Payer coverage rules typically do include that. This is known as step therapy. If a physician requests prior authorization for a branded medication then the insurer might deny it and recommend trying the generic alternative first.
A lot of these issues arise because providers fail to review payer coverage rules before deciding on a treatment plan. And in fairness to providers, this takes extra time which they don't get paid for and the rules are inconsistent between payers. The new HL7 Da Vinci Project prior authorization burden reduction standards can help automate this to an extent by giving providers an API to check coverage rules in real time.
At a fundamental level, medical insurance has to involve some form of cost control and care rationing. Much of what insurers do is preventing waste, fraud, and abuse by verifying that treatments are medically necessary as per current best practices and balancing costs versus benefits. Unfortunately, patients sometimes get caught in the middle.
"A lot of these issues arise because providers fail to review payer coverage rules before deciding on a treatment plan"
A system wherein the trained professional with direct access to the patient has to defer to a board of anonymous bureaucrats to determine the course of treatment is absurd. These issues don't arise because "providers fail" they arise because the system is built to fail and the burden falls on everyone except the people making the rules (and the profit).
Not true for Medicare. How it works is that Medicare splits the US up into regions (can’t remember if it’s currently 5 or 7). For each of these regions, a private medical insurance company handles all of the claims paperwork and the money for said claims comes from Uncle Sugar. This is also why it’s disingenuous when folks trot out the “claim dollars per Federal employee” argument for Medicare.
Note: I’m not talking about Medicare Advantage which is a separate program whereby Medicare pays the premiums for private health insurance plans.
I'm not sure what you mean there. Even Medicare in the US and single payer systems in other countries have strict rules to prevent waste, fraud, and abuse. They will refuse to pay claims that don't comply with coverage rules. In many cases those are even more strict than US private medical insurers.
What I mean is that what insurers do is try to screw people out of money and receiving necessary treatment to line their own pockets. Here’s a fairly concrete example:
Insurers do deny some claims and authorization requests, but in most cases this doesn't line their own pockets. Rather the opposite. Most large employers are now self insured, and the medical "insurance" companies just administer claims. Due to the 85% minimum medical loss ratio imposed by the Affordable Care Act (Obamacare), insurers actually make more profit when they approve more treatments.
When claims or authorizations are denied it's generally because large employers have been pushing back to control their own costs. Unfortunately, many consumers don't understand this market dynamic and direct their blame in the wrong direction.
Apologies, but this is complete bullshit. They make money by denying expensive claims, regardless of whether or not people actually need the treatment, and optimize for this despicable behavior.
I have given you accurate information. If you choose to remain ignorant then that is your affair. The reality is that payers that offer health plans to self-insured employers don't make money by denying claims.
No, you’ve intentionally tried to deflect and deceive across this entire thread, as is obvious from all the downvotes and comments you’ve received. It’s quite bold to lie and say insurance companies don’t deny claims to make money, since there are only myriad news stories, court cases, books, films, etc about them doing so, but you do you.
> A lot of these issues arise because providers fail to review payer coverage rules before deciding on a treatment plan. And in fairness to providers, this takes extra time which they don't get paid for and the rules are inconsistent between payers. The new HL7 Da Vinci Project prior authorization burden reduction standards can help automate this to an extent by giving providers an API to check coverage rules in real time.
I'm sorry but how with a straight face can you really write this paragraph. The Doctor, the person who is seeing you needs to check a system of what you they are authorized to do for you? That is dystopian.
FFS we had an episode of this on Star Trek Voyager showing how bad this system is and yet that is exactly what we do.
What you are describing id disgusting, end of story. There is no justification of any of this.
Are there corrupt doctors? Sure. But insurance should not have a right to say what can and cannot be done if here is a good reason and it should be an actual discussion instead of Insurance having all of the power. ALL
You're arguing with the wrong person. I gave you accurate information about how the system works today, and a reference to technical information that hackers can use to mitigate certain problems. And I can do that with a straight face.
Technically insurers don't say what treatments can and cannot be done. Their role is purely financial. Patients can always pay out of pocket, and some do. But in practice an insurance denial does sometimes leave low income patients without access to care.
Ultimately though there does have to be some system for rationing care. Demand is effectively infinite and resources are finite. Even countries with single payer or socialized medicine restrict which treatments they make available, and often restrict patient access to expensive treatments by imposing queues.
I didn't claim that the current system is a good one. I have no power to change it. Any real solution will have to be mainly political so complain to go take your proposals to Congress.
A lot of these issues arise because providers fail to review payer coverage rules before deciding on a treatment plan. And in fairness to providers, this takes extra time which they don't get paid for and the rules are inconsistent between payers. The new HL7 Da Vinci Project prior authorization burden reduction standards can help automate this to an extent by giving providers an API to check coverage rules in real time.
https://www.hl7.org/fhir/us/davinci-crd/
At a fundamental level, medical insurance has to involve some form of cost control and care rationing. Much of what insurers do is preventing waste, fraud, and abuse by verifying that treatments are medically necessary as per current best practices and balancing costs versus benefits. Unfortunately, patients sometimes get caught in the middle.