From the New York Times article, “U.S. Finds Many Failures in Medicare Health Plans: In more than half of all audits, “beneficiaries and providers did not receive an adequate or accurate rationale for the denial” of coverage when insurers refused to provide or pay for care.
• When making decisions, insurers often failed to consider clinical information provided by doctors and failed to inform patients of their appeal rights.
• In 61% of audits, insurers “inappropriately rejected claims” for prescription drugs. Insurers enforced “unapproved quantity limits” and required patients to get permission before filling prescriptions when such “prior authorization” was not allowed.
• Medicare plans frequently missed deadlines for making decisions about coverage of medical care, drugs and devices requested by doctors and patients.
Unfortunately this story does not surprise physicians and many patients. This report focuses on Medicare, but we would all believe that private insurance plans would have the same “track record”.
The profit motive is at work here. While I love capitalism, sometimes it has a dirty underside. In health care insurance, 1 way to improve profits is through rationing care. We would hope that the rationing has logic, but indeed it appears to not have logic.
One could easily make the case that these companies are committing malpractice. Their denials constitute a practice of medicine. When you practice medicine and deny need prescription drugs or testing that the physician has recommended, how can that process be anything but the practice of medicine.
This story is very important. It confirms the belief of almost every physician with whom I talk. This story is an outrage.
db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.