As insurers increasingly deny treatment provided to members that they deem isn't medically necessary, some industry experts worry that there is no specific standard in the Affordable Care Act that states who determines what is a medical necessity, reported the Los Angeles Daily News.
Insurers see it as a way to push back against doctors who are habitually prescribing what they call "Rolls Royce treatments." Anthem Blue Cross of California says claims denials based on medical necessity isn't a cut-and-dried issue because some doctors prescribe more expensive, but not necessarily more effective, treatments, spokesman Darrell Ng told the Daily News.
For example, a doctor prescribed an expensive device for a patient who suffered a knee injury. That device was supposed to cool down the knee's muscles and tendons. "An ice pack works just as well," Ng said.
Meanwhile, more consumers are standing up to insurers for denying their claims. In California alone, more than 1,000 consumers appealed denied claims, and they won about half of those appeals. In fact, a California state data show that consumers usually win about half of the time when they appeal claims denials, FierceHealthPayer previously reported.
"I think the Affordable Care Act has really helped in many ways," William Shernoff, a healthcare attorney in Beverly Hills, California, told the Daily News. "But I think they left one big loophole."
Shernoff is referring to the fact that the ACA allows insurers to deny procedures, even ones recommended by doctors, if they consider them unreasonable or not up to the standard of care. "There doesn't seem to be anything in the ACA that lays down any guidelines or standards on who determines medical necessity," he added.
In particular, Shernoff said insurers use the medical necessity clause most often when a new, expensive drug is introduced to the market like the costly hepatitis C drug Sovaldi. The insurance industry has been battling drug makers over the pricey Hepatitis C drug Sovaldi for months now.
To learn more:
- read the Los Angeles Daily News article