7 ms·

These "doctors" should be barred from practicing medicine. I am not a lawyer, but it would seem that this practice also borders on criminal negligence.

ceejayoz 2y ago
Oddly, it's not currently considered to be. > Having the weight of an MD behind a decision can be powerful, but lawyers and judges who’ve handled these sorts of cases say it can be misleading. Although doctors ultimately determine whether to cut off insurance coverage for a particular treatment, those decisions are generally not considered the practice of medicine and therefore cannot be challenged in a malpractice lawsuit. The doctors advising insurance companies can’t be individually sued on medical grounds, even if something goes wrong after the denial. As a result, their names are cited in lawsuits filed against the insurers, but they are not defendants in suits brought by people denied insurance.
- franktankbank 2y ago
  > Oddly, it's not currently considered to be. Odd indeed. Is it some semantic thing? Denying care is the purest form of not practicing medicine?
  - ceejayoz 2y ago
    I'm guessing it's some thin veneer of bullshit like "well, the patient can still pay $500k directly out of pocket, so we're not technically interfering with the care, just the payments!"
  - razakel 2y ago
    They're not the responsible clinician, so they're not practicing medicine. It's like taking legal advice from me: I'm not your lawyer (or even a lawyer) and I'm probably wrong. But it was your decision to take it.
    - ceejayoz 2y ago
      These are licensed doctors (required!) being paid to explicitly evaluate the case, though, to determine if treatment is "medically necessary". Seems like a deeply different scenario.
  - staticman2 2y ago
    In many circumstances denying care is not malpractice. Even a doctor saying "I'm not taking on new patients" is technically denying care.
    - TheCoelacanth 2y ago
      That's a very different scenario than a doctor who is being paid to provide an expert opinion on the medical necessity of care. That obviously should be considered practicing medicine with all the normal liability.
      - SoftTalker 2y ago
        These insurance doctors are not really evaluating case particulars. They are not second-guessing the diagnosis, they are looking at whether the proposed treatment is the "standard of care" for the diagnosis, and that customary less expensive/invasive treatments have been exhausted. Medicare and any other potential "single payer" government plan would do this also because sadly fraud by clinicians does exist. For example when I had an injury I had to do 6 weeks of physical therapy (without improvement) before they would authorize an MRI scan and then surgery.
        DangitBobby 2y ago
        This is all just semantics. Arguably, the arbiter of what is "medically necessary" is practicing medicine. They have chosen to intercede in your care, and they should be liable for the decisions that they make leading to your health outcomes. The legal system could just as easily have seen that the determination of which procedures are "medically necessary" is indeed part of medicine itself. It's a miracle of delusion and corruption that it went the other way.
        staticman2 2y ago
        If you were designing a legal system you probably wouldn't want for profit insurance companies to decide who gets to determine if a patient needs treatment, due to the obvious conflict of interest. But that doesn't mean applying the same "malpractice" framework to the people deciding what's covered under the program is necessarily the right approach either.
  - SoftTalker 2y ago
    Denying care is the default state. It's the basis of the Hippocratic Oath, "First, do no harm." I.e. the determination of whether a treatment is beneficial is made by comparing it to doing nothing.
    - ceejayoz 2y ago
      That's more "think first, treat second" than "denying care is inherently good".
      - SoftTalker 2y ago
        It's also how first responders deal with feeling responsible if someone dies on them. They did more than nothing, so their presence improved the odds even if the result was the same.
    - clcaev 2y ago
      In these cases, a clinician has already decided that care is needed. It is a third party, who is not responsible for providing care, that is making the final determination. This has little to do with the Hippocratic Oath.
jandrese 2y ago
Or maybe the opposite. The doctors should be turned into GPs who then have to deal with insurance companies to get paid for their work.

ceejayoz 2y ago

Oddly, it's not currently considered to be. > Having the weight of an MD behind a decision can be powerful, but lawyers and judges who’ve handled these sorts of cases say it can be misleading. Although doctors ultimately determine whether to cut off insurance coverage for a particular treatment, those decisions are generally not considered the practice of medicine and therefore cannot be challenged in a malpractice lawsuit. The doctors advising insurance companies can’t be individually sued on medical grounds, even if something goes wrong after the denial. As a result, their names are cited in lawsuits filed against the insurers, but they are not defendants in suits brought by people denied insurance.

franktankbank 2y ago
> Oddly, it's not currently considered to be. Odd indeed. Is it some semantic thing? Denying care is the purest form of not practicing medicine?
- ceejayoz 2y ago
  I'm guessing it's some thin veneer of bullshit like "well, the patient can still pay $500k directly out of pocket, so we're not technically interfering with the care, just the payments!"
- razakel 2y ago
  They're not the responsible clinician, so they're not practicing medicine. It's like taking legal advice from me: I'm not your lawyer (or even a lawyer) and I'm probably wrong. But it was your decision to take it.
  - ceejayoz 2y ago
    These are licensed doctors (required!) being paid to explicitly evaluate the case, though, to determine if treatment is "medically necessary". Seems like a deeply different scenario.
- staticman2 2y ago
  In many circumstances denying care is not malpractice. Even a doctor saying "I'm not taking on new patients" is technically denying care.
  - TheCoelacanth 2y ago
    That's a very different scenario than a doctor who is being paid to provide an expert opinion on the medical necessity of care. That obviously should be considered practicing medicine with all the normal liability.
    - SoftTalker 2y ago
      These insurance doctors are not really evaluating case particulars. They are not second-guessing the diagnosis, they are looking at whether the proposed treatment is the "standard of care" for the diagnosis, and that customary less expensive/invasive treatments have been exhausted. Medicare and any other potential "single payer" government plan would do this also because sadly fraud by clinicians does exist. For example when I had an injury I had to do 6 weeks of physical therapy (without improvement) before they would authorize an MRI scan and then surgery.
      - DangitBobby 2y ago
        This is all just semantics. Arguably, the arbiter of what is "medically necessary" is practicing medicine. They have chosen to intercede in your care, and they should be liable for the decisions that they make leading to your health outcomes. The legal system could just as easily have seen that the determination of which procedures are "medically necessary" is indeed part of medicine itself. It's a miracle of delusion and corruption that it went the other way.
        staticman2 2y ago
        If you were designing a legal system you probably wouldn't want for profit insurance companies to decide who gets to determine if a patient needs treatment, due to the obvious conflict of interest. But that doesn't mean applying the same "malpractice" framework to the people deciding what's covered under the program is necessarily the right approach either.
- SoftTalker 2y ago
  Denying care is the default state. It's the basis of the Hippocratic Oath, "First, do no harm." I.e. the determination of whether a treatment is beneficial is made by comparing it to doing nothing.
  - ceejayoz 2y ago
    That's more "think first, treat second" than "denying care is inherently good".
    - SoftTalker 2y ago
      It's also how first responders deal with feeling responsible if someone dies on them. They did more than nothing, so their presence improved the odds even if the result was the same.
  - clcaev 2y ago
    In these cases, a clinician has already decided that care is needed. It is a third party, who is not responsible for providing care, that is making the final determination. This has little to do with the Hippocratic Oath.

jandrese 2y ago

Or maybe the opposite. The doctors should be turned into GPs who then have to deal with insurance companies to get paid for their work.