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Conway McLean, DPM, Journalist Columnist

Health care is big business in the United States. America spends nearly $4 trillion on health care, making it the most expensive system in the world. With those kinds of numbers, funding our medical care brings some high-powered players to the table.

But aside from Medicare and Medicaid, both federally administered plans, the other entities involved are private insurers. They are in the business of paying for the care of millions of Americans. And they get paid well to do it.

Unfortunately, the average citizen doesn’t know much about health insurance, how it works and how it doesn’t work. One rarely learns what a deductible is or how a co-pay works. Employees at most health care providers have been asked many times. “Why won’t my insurance pay for all of this?”

Our system is low among the developed countries of the world. It is very expensive compared to the general indicators of the disease. But we are the only industrialized country in the world with a for-profit model of health care financing. Health insurance for seniors is provided by Medicare, a government agency, and it has its share of problems. But no one in Medicare profits from funding America’s health care. This is not the case with private individuals profiting from withholding payment and denying treatment.

Many Americans have had their health insurance claims denied, a rare occurrence in earlier days. The reason for rejection is often missing or unclear, generally arbitrary, sometimes a little ridiculous. The frequent rejection of claims should be understandable because insurers use computer programs to summarily reject claims without conducting an evaluation. Often there is no analysis of the patient’s medical history, illnesses or medical courses. People with little to no relevant experience can quickly-fire denials of health care claims, the whole package with a single keystroke.

One of the most frequent methods used by insurance companies is pre-authorization. Once called ‘pre-certification’, this concept was developed decades ago to prevent doctors from ordering expensive tests or procedures. “proper” At least according to the insurer. The goal was originally to deliver cost-effective care, but it became a means of reducing care or delaying payments. When multiplied by millions of insured individuals, the interest alone becomes a huge source of income for these corporations.

Prior authorizations are especially frustrating for physicians, as they require a large portion of our time to be focused on bureaucratic needs away from our patients. Because of this device, insurance companies have entered the modern medical care process. The process seems to be deliberately burdensome, so doctors and patients often give up and use a cheaper alternative or refuse some test or treatment.

Usage “Preliminary Confirmations” It has exploded with insurers in recent years. At one time, early licenses were focused only on the most expensive treatments, things like cancer care. But that was a (relatively) long time ago, now insurers want these for much less expensive medical bills. Even routine radiographic studies and prescriptions may require prior authorization.

But prescriptions are expensive and prior authorizations are an easy way for insurance companies to save money. Certainly, any therapy or medication requested must be medically necessary, but when the nurse (due to financial constraints and financial motivation) can overrule the patient’s doctor, a person who knows the individual’s medical history well, the authorities on the topic agree. Problem

Insurance companies say this is a useful approach to reign in health care costs. Any procedure or medication paid for by an insurer should be the most economical treatment option for a person’s condition. But in reality, a paper-pusher at the insurance company is making clinical decisions with little training. You argue that some service or medication of PA should follow current recommendations for the medical problem you are dealing with. Often times, insurance policies do not conform to common practices. Typically, the doctor recommends a new treatment, which is often very expensive, and the insurance company does not want to pay for it.

There is little accountability or control in this process. And the implication that patients need protection from their doctors is offensive to many doctors. Providers have to jump through hoops, often spending twenty or thirty minutes on the phone, often after a staff member has gone through the usual pre-approval process twice. Typically, the insurance agent will ask the doctor to make a phone call to take care of the patient.

The AMA and other organizations have pushed for regulatory changes, but little progress has been made. The opposite trend has occurred, with an increasing number of medical expenses requiring prior authorization. It’s clearly a sleazy strategy that allows insurance companies to earn millions of dollars in interest.

We are talking about a multi-billion dollar industry. The financial potential on behalf of these giant corporations is not to be underestimated. But changing the rules is still impossible. Most experts agree PA insurers, and not the patient, even occasional damage. Many groups have complained but nothing has changed, the previously granted license continues to be stressful for doctors, an obstacle to better medical services and disappointing for many citizens. Now it’s clear to anyone watching, that the prior authorization requirement has helped stress health care providers. After all, they put patients at risk.

Editors’ Note: Dr. Conway McLean is now a podiatrist practicing foot and ankle medicine in the Upper Peninsula in Dr. Ken Tabor’s practice. McLean has lectured internationally in both surgery and wound care, and is board certified in both, subspecializing in orthopedics. Dr. McClean welcomes questions, comments, and suggestions at drcmclean@penmed.com.



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