Insurance Reform Needed: Lay Decision Makers Delay Treatment

By Judy Cresanta
  • Monday, February 26, 1996

The Problem: Conflict of Interest

In these times of health care reform, insurance companies require that pre-authorization be obtained for surgical procedures recommended by a physician before insurance reimbursement can be considered. If the insurance company does not feel that the recommended procedure meets the standards of medical necessity the patient and the physician may appeal their decision , ands the claim then goes to the medial review department. The problem lies in that the "reviewer" is rarely a physician from the same medical specialty as the procedure in question and is usually a person employed by the insurance company. The reviewer thus has a financial interest in the company which may tend to slant the reviewer’s consideration of the claim in favor of their employer over the patient‘s best interest.

Reform Idea

NPRI proposes that reform legislation be introduced which would require insurance companies to send all claims in which the medial necessity of a procedure is being questioned to a peer review committee which would consist of a minimum of three board certified physicians whose specialties are in the same area of medicine as the procedure in question. The committees could be drawn form physicians practicing in the state who are rotated on an annual basis, volunteer basis to sere as a peer review member. It would behoove the physicians in the state to cooperate with the review requirements as it would assist in placing medical decisions back into the hands of those individuals providing the medical care.


Physicians and patients alike are becoming increasingly frustrated with the current maze of health care reform. Many professionals in the health care industry are aware of patients who have fallen prey to the insurance practice of routinely denying claims as not medically necessary in hopes that many patients will not proceed with the appeal process. For the doctors who have dedicated their lives to taking care of people, it is an aggravation to have their medical judgment questioned if not completely overruled. All professions have their share of unethical representatives, and the medical industry has not been omitted form this list. The majority of physicians in the industry today do not approve of unnecessary procedures being performed on patients under their care. The current insurance system is nothing short of harassment for those having to experience their gauntlet of requirements. The time has come to install a system of checks and balances of the providers of health care and the insurance companies responsible for reimbursing them for their services. The most important aspect of this system should be the fairness and quality of care for the insured patient. People deserve to know that they are being cared for by competent, ethical physicians and that their insurance company is basing their approval for coverage of medial services rendered in an impartial and expedient manner.

Judy Cresanta is the president of NPRI.

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