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Do you need care? Why should your health insurer decide

Written by Diane Archer

In a Washington Post op-ed, William E. Bennett Jr., a gastroenterologist and associate professor of pediatrics at the Indiana University School of Medicine, makes the case that health insurers should not be allowed to practice medicine. They too often deny medically necessary care unless and until your doctor is willing to go through hoops with their medical staff. But, medical staff who work for health insurers have no clue whether you need care.

Bennett appreciates our need for health insurance. He also recognizes that having health insurance is necessary but not sufficient for our well-being. To get his patients needed medicines and tests, he must request prior authorization from his patients’ insurers, which can needlessly delay their access to care for weeks. And, still, the insurers may deny needed care.

Only if Bennett appeals to a doctor who works for the insurer and says the right key phrases, will the insurer reverse its denial. Most of the time, the doctor in the employ of the health insurer has little accurate information about the patient; the doctor has never had any contact with the patient. Bennet explains that the insurer’s doctor is unqualified to know whether the treatment or medicine is needed.

There is nothing beneficial about this process for the doctor or the patient. It does not assure the patient gets the proper treatment. In fact, it keeps many patients from getting needed care. And, it burdens the doctor excessively and unreasonably.

Bennett experiences the system from the patient’s side as well because his daughter has a serious health condition, and he has had to deal with an insurer that has limited her access to needed treatment. Appealing is a challenging process that requires Bennett to rely on the advocacy of his daughter’s doctors. It takes time and does not always work. In the meantime, his daughter suffers, even though his daughter’s treating physicians all know she would benefit from the treatment.

In short, when health insurer denials are based on the insurer’s claim of lack of medical necessity, the system breaks down, and the most vulnerable patients are harmed. One study revealed that one health insurer denied claims for emergency visits that met a “prudent layperson” emergency coverage standard in more than 85 percent of cases. Patients can appeal the denials with a high likelihood of success on appeal. But, only a tiny number know they can appeal and have the wherewithal to do so.

Bennet concludes that health insurers should not be able to decide the care people need: “When an insurance company reflexively denies care and then makes it difficult to appeal that denial, it is making health-care decisions for patients. In other words, insurance officials are practicing medicine without accepting the professional, personal or legal liability that comes with the territory.”

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