MEDICAL INSURANCE: PROCEDURE COVERAGE

The doctor says: You need this test or procedure. The insurance says: We won't pay for it. Right now, the insurance has the final decision.

Insurance has a incentive to refuse: money. Moreover, the employer who pays for insurance has an incentive to use the insurance which is cheapest (unless the employee who chooses the insurance company is sick and has an incentive to choose the best coverage).

One might think the doctor who requests the procedure is always right, but that is not necessarily so. The doctor may have an incentive for using the procedure, or the doctor may not actually be the best expert on state-of-the-art treatment. (In the best of all possible worlds, an insurance company would have the best statistics and most accurate up to the minute information on the best treatment practice -- since they deal with many cases all over the country.)

Negotiation between the doctor and the insurance company now seems to be the standard (and perhaps only) method -- other than going to court -- of resolving such differences.

It might be very helpful if there were a permanent council of expert doctors, completely independent of the insurance company -- and, in any particular case, independent of the doctors or hospitals or teaching institutions involved -- to arbitrate and decide (both routine and difficult differences) between doctors' recommendations and insurance companies' rejections.

To prevent doctors or insurance companies from simply dumping all decisions on this panel, there should be a review and possible penalty for doctors proposing unnecessary or unwise procedures, and insurance companies rejecting valid claims.