Peer to traitor review
This is not medical advice.
Firstly, I’m a hypocrite. I work for “the man”, and the industry I am so critical of. I should be self employed. I mostly work in the industry because of health insurance. Our family health insurance more than tripled after passage of the Affordable Care Act. Wasn’t one of the arguments for passage that it would allow people to not be tied to employers for health care?
For the record, Benedict Arnold was not a traitor at first. He was an extremely brave and courageous general. Some even thought he was better than Washington. Vanity, greed, and temper led to his downfall. But so did bureaucracy. The Continental Congress repeatedly screwed him over for promotion and denied him the tools he needed to complete the job. That ultimately helped him to switch sides.
In the medical industry there is something called a peer to peer review. This is when a medical professional chooses to work for an insurance company.
That person will review claims that have been submitted. The theory is that a similar trained professional will have the same medical training, and will be able to discuss or argue a need for medical care.
I don’t begrudge someone needing a job. We all make sacrifices. However, I’m going to guess that 90% of the time, the traitor is arguing for a medical claim to be denied.
Does someone who doesn’t see patients have the same expertise as someone who does? I would argue no. How do they know what’s appropriate?
In fairness, providers might be trying to over bill for services. So this is part of the checks and balances.
But most of these checks and balances are just orchestrated excuses for denying care, and the peers are used to help deny claims. “Our expert deemed this unnecessary.”
The experts are usually burnouts in the profession, who didn’t like seeing patients, but instead would rather sit at a desk all day. They typically have far less experience in treating patients. They are armed with studies to argue their case. Studies frequently sponsored by the industry.
Insurance companies will make many arguments for why claims are denied, and they are very good at manipulating the public into believing them instead of the provider.
One of my favorites is, “oh, well that was denied because the provider did not code the procedure correctly.” Medical facilities are highly motivated to get this correct, because they want to get paid. It’s extremely rare that they coded incorrectly.
Why the need to code in the first place?
Private health insurance companies come in at hundreds of billions of dollars of valuation. They didn’t become that wealthy by paying claims, they reached that valuation by denial.
Your next thought is, “Right! That’s why we need Medicare for All!” And in some ways I agree, but they also have issues.
