These days, it's getting harder for doctors and hospitals to get paid for the work they do on or for patients who...supposedly...have insurance coverage. As one provider sharing his opinion, in the recent past especially with both the opioid epidemic and the Covid crisis, my experience has been that while society was struggling, insurers have helped themselves to increased profits by eliminating a major expense: taking care of patients.
They have all the control, and none of the liability.
Look at the business model of an insurance company:
--Take in revenues (premiums),
--Have to pay for care,
--Whatever is left over is profit.
Of course they have a conflict of interest and would clearly benefit from denying requested services for evaluation and treatment of patients with medical issues.
I can relate that as a provider, denials have become more frequent and borderline ridiculous. I can see a patient with back pain and order physical therapy, which is denied. The patient’s pain gets worse, so I order an MRI. Of course the MRI is denied, but the reason given? That the patient has not had physical therapy.
Insurers also deny care by delaying care. Just like the expression that "justice delayed is justice denied," same goes for medical care. I have many situations where patients are in significant pain, with treatable conditions, and the insurer always wants another form or report or other document, in a process that seems interminable, all while the patient, with a treatable problem, suffers. I am quite confident that no insurance executive would stand for any friend or family member of theirs receiving similar treatment.
Though it is patently ridiculous that this type of advice would be needed, and given my impression that many of the denials border on bad faith, here are some tips on filing an appeal: