Not Medically Necessary

The Non-Prophets

“Not Medically Necessary”: Inside the Company Helping America’s Biggest Health Insurers Deny Coverage for Care
Pro Publica, By T. Christian Miller, on Oct 23, 2024
https://www.propublica.org/article/evicore-health-insurance-denials-cigna-unitedhealthcare-aetna-prior-authorizations
The panel delves into the complexities and pitfalls of the U.S. healthcare system, particularly the insurance industry's reliance on algorithms and outsourced decision-making to approve or deny pre-authorized medical claims. They examine the unsettling trend of companies like Evicore, which utilize algorithms to deny claims based on perceived discrepancies, leaving critical decisions to doctors who have limited time and often lack specific expertise. AJ and Jonathan discuss personal experiences, highlighting frustrations with insurance companies’ arbitrary denials that delay essential treatments, turning healthcare into a bureaucratic struggle that often prioritizes profit over patient well-being.
AJ recounts enduring unnecessary delays due to insurance denials, underscoring how slight procedural changes—such as different anesthesia types—can lead to rejections. A poignant example involves a friend’s life-saving Crohn’s disease medication, which, despite its necessity, was repeatedly denied, demonstrating the callous indifference inherent in these processes. Jonathan discusses his experiences with the VA, which he acknowledges as imperfect but effective in comparison to private insurance. The panel further explores the tangled connections among major health insurance companies, pharmacies, and outsourced providers, underscoring the corporate consolidation that prioritizes profit margins over patients’ lives. Their conversation critiques how healthcare has morphed from a fundamental right into a profit-driven service, emphasizing that for these companies, patients are merely "price tags" whose wellbeing is secondary to the financial bottom line.
The Non-Prophets, Episode 23.45.2 featuring Phoebe Rose, AJ, Cynthia and Jonathan Roudabush
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