haspfoot t1_jdzin4y wrote on March 28, 2023 at 10:08 AM

Reply to comment by jamesgelliott in ELI5: Why are health insurance companies in the US allowed to deny coverage for doctor-approved medical care? by adamzam

But ideally, the system would deal with the pathway/guideline issue on a provider level and eventually drop Doctors/facilities from their network if they have a demonstrable track record of inappropriate clinical practices. Not shift the burden upon the individual. In particular, not drop it on the individual after service has been provided.

jamesgelliott t1_jdzokfa wrote on March 28, 2023 at 11:21 AM

It's not inappropriate treatment. You can't expect every MD, Nurse practitioner and Physician's assistant to know every clinical pathway for every insurance provider.

Recently I had a colonoscopy. The MD ordered a prep that wasn't covered by my insurance but it did cover an older less expensive option. The pharmacy simply had to contact the MD and get the order changed.

haspfoot t1_jdzovcx wrote on March 28, 2023 at 11:24 AM

Well, if providers can't be expected to know, then certainly the burden shouldn't be shifted onto the patient. Ideally the whole thing would be overhauled with a focus on medical outcomes and not profits.