this post was submitted on 10 Sep 2024
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Medicare or Medicare Advantage? Because Advantage is private. Medicare has like 5 levels of appeal, including to a federal court, most of which is free. There are systems in place to allow challenges to the reviewing doctor's denial. Private insurance typically forces arbitration.
I have problems with Medicare's system too, especially when it comes to claims denials. If it is a covered item or procedure, the claim is not fraudulent, and the insurance provider has not met the patient to perform any exam, then going off of notes and comparing with best practices is insufficient to deny a claim. This may surprise you, but the doctors hired by insurance are not magically better than the ones treating the patient.
It's Medicare. She has a friend who works on the private insurance side of the company and she always makes fun of him for it.
The metric is based on medical necessity, and it's standard for Medicare to deny claims for things that are not medically necessary. Again, if the doctor thinks it is medically necessary, they can appeal the decision and make their case, and that happens frequently.
I've already stated that I know doctors are not perfect and omniscient, so I'm not sure why you would imply I think otherwise. Although, this isn't the first time you've implied I think the opposite of what I've explicitly stated. Is this going to be a trend?
Then fair enough, I apologize for assuming she works in private insurance. Your initial framing and argument made it seem otherwise. I still think you and I disagree on the need for widespread chart reviews for medical necessity.
When you said doctors are not infallible, you said it in response to my claim that, in essence, the treating doctor should always get deference. It is natural to assume that you did not believe the same standard applied to reviewing doctors at Medicare since you've been arguing the same.
As you note, treating doctors frequently appeal Medicare denials. That's a lot of wasted time and money. I see no evidence that these denials are saving more money than is being wasted fighting them. I'm having trouble finding data for traditional Medicare, but for Medicare Advantage, appeals routinely get overturned to such a degree that Congress investigated it.
You stated earlier that doctors are required to take notes and your wife relies on these notes when making a recommendation. Doctors are notoriously bad at documentation. It's why relying on their notes to make a judgment as to medical necessity is a terrible idea. I firmly believe no one should be denied coverage because their doctor sucks at writing a report.
Understandable because I said she works for an insurance company. But it was not my intent. No need to apologize for this.
I disagree that it's natural. I said doctors, not just doctors providing care (which my wife is still one of, btw). I suspect that this is an issue of viewing it as too black and white ... so because I said one "side" is not perfect...well I must then think the other "side" is perfect.
This is a different question than the one I'm trying to answer. I haven't seen the books or analysis, so I don't know whether it is more efficient. However, just peripherally, even i can see how much waste there is an even as a laymen it's easy for me to understand that so many of the things she sees are just blatantly not medically necessary.
Times they are a changing. Them not justifying why they are doing something is no longer adequate, and wont be adequate even if (maybe even especially if) we move to universal health care.