There's some doc on twitter who was denied by insurance and he filed a board complaint against the insurance doc claiming malpractice. I think he won.

Yep, basically we should make it much easier to identify the specific doctor that is responsible for the denial (to make them easier to sue personally, and discipline professionally), and we should make the liability for such a denial extremely explicit.

Know any more details? This seems rather promising.

the claim denier worked for insurance. he had a complaint on file for entering a hip replacement backwards

the tweeter thread shows devastating images . the point is that a provider like that, has no business denying coverage. plus apparently he was not board cert and other issues from lapses in licensing

In a way, a denial is accusing the ordering/prescribing of trying to commit some type of insurance fraud. I agree if you’re trying to override a doctor that knows me, has cared for me, likely already done some labs/scans/etc to make their order, well - the burden should be yours to prove it’s not necessary.

That doesn’t make any sense.

Insurance claims are submitted to insurers after providers have already performed the care.

More and more often care is gated by prior authorizations by insurance. This is because insurance companies have more and more often required many procedures to have a prior authorization before hand and will refuse to pay bills if a prior auth wasn’t obtained.

My proposed policy would apply both to prior authorizations and post care claims.

Post care claim denials can be serious too. If you need repeated treatments a denial to a claim can have an impact on your ability to receive subsequent treatments.

I have a dear friend that was suddenly paralyzed, and now needs ongoing PT from specialists to work to regain use of their limbs. Their insurance has tried to get out of paying the bills several times (they’ve gotten it done so far, but each of the claims has been… a near thing). If one of those bills doesn’t go through, their ability to continue PT at this facility would almost certainly be impacted.

So, yes, a claim denial may impact ongoing care in similar manner to a prior authorization denial.

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Finally, I’d actually want to add criminal liability for what was described in this particular article.

> “We literally click and submit,” one former Cigna doctor said. “It takes all of 10 seconds to do 50 at a time.”

A doctor working for an insurance company issuing medical denials in this kind of a scheme should be facing jail time, not just personal liability or professional discipline.

What about prior authorizations?

The article is about claims, which are a difficult thing than pre-auths.

There are some restrictions on pre-auths and when an insurer can require one. If you are in need of immediate care to save your life, they are not required and your provider will give you care before even telling your insurance company about it.

The grey area with pre-auths is with nonemergency care that could lengthen someone’s life. There are requirements by law for appealing these denials but yes, this is where those stories about “I can’t get my cancer treatment” come from.

This is not the situations in the article, though.

What’s shitty about the actions in the article is that many people don’t even realize that erroneous health insurance denials are common and they just accept the denial and pay out of pocket. It is very common to get a denial, send in a challenge like “no this should be covered” and then they pay.

A claim denial will result in patient responsibility, which ends up with a service but costing patients a lot of $$.

OR in this case, the pa was denied for the cpts requested. In which case care may be denies by the provider or facility

Critically, many patients also require ongoing services, where a claim denial wouldn’t prevent you from receiving the first service, but it may absolutely impact the second, third, etc.

So, I don’t think I’d exempt claim denials from my proposed regulation. Named doctor, personally and professionally liable from the consequences of their denial.