Berks County Medical Society Medical Record Summer 2017 - 22

M e d i c a l R e c o R d F e at u R e

Prior Authorizations -
One More Reason To Be
Angry At Health
Insurance Companies?
by Heath Mackley, MD, FACRO
Don't you get upset at health insurance companies?
To that frequently asked question, my short answer is, "No."
I have no love for health insurance companies either, but the anger that physicians and
patients feel about them should probably be more evenly distributed between the insurance
companies, the health care providers, the lawyers, the government, and anyone that receives the
benefits. Like most of our modern "messes," it started with a mixture of theory, good
intentions, self-interest, and lack of appreciation of the consequences of government
policy decisions. From that point, it evolved in directions that reflected the
competing interests of the parties involved. But this is not going to be a historical
treatise about how we arrived to where we are, instead it's a description of where we
are, so we can best move forward with our eyes open.
Your insurance policy is a contract. Like me, you've probably never seen this
contract. In my case, I'm not a party of this contract, it is between the Hershey
Medical Center and Highmark Blue Cross Blue Shield. However, the simplified
core of the contract is that the insurance company will cover medically necessary
medical interventions in exchange for a premium. Both sides voluntarily enter into
this agreement, and I voluntarily signed up for the benefit.
The medical interventions are paid for out of a pot of money that all members of the
"premium paying community" pay into. Like all communitarian arrangements, the labor of
the healthy pay for the medical interventions of those that need them. The insurance company
keeps a portion of this money because of the services it provides. This includes: defining "medical
necessity" for the group, negotiating a lower "price" for the medical interventions, following the laws
that regulate this financial product, and marketing the product to encourage new members to join the
"premium paying community."
A key point is that the insurance company, whether it is a government agency or a corporation,
defines medical necessity. There may be an appeal process, but the final decision is made by the
insurance company. You may have legal recourse, and the court may intervene and interpret
your view of medical necessity as the correct one, but other than that rare instance, the insurance
company decides.

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