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The Prior Authorization Scam

Daniel Paull, MD asks who you would rather trust your care to: an incentivized health insurance company or the doctor who has actually examined you.

June 3, 2024

What are prior authorizations really?

The health insurance companies would tell you that they are necessary to make sure that the patient isn’t getting any “unnecessary care”.

How do they make these decisions?

They look at your chart, and apply an algorithm (probably uses AI at this point), and then make the decision.

Example: Patient with bone on bone knee arthritis see’s a joint surgeon who recommends a knee replacement. The health insurance company denies it, stating that physical therapy has not been tried and failed first.

 

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Maybe that sounds good, unless you are the patient with excruciating pain from bone on bone arthritis who can’t tolerate even a single PT session.

The question is who would you rather trust your care to:

A health insurance company who is financially incentivized to deny care based off of a barely readable clinic note and a computer algorithm

OR

You doctor who HAS ACTUALLY SEEN AND EXAMINED YOU, and mostly always wants you to get better.

 

 

The bottom line is that health insurance companies could not care less if you suffer or experience bad outcomes.

They get to keep money by not paying for your care and have absolutely zero liability.

Your physician wants you to get better and has liability if things go wrong.

All opinions published on SomeDocs-Mag are the author’s and do not reflect the official position of SoMeDocs, its staff, editors. SoMeDocs is a magazine built with the safety of free expression and diverse perspectives in mind. For more information, or to submit your own opinion, please see our submission guidelines or email opmed@doximity.com. Do you have a compelling personal story you’d like to see published on SoMeDocs? Find out what we’re looking for here and submit your writing, or send us a pitch.

All opinions published on SomeDocs-Mag are the author’s and do not reflect the official position of SoMeDocs, its staff, editors. SoMeDocs is a magazine built with the safety of free expression and diverse perspectives in mind. Do you have a compelling personal story you’d like to see published on SoMeDocs? Submit your own article now here.

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2 Responses

  1. Absolutely
    We need tort reform, & hold denying physician responsible/ liable for denying care, So physicians stop working for insurance companies.

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