I somewhat get why you'd build such a system when on the other side you've got pharma and labs pulling for useless medication and tests through doctor presents and "seminars". What's beyond me* is how health insurances get to be the deciding entity when there's such a blatant conflict of interest in the matter, which gets abused as it is here demonstrated.

If you get a home insurance claim, at least here in Canada the insurance company has to use an external adjuster. Even though it's not perfect, it seems a widely better solution to handling claims.

* it's not beyond me, it's probably just the result of lobbying