The sad thing is they do hire some licensed healthcare professionals to fall back on when appealed. They just look for the least compassionate MDs to rubber stamp denials.
Eh, generally a peer to peer won’t get denied but requiring a peer to peer is a good way to waste the doctors time in the hopes they’ll give up on the request. The instance company isn’t paying the doctor extra time to perform the peer to peer after all. Now if that time was billable, you’d see it go away real fast.
While I think the job selects for doctors with less compassion, but I believe some of them are there for genuine harm reduction
The system they’re installed in is just insidious. They are given extremely short amounts of time each request, they face basically no consequences for a bad rejection, but they do face them for a bad acceptance. Their main metrics boil down to “rejections per hour”
A “bad acceptance” often means “improper paperwork”. If the doc fills in a form wrong, you send it back. If the doctor files in a way that doesn’t link relevant history correctly in their system, send it back. If the doctor fails to state a required prerequisite for the procedure, send it back (even if it was previously stated, or stated differently)
It’s a pure lawful evil system, it’s designed to slow things down and delay, hoping the problem will go away. It requires doctors to navigate a complex hostile bureaucracy perfectly, and often blindly. We’re at a point where each patient is seen for an average 15 minutes before 45 minutes of paperwork to get insurance to pay for it
Then the requests are read feverishly to meet metrics. They can’t think they’re doing good, but I buy that some of them are doing their best to reduce harm in a broken system
The sad thing is they do hire some licensed healthcare professionals to fall back on when appealed. They just look for the least compassionate MDs to rubber stamp denials.
Eh, generally a peer to peer won’t get denied but requiring a peer to peer is a good way to waste the doctors time in the hopes they’ll give up on the request. The instance company isn’t paying the doctor extra time to perform the peer to peer after all. Now if that time was billable, you’d see it go away real fast.
While I think the job selects for doctors with less compassion, but I believe some of them are there for genuine harm reduction
The system they’re installed in is just insidious. They are given extremely short amounts of time each request, they face basically no consequences for a bad rejection, but they do face them for a bad acceptance. Their main metrics boil down to “rejections per hour”
A “bad acceptance” often means “improper paperwork”. If the doc fills in a form wrong, you send it back. If the doctor files in a way that doesn’t link relevant history correctly in their system, send it back. If the doctor fails to state a required prerequisite for the procedure, send it back (even if it was previously stated, or stated differently)
It’s a pure lawful evil system, it’s designed to slow things down and delay, hoping the problem will go away. It requires doctors to navigate a complex hostile bureaucracy perfectly, and often blindly. We’re at a point where each patient is seen for an average 15 minutes before 45 minutes of paperwork to get insurance to pay for it
Then the requests are read feverishly to meet metrics. They can’t think they’re doing good, but I buy that some of them are doing their best to reduce harm in a broken system