I wonder what would happen if we moved the "medically necessary" requirement burden of proof from the doctor/patient to the insurer. So the insurer would be required to pay out a claim regardless of whether the insurer thought it was medically necessary, but their recourse could be to try to claw it back post-payment.
They'd most likely go bankrupt. There is already an incentive for them to spend on medical care due to the Medical Loss Ratio (MLR) which caps their profits on collected premiums.
If you're saying they need to be forced to pay whatever invoice comes to them and start legal battles for each suspect case then yeah... that doesn't seem feasible.
Doctors/patients are human too and your proposed system would be ripe for abuse. If you're well versed in submitting claims, and you know they have to pay out, then you could inundate them with fraudulent ones.
> That to me would imply that doctors/patients are submitting a huge amount of incorrect claims
UnitedHealthcare says that 10% of claims go through additional review for various reasons[0].
I don't know if there are stats for the industry as a whole, but my guess is that they deal with a lot of errors.
I'm not proposing that all guardrail responsibilities be shifted to the insurer. Just the "medically necessary" provision.
Doctors would still have a Duty to Code Services Accurately and a Duty to Maintain the Medical Record (which would clearly enable an insurer to prove a non-medically necessary therapies). There would be plenty plenty of evidence for an insurer to immediately respond.
So claims could be rejected on the basis of failing to code accurately or lack of record.
What would happen is that costs to self-funded employers would increase so much that many of them would simply stop offering health insurance benefits and choose to pay the tax penalty instead. The only way the current system sort of works is with health plans maintaining strict utilization management.
(In general society would be better off if access to healthcare wasn't tied to employment but that's a separate issue.)
I wonder what would happen if we moved the "medically necessary" requirement burden of proof from the doctor/patient to the insurer. So the insurer would be required to pay out a claim regardless of whether the insurer thought it was medically necessary, but their recourse could be to try to claw it back post-payment.