Doctors working for health insurers can rule on 10,000 or more requests for care a year. At least a dozen were hired by major insurance companies after being disciplined by state medical boards or making multiple or outsized malpractice payments.
Doctors working for health insurers can rule on 10,000 or more requests for care a year. At least a dozen were hired by major insurance companies after being disciplined by state medical boards or making multiple or outsized malpractice payments.
From what I can tell, those peer to peers are primarily used to make the physician decide he doesn’t want to waste the time doing a peer to peer. You’ll eventually get to the point that the insurance company WILL be liable for adverse outcomes for denying the intervention, and they want to toe as close to that line as possible.
No the insurance company is basically never held liable (at least to the best of my knowledge). They claim they aren’t dictating care, just determining whether or not they would pay, and that the patient’s treating doctor should be the only one liable even if the insurance company denied coverage for recommend treatments or tests that would have prevented the adverse outcome. People have tried to sue them for delays in care they’ve caused but generally unsuccessfully as far as I know. Unfortunately insurance often denies payment for very needed care even after many appeals and prior auths and tons of other bull. So yes they are trying to waste time and hope the doctor doesn’t try to go through appeals and peer to peers and things (that eat up many hours of time and end up costing the healthcare system as a whole even more money), but there’s no guarantee they will come around and actually pay up in the end even if that’s all done. And they aren’t held responsible even if they effectively prevented needed care by refusing payment. They’re a cancer on our healthcare system.