In “Denying Essential Medical Care Doesn't Save Money—Or Lives” (KevinMD, July 30, 2022), partner Steve Cohen compares the healthcare costs in the U.S. with those of other countries such as Germany and Canada, and explains the prior authorization process through which insurance companies review a particular test, procedure, or medication prescribed by a doctor and decides whether it is “medically necessary” and covered by the patient's plan.
Although 3 to 10% of health care expenditures are fraudulent, the prior authorization process can cause significant delays in treatment. Nearly one in four doctors report that such delays “have led to serious adverse events for their patients” and 16% report that “such delays have led to hospitalization.”
In the case of “Jennifer,” for example, her doctor ordered an MRI that was denied by her insurer 38 days later.
Once an MRI was conducted, the test revealed that she had a rapidly-growing sarcoma in her hip. The doctors told her she could have been treated with just chemotherapy had she come to the doctors a month sooner but now, her leg, hip, and pelvis had to be amputated. Jennifer died two years later. Her family sued the insurance company but a federal judge dismissed the case because of the absence of law “holding insurance companies accountable when they allegedly commit medical malpractice.” Jennifer’s husband is “appealing the ruling and has argued that case law and the public interest-if not statute-make his wife's insurance company accountable.”
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