Good day, family and friends!
Let's plow right ahead...
Once again, depending on whose data you choose to use, Insurance Fraud perpetrated by both patients and physicians account for between 3% and 10% of the cost of healthcare every year. This has resulted in insurance companies creating "Benefits Coverage Panels" made up of non-medical personnel making medical decisions which, in turn, often result in patients being denied treatment based solely on cost and "likelihood of fraud" statistical models and not on the medical data.
I propose two different options for putting medical decisions back into the hands of those most concerned with the results of the decision...the patient and the patient's physician:
1) While I do believe that private insurance companies do have the right and the fiduciary duty to take every legal, ethical, and moral action they can to minimize costs and protect their bottom line, I do not believe that accountants and lawyers are qualified to make decisions as to whether or not a medical procedure is necessary. Therefore, I suggest that medical professionals from all specialties, as part of their professional licensing, be required to serve a minimal amount of time every year on a regional independent board that reviews case histories for the insurance companies and determine whether or not a procedure is medically necessary and should be covered. This would allow medical decisions to be made by qualified medical professionals. It would also allow for insurance companies to reduce their costs by not maintaining the permanent staffing necessary for the "Benefits Coverage Panels", even allowing for the contribution to a central funding pool that would be used to compensate the medical professionals for their time.
2) Periodic review of cases denied by the insurance companies to make certain there is a legitimate medical reason for denying the coverage, as long as the patient met all the other requirements for coverage in their policy. These reviews could be handled by the same regional boards proposed in Option 1.
These independent regional review boards would serve to reduce fraud on both sides of the fence. By not having a vested interest in the case, they can objectively look at each case and determine: whether or not it is a legitimate medical procedure, based on the patient's medical history and current medical status; whether or not the physician prescribing the procedure is merely feeding a hypochondriac's condition to fatten their bank account; whether or not the doctor and patient are working together to out and out defraud the insurance company; or even whether or not the insurance company is attempting to defraud the patient by selling them a policy, then issuing 'rubber stamp' denials in order to avoid paying out on claims. The boards will also reduce the operational costs of the insurance companies...part of which the companies would most likely pass on to their consumers in a competitive market, reducing the cost of healthcare coverage for consumers.
Next time: Competition...it does a body good!
Until then, best regards...
© James P. Rice 2011
