“The algorithm cannot say no, however. If it finds problems, it sends the request for review to a team of in-house nurses and doctors who consult company medical guidelines. Only doctors can issue a final denial.”

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.

I’ve saved a message that was reposted by Bill Ackman on dealing with denials. Thankfully, never had occasion to use it yet:

>> 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.

I feel like this should really be something people should lose their license over.

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.

As someone who needs expensive medication, thank you. I appreciate it.

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?

This is good to hear. My mother was a PA for a private practice and also would often call the insurance providers to challenge denials, often from people far from the relevant specialty. By her accounts she was usually able to reverse the denials.

First off, thank you for taking the time to do it. I know most people don't agree on many things today, but most Americans agree the current system is stacked against them. Not to search very far, I have good insurance and I still have to deal with things that border on criminal.

Two, that book may be a good idea:D

seriously consider that book if you can fill it up with these types of stories. A book like this could be a huge hit, get this issue even more spotlight and maybe some fixes.

As a random person, I'm becoming convinced that the first stone to get things rolling is full price transparency at all scales.

You want to try to change things? Great. So write the book!

In the early 2000s I got a job right out of highschool working at a Blue Cross Blue Shields call center. I thought it was going to be customer service but it was insurance claims. Training was supposed to be 6 weeks but they pushed me live after just 2. I had no idea what I was doing. After floundering for a couple weeks trying to learn to basically be a fuckin doctor, I just started approving everything. "Patient needs emergency surgery for X" "Approved". The whole experience was completely insane.

Physician and Hospital resources is a real zero sum game, how do you fairly regulate the medical landscape so those who's lives will benefit most from a procedure will receive the procedure?

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?