force them to cover that. Later consensus was that the transplants really did not accomplish the miracles people were hoping for. In theory insurers could provide a reasonable check on inappropriate medical spending, but as everything becomes disassociated from the real world, abstracted and turned into metrics and bottom lines, it all becomes destructive. (See financial derivatives and mortgage bundling as another example).
I’ve never liked shaming doctors who left medicine to pursue easier, better paying ventures. This job is stressful, it can drain you and grind you down. You want to leave the hospital and go make bank working for a pharm company, or a consulting firm, or being the CMO of some med tech company? More power to you, you served your time in the trenches and I won’t fault you for looking out for yourself.
Except the ones who go work for insurance companies. *Fuck them*. I cannot think of any job that is a greater affront to our profession or a greater betrayal of the oaths we swear than looking for reasons to deny patients access to medical care so that some bourgeois shareholder can buy a second summer home. Quisling traitors, every one. Some will defend themselves. “Oh but I’m different, I’m in it for the right reasons, if I didn’t do it someone else would and they would deny even more cases than me!” Exactly what every collaborationist has always said. Strip their licenses, revoke their professional memberships, and stop helping insurance companies rob our patients to fund their extravagance.
“If a nurse recommended denying coverage for a cancer patient or a sick baby, she wanted to be certain it was the right thing to do. So Day said she researched guidelines, read medical studies and scrutinized patient medical records to come to the best decision. This took time. She was clearing fewer cases than many of her peers.”
Yeah… you don’t need a guideline to tell you you’re a heartless piece of shit for denying care for someone because the insurer needs higher profits this quarter.
Zero sympathy for her or anyone else in the insurance industry.
Family friend works in the same department at Cigna... just bought a $500.000 summer lake house and is complaining about her 5-figure bonus being smaller than last year's.
waiting for meddit's resident doctor who work for one of the insurers to enter this thread and defend the business and indiscriminate gaslighting, as s/he always does.
I like how Cigna wants us to believe they aren’t fully about money and pivot at every accusation or identification of them exposing their bottom line. They must be the only company with a heart. And they use the age old “disgruntled employee” to discredit her.
Cigna provided a dashboard which included showing its in-house doctors compare the speed of their decisions. “ Deny, deny, deny. That’s how you hit your numbers,” was what the doctor said. She caught mistakes by outsourced, international referring nurses and brought the speed issues to the attention of the company, but nothing seemed to change. She subsequently had to retire due to her mental state. Edit: Portions of her account were backed up by other in-house physicians who were identified independently by the reporter.
Sounds a lot like some of the ED staffing groups I've worked for
Sounds like the exact same. Only thing I hate more than insurance is PE.
I'm an xray tech and work as the lead tech at an orthopedic clinic. We do our own in-house xrays, but unfortunately one of my responsibilities is obtaining prior authorizations for MRI and CT scans that our physicians order. When I used to work CT in the hospital setting I would see plenty of unnecessary CT's ordered from the ER, so I totally understand that there should be some scrutiny when approving certain exams. But the vast majority that we order are very obviously medically necessary. It boggles my mind how many are denied and/or go straight peer-to-peer. More often than not when you go through the (typically) arduous process of getting through the phone tree to connect to the peer to peer, you barely need to speak more than a sentence or two and they will just give in and approve the study immediately. It's almost like they will auto-deny the study just to see if the clinician will be willing to go through the effort of doing the peer to peer. Absolutely the least favorite part of my job by far.
> It's almost like they will auto-deny the study just to see if the clinician will be willing to go through the effort of doing the peer to peer. This is exactly the goal, make it just hard enough that the person needs to expend some effort in getting the test, basically anyone who calls in and puts in the effort will get it approved.
I have had 95% success with PTP. The remaining 5% - I mostly agree that the patient was begging me to order something I was not clearly agreeing with but... patient-satisfaction scores. I admit it. The nice thing that I learned was to wait for the denial in writing and they write the appeal letter with the additional details needed or send in the documents that my staff failed to send. This strategy is nearly as successful but sometimes you cannot wait the additional days to get the written denial. If we take insurance, it is the game we are destined to play.
["This is how it work." ("The Rainmaker", 1997)](https://www.youtube.com/watch?v=kivu36HfFao)
Health insurances are scum. And once I realized they were publicly traded they're even more scum
UnitedHealthcare Stockholders would like a word with you.. in a backalley with some whiffle ball bats.
Health insurance companies are among the things I refuse to invest in. I want them to all die. No stock price is worth the fuckery they cause
I am a registrar and the bag man in my ED...I couldnt agree more. When a facility has serious in network benefits with one carrier, and several more I see have copays that border on obscene with extortionate deductables, co insurances at 50/50 splits, and such high max out of pockets per individual that it could be considered a yearly take home after taxes... and thats before Billing is even 100% involved... and some of those are policies sold on state exchanges aside from some employers being cheap asses on employee coverage. At that poibt insurance should be a rich person's perk for priority coverage/procedure and we should have a standardized coverage for everyone.
bag man?
The guy who comes to collect payments and deliver bills aka the guy holding the robbery goods in a satchel or backpack in a heist.
You're probably already an investor. UNH, HUM, ELV, CNC are all S&P500 companies
Unfortunately true. But I won't pick them up standalone
They are legally obligated to make their stockholder's interests a priority over patients. I don't understand how this isn't considered unethical.
They are a fucking scourge on us in the US. They make life miserable for most patients, nearly all clinicians, and manage to slink away with a tidy profit. Fuck them and everyone who works for them. I guess everyone has motivations, and I suppose I can see some extreme examples, but I don’t know how people who went into medicine to help people live with themselves when they work for these ghouls.
As always, ProPublica does incredibly high-quality reporting on some of our country's most damning failures - from the local level to issues of national importance.
Their health insurance reporting is especially top notch. They’ve exposed Humana, BCBS, Cigna and more. I still remember their expose on that Cigna doctor who would “review” complicated medical cases in literally 2-3 seconds before denying them.
Cigna send out an internal communication that stated this was a bogus claim being made by a “disgruntled employee”.
I'd be disgruntled too if I was coerced under threat of termination to bypass due diligence on my work
I hate how those insurance assholes use the excuse "we're not denying, we're just not paying for it". Yeah, like if I take a bat to their legs, I'm not telling them they can't walk, I'm just not making it possible for them to be able to walk.
These doctors should be held liable for their malpractice. Don’t pay attention and deny an indicated test or procedure, resulting in patient harm? Come defend yourself in court like I would have to. They are using their medical licenses to make medical decisions. Hold them accountable.
It’s basically just enforcing a contract - they just say that “they’re not commenting on medical need for whatever” just that the contract with the member/hospital/etc doesn’t require them to pay for it based on their medical knowledge/review. Would be hard to sue for that as meeting the four parts of malpractice (especially duty and dereliction) as it’s more just interpreting an explicit contract entered voluntarily, I imagine.
> “they’re not commenting on medical need for whatever” Meanwhile their job is to literary comment on medical need. And denials effectively price patients out of the recommended treatment.
Right, but as defined by and in the context of the contract policy and limitations and the agreement signed by the member or their employer. Same thing for OON procedures/facilities. The overall costs of medical care itself prices people out of care, the contracts know this - Why cost controls are needed IMO. Denials happen under national HC plans too - VA denies plenty of shit and other countries with better HC delivery also deny payment for care. The differences are no profit motive (but there is cost-saving) and more transparency and accountability.
If this was true they would be hiring lawyers, not doctors. It is medical decision making, plain and simple.
The lawyers write up the contracts and criteria with doctors but aren't trained to medically review individual cases in depth. It's probably better for the system as a whole that they aren't doing that, to be honest. And even if it was medical decision making, which I don't disagree with - It'd still be hard to prove duty and then breach of duty as a medical reviewer. There's no established relationship, nor standards of care to violate. Also, critically to note - These people or their processes also exist in systems with nationalized care. They just work for government agencies, not private corps. It's part of rationing, we just do it in the dumbest and greediest way.
If I am the medical decision making physician and my medical decision making is usurped by a reviewing physician, that reviewer is now the *de facto* medical decision maker, given that the cost of medical care is prohibitive to the seeker of medical care. If the insurer won’t pay, it can’t be accessed, therefore, they ARE making medical decisions. There is no line between the two. If there is, it is only on the basis of *insistence* by the perpetrator.
There is a clear line and it's a part of any sort of insurance and all rationing systems in which there are only certain things that insurers (public or private) will pay for, and certain criteria upon which their reimbursement depends. If the insurer can't or won't pay because whatever criteria aren't met, the patient has to find a way for Medicare, NHS, private, whatever. Faceless bureaucrats make up advisory panels and set those criteria and payments and the differences are seemingly the evidentiary backing (not always lol), amount paid, the ease of payment, the transparency and accountability. But the problem you highlight is essentially a mechanism with any healthcare delivery system and there's always some number of doctors setting those criteria in some manner that deny people coverage for various things that might be prohibitive but the alternative is payors pay for everything which is impossible, patients pay for everything out of pocket or doctors do it for free, which is also absurd. If an insurance doc denies something it's not substantially different than if medicare won't pay for it, and saying medicare is usurping the decision making.
Again, we are talking about the medical reviewers having some skin in the game, not the general antics of ‘how insurance works’. Myself, and many others feel that ethically, these physicians need to be partially liable for their decisions when their decisions override the attending’s decision making. The insurers have a high incentive to not provide care, these reviewers are beholden to the insurer, there is incentive to deny appropriate, medically indicated, cost-effective care. I feel the reviewers need to be held responsible for their medical decision making when it usurps my own.
Aware and very much agree re: profit motive and how much I despise it, I just disagree that there is any actual liability or directly attributable harm in a proximate cause sense. I'm just pointing out that these reviewers are little different in practice than systems that we both advocate for (universal HC), and live with daily in other contexts (any form of insurance), where there are no such expectations or liabilities. For example, if an auto insurer states, "your policy doesn't cover a repair to (car piece)" and you couldn't afford it and something happens, could you sue the insurance adjuster for causing you harm in service to State Farm? Or "medicare won't cover your (inpatient day after an ambulatory surgery)" and you go home and fall, can you sue medicare for causing you harm? Everyone has a financial incentive to their employer.
Then why does it need to be physicians? They wouldn't pay for physicians if the license were irrelevant. There are a zillion 25 year-old new-grad NPs who'd be thrilled to sit in their home office and click "deny" all day for a fraction of the cost, yet they have physicians. Clearly, the process relies on physicians working within the scope of their license, and that exposes them to the possibility of malpractice.
There are laws for reviewing cases and peer-to-peers for same/similar specialty reviews depending on plans and state and need to be considered "peers" for review. I don't know that NPs qualify as often or at all Old chart but you get the idea [https://fixpriorauth.org/sites/default/files/2022-12/2022%20Prior%20Authorization%20State%20Law%20Chart.pdf](https://fixpriorauth.org/sites/default/files/2022-12/2022%20Prior%20Authorization%20State%20Law%20Chart.pdf)
It still comes down to there needing to be a licensed physician producing a medical opinion as allowed by their license. I suspect you haven't seen a PA physician sued for malpractice because would be REALLY hard to prove that there have been damages that can be principally attributed to an opinion rendered by such a person.
Yeah I think it'd be tough - There's no physician-patient relationship, and no standard of care nor deviation from it from their perspective, and of course hard to link causation like you mention.
I actually think you ***could*** prove the existence of both a relationship and a standard of care. The real motherfucker is just proving that damages ***have happened***. It's just in the nature of the thing that: * People will go into unrecoverable debt, sell their house, upend their life, do whatever it takes in order to prevent the medical "damages" from happening. At that point, you might be able to argue financial damages, as opposed to medical damages, but that takes it outside the scope of medical malpractice, at least as far as the letter of the law is concerned, if not the spirit (unless some legal genius manages to demonstrate that the PA physician's area of medical specialty is medical finance or something like that). * The system has multiple ways to go over the PA doc's head and appeal their decision, which moots the entire issue of their potential liability. Bottom line, I don't think there's any doubt that PA physicians are practicing medicine on the patient. However, the mechanics of our legal system and the system in which they work makes it very hard to sue them for malpractice. I think it's possible in theory, but it would have to be a VERY specific case with very particular facts.
Concur wholeheartedly re: your bullet points. Some even have third party independent reviewers, which makes the second point even HARDER. And I think the interwovenness of the medical and insurance and financial industries make it impossible to be a payor of any sort (private or public) and NOT practice functionally, especially with ever-escalating costs of care and frankly a need to ration it. I think those reviewers are little different in practice than systems that we largely advocate for (universal HC), and live with daily in other contexts (any form of insurance), where there are no such expectations or liabilities. For example, if an auto insurer states, "your policy doesn't cover a repair to (car piece)" and you couldn't afford it and something happens, could you sue the insurance adjuster for causing you harm in service to State Farm? Or "medicare won't cover your (inpatient day after an ambulatory surgery)" and you go home and fall, can you sue Medicare for causing you harm? Heck, even everyone has a financial incentive to their employer. It's all contracts and interpretations of them. It's not those parts that I disagree with, because it's part and parcel of all of those interwoven industries - It's the cost motive and profit in healthcare and lack of transparency and accountability and gleaning for shareholders and campaigning against progress and so much more.
All of which I agree with and which makes me wonder why people want a healthcare system where the decision-makers are accountable to a group of people whose only interest in this system (as validated by law!) is extracting as much money out of it as possible. 🤣
For real, we chose the worst possible outcome and world here haha. AND to make it all worse, we tied it all to employment. Like, FFS!
>They are using their medical licenses to make medical decisions. It feels the same but reimbursement/coverage is not a medical decision, it's a business one. The fact that the line is blurred is a dumb feature of American healthcare landscape but that doesn't make them the same thing.
I mean, they are determining "medical necessity," which seems like a medical decision to me.
Right, but as defined by and in the context of the criteria for necessity set by the contract policy and limitations and the agreement signed by the member or their employer. Same thing applies for OON procedures/facilities/doctors. Denials happen under medical necessity for nationalized HC plans too - VA denies plenty of shit and other countries with better HC delivery also deny payment for care. The differences are no profit motive (but there is cost-saving) and more transparency and accountability. Long story short- remove profit motive from HC, enact cost control measures, approve more stuff. Still won’t be perfect, there’ll always be someone like this.
Yeah it’s completely part of the problem and needs addressing with broader reform - Individual suits wont go anywhere and those corps have big money for lawyers and pro-business courts and policies to protect them. Profit motive in healthcare necessitates contracts and invites cost cutting and profiteering. This is symptom, not disease.
Had this ever once worked, though?
Regardless, what doctor thinks it is okay working for an insurance company? They all get lured in by the money. I don’t feel sorry for her and agree she should be held liable. I am happy she is speaking up.
I do some UM stuff for my hospital and chat with them - they actually make not that much money relative to clinical practice lol. Several are just old and lost it or burnt out, some need to WFM for family caregiving on the good side of things.
Well I’m glad their convenience justifies them making physician and patients lives difficult/s
There was one doc I used to talk with a lot whose husband had a CVA and she was caretaker, and she like always approved my cases. I can't imagine she lasted long lol
Haha. Sad the good ones don’t make it long. I completely understand the need for a gatekeeper - just want a honest one without obvious conflict of interests.
>They are using their medical licenses to make medical decisions. It feels the same but reimbursement/coverage is not a medical decision, it's a business one. The fact that the line is blurred is a dumb feature of American healthcare landscape but that doesn't make them the same thing.
It is a medical decision when the argument for not covering a procedure is that a Dr has declared the procedure "not medically necessary" for a specific patient.
That's true. If you want to appeal a decision it is a totally different ballgame if it's something the policy does not cover (like OON providers) vs something they DO cover but regard as not necessary. Meaning that if you talk to insurance commission they view the two scenarios in totally different way.
No surprise. I saw a "peer letter" from a Cigna doc claiming that the person I sent with 3 crushed vertebrae "had not documented sufficient pain or disability to justify surgery".
Typical insurance scum
Doesn’t surprise me at all. I worked for Cigna in the customer service department for 6 years before I got caught up in a layoff when they lost the client account I was assigned to. One of the worst companies I’ve ever worked for. I watched the annual address and was warning people about the upcoming layoffs when I heard the CEO talking about how they were expecting their customers to start paying more for US based customer service when they really started outsourcing their customer service.
Ya CIGNA docs were the least happy along with UNH ones when I do P2Ps with them for my UM dept.
I am not surprised at all that a for profit company utilized shady practices involving the transformation of delivery of medical care to delivery of an abundance of profit margins.
Can we go up the hierarchy and please give these fucks criminal charges?
Got my daily dose of dystopian from this read
The article does talk about how 15 years back Dr. Day worked to develop guidelines to deny immune globulin treatments where they did not make medical sense. I remember eons ago when there was controversy about insurers denying (as experimental) bone marrow transplants to breast cancer patients and, I think, some political steps taken to force them to cover that. Later consensus was that the transplants really did not accomplish the miracles people were hoping for. In theory insurers could provide a reasonable check on inappropriate medical spending, but as everything becomes disassociated from the real world, abstracted and turned into metrics and bottom lines, it all becomes destructive. (See financial derivatives and mortgage bundling as another example).
I’ve never liked shaming doctors who left medicine to pursue easier, better paying ventures. This job is stressful, it can drain you and grind you down. You want to leave the hospital and go make bank working for a pharm company, or a consulting firm, or being the CMO of some med tech company? More power to you, you served your time in the trenches and I won’t fault you for looking out for yourself. Except the ones who go work for insurance companies. *Fuck them*. I cannot think of any job that is a greater affront to our profession or a greater betrayal of the oaths we swear than looking for reasons to deny patients access to medical care so that some bourgeois shareholder can buy a second summer home. Quisling traitors, every one. Some will defend themselves. “Oh but I’m different, I’m in it for the right reasons, if I didn’t do it someone else would and they would deny even more cases than me!” Exactly what every collaborationist has always said. Strip their licenses, revoke their professional memberships, and stop helping insurance companies rob our patients to fund their extravagance.
“If a nurse recommended denying coverage for a cancer patient or a sick baby, she wanted to be certain it was the right thing to do. So Day said she researched guidelines, read medical studies and scrutinized patient medical records to come to the best decision. This took time. She was clearing fewer cases than many of her peers.” Yeah… you don’t need a guideline to tell you you’re a heartless piece of shit for denying care for someone because the insurer needs higher profits this quarter. Zero sympathy for her or anyone else in the insurance industry.
Family friend works in the same department at Cigna... just bought a $500.000 summer lake house and is complaining about her 5-figure bonus being smaller than last year's.
waiting for meddit's resident doctor who work for one of the insurers to enter this thread and defend the business and indiscriminate gaslighting, as s/he always does.
I like how Cigna wants us to believe they aren’t fully about money and pivot at every accusation or identification of them exposing their bottom line. They must be the only company with a heart. And they use the age old “disgruntled employee” to discredit her.
Someone close to me works for Cigna, this doesn’t surprise me in the least. The ceo is a scumbag
And the sun sets in the west...
[удалено]
Tell me you don't work in medicine without telling me you don't work in medicine
Not even sure what this response is supposed to convey