Correct me if I'm wrong: it is illegal for anyone other than a doctor to practice medicine, right?

[closeupready]

So why isn't it illegal for insurance companies to say, for example, a woman's bleeding breast is NOT an emergency or dictating who can see the patient in order for it to be covered? That is de facto practicing medicine. Aren't there laws against that? If insurance companies are corporations, and corporations are people, then can't they be prosecuted?

[Lucy Goosey]

1. Don't they have physicians at the insurance companies signing off on this stuff, though?

I swear there was one (or more?) interviewed in Sicko

I'm not saying that's acceptable, obviously - I think these doctors are worse than the non-doctor insurance execs.

[closeupready]

4. Is that correct? That must have been later in the film?

Because I don't recall from the first part of it, and I missed the later part of it.

Anyway, I ask this question, because that is what I've heard some doctors say, that they are now making medical decisions illegally, and that there are indeed laws against it but that the laws are not being enforced.

[Chulanowa]

11. I think they do

However, since those doctars are paid by the company that profits if coverage isn't granted, their judgement can be seen as comprimised, at best.

The patient's doctor should be the one making these decisions

[robinlynne]

14. yes. I had an insurance problem like that. there are 3 doctors in cahrge of

making the decisions. I was NOT allowed to speak with them, or be present, or present my case. Then I appealed. Again I was not permitted to speak or be present.Both times the insurance company ruled against my claim. That's how it works. judge, trial, and jury, but you dont get to be a part of it.

[closeupready]

15. But then when they are wrong (because they didn't see you), isn't that malpractice?

Couldn't you sue the doctors and the insurance company?

[robinlynne]

22. In my case, it was not serious, like this woman's case. I dont know the answer to your

question. I got a scar from a dermatologist. And the "dermatologist" was a nurse, not a doctor, so I probably could have sued. because I asked for an appointment with a doctor and got a person who did not know what they were doing. All I was requesting was my money back (200.00) and to fix the scar... I probably could have sued, but it was not worth it in my case to spend more time and money. This woman's case is more serious.

[truedelphi]

25. I am sorry to hear of your situation. That SUCKED! n/t

[madrchsod]

17. they have "health professionals" decide on treatments

these people really piss off the doctors who have to wait to see if their procedure will be approved. one doctor of my doctors hated these people. others just figured it was just part of doing their job.

[mainer]

36. Not necessarily. Sometimes they're untrained clerks.

That's been the experience of a few doctors who appealed the insurance companies' decisions. One doctor told me that the insurance company denied treatment of a "greater trochanteric fracture." He called them up, spent a frustrating time on the phone with the clerk who denied payment, and then said "what the hell am I supposed to do with a broken hip, leave it untreated?" At which point the clerk said, "Oh, that''s a broken hip? Why didn't you say so?"

[hedgehog]

2. They aren't deciding what treatment the woman should get, they're

deciding what treatment they should pay for. It's a fuzzy area though, since in this case they're practicing triage.

[Cleita]

6. It seems to me that they are making a diagnosis which would be

practicing medicine.

[closeupready]

7. Yup.

Exactly.

[Chulanowa]

19. In a way they are deciding the treatment a person gets

Because many people, if unable to afford a treatment, will not take it.

[Cleita]

3. You have a really good point and hopefully prosecutors might start going

after the insurance companies for this. They are fighting a really powerful industry and will need a big stick, but maybe some will be bold and brave enough to do it.

[KittyWampus]

28. Didn't Congress give Insurance Co's immunity from liability?

[Cleita]

29. Maybe they did. There was so much deregulation that went on with

the Republican dominant Congresses that all kinds of abuses are now tolerated.

[MiniMe]

5. They aren't practicing medicine, they are practicing denial of medical treatment

All the insurance company says is "we won't pay for it", which makes a big difference to some people.

[aint_no_life_nowhere]

12. The decision to withhold treatment is the practice of medicine

If a decision is made that someone doesn't need a particular procedure, whether it's a doctor or the one employing the doctor, it's still a medical decision and is the practice of medicine.

I wonder how this works in an HMO where the doctor is the employee of the administration that controls the purse strings. In that case, the doctor defers his practice decisions not to someone who is just decising whether to pay for treatment, but to someone who is telling him directly what treatment to provide as his employer.

[MiniMe]

23. They aren't deciding if a person should receive a treatment, only if they will pay for it

So they are practicing the denial of payment, not of care. I think it is pretty rotten, especially if they had previously approved paying for the procedure.

[aint_no_life_nowhere]

24. In most cases they are deciding which among several medical options they will authorize

Insurance company authorization is a de facto administration of treatment. What kind of treatment to give and what kind to withhold is a medical decision.

And when the doctor is an employee of the HMO, they are practicing more than the mere denial of payment. They are directly practicing medicine by telling their employee doctor the scope of his duties and activities as an employee. It doesn't get closer to the actual practice of medicine than that, when they completely direct an employee doctor as to what to do.

[MiniMe]

39. It is a very fine line, however, the doctor is free to do and prescribe what he wants

And the insurance company may not pay for it. It is definitely a fine line, but they aren't saying "don't do this or that", they are saying we won't pay for this or that, and many times you don't find out until after the fact. I hate the way insurance companies work.

[aint_no_life_nowhere]

40. In the traditional HMO model, called the "closed panel" type, the doctor is an employee

In that case, there is no situation where the doctor prescribes something and the HMO decides not to pay. The doctor is working for the HMO and they call the shots. Again, he is an employee in that case, not an independent contractor. In this type of case, the doctor will not prescribe a procedure he knows in advance will not be authorized by his employer. That's controlling the way medicine is practiced. Some doctors have been up-in-arms over that situation and very depressed at what their practice of medicine has become.

[Turbineguy]

8. It's the Shakey's Pizza doctrine.

'We made a deal with the Bank. The Bank doesn't make Pizza and Shakey's doesn't take checks."

The insurance company doesn't practice medicine and the emergency room doesn't pay the bill.

[Barack_America]

9. Insurance companies don't "practice" medicine, they just pay for it.

Which we all know is essentially the same thing, but "technically" it's not, which is why they haven't all been sued to extinction.

That's also why doctors hate insurance companies and 65% support either single-payer or the PO. Insurance companies are constantly putting doctors in the position of either seeing patients not get the care that they need or bankrupting their patients. When the insurance company denies payment, the doctor still has to recommend treatment or face a lawsuit.

[Statistical]

10. Insurance company isn't decided what treatment you can get...

they are simply deciding what they will PAY FOR.

Not that it is right but that is enough for them to not be considered "practicing medicine".

If you doctor recommends procedure "xyz" the insurance company will never PROHIBIT you from having "xyz" done they simply may not pay for "xyz".

Insurance isn't health care.

[hedgehog]

13. What's really happening here is the insurance company penalizing the

customer for not having an advanced medical degree. The insurance company is thinking that the customer failed to guess the diagnosis ahead of time, didn't realize there was no emergency , so the customer should pay the ER fee.

[thereismore]

18. Very good summary. They did that to us too. Had to pay ER visit. Not life threatening. nt

[johnaries]

16. 2 words. Death Panel. nt

[Buzz Clik]

20. I guess it doesn't require a license to deny medical attention, only to administer it.

[ddeclue]

21. there are various kinds of medical licenses: nurses, P.A's, pharmacists and EMT's are all licensed

to perform various medical activities, doctors are just at the top of the food chain.

[Treo]

32. No HMO's are the top of the food chain NT

[Turbineguy]

26. Next Contestant please!...

Make up a sentence using the terms, "Insurance Company" and "Benefits".

(Pssstt.... the secret word is "deny")

[AngryAmish]

27. Nurse practioners practice medicine

[cabluedem]

30. And you still pay them the same co-pay as a doctor. Something wrong there. nt

[AngryAmish]

37. Not really

The purpose of a co-pay is to make people pay something to see the doctor. When no money comes out of your pocket then the good or service is perceived to be free. When things are free you use it more. I have a kid. Going to the public park is freeto me. We go there all the time. Going to an amusement park is not free. That is a rare treat.

Co-pays are designed to hurt so you don't overuse the resource.

(And nobody would overuse a doctor's care? Ha.)

[WeCanWorkItOut]

42. You know, it might work out if the co-pays for NPs were a bit lower

It would encourage more people to use NPs.
So more people would discover how good they are.
Thus it would lead to a better use of talent,
as well as saving some money.

They wouldn't want to drop the co-pay to zero
(although the time and travel costs are still operative).
But why they don't take five bucks off is not clear to me.

[AngryAmish]

44. I think you are on to something

NPs are a fantastic use of resources. They should be used a lot more. 80% of routine medicine could be done by them.

[Treo]

31. You're wrong

P.A's practice medicine N.As practice medicine and N.Ps practice medicine

[aint_no_life_nowhere]

34. But are they making the insurance company decisions?

That's the issue. Who is making the decisions on what treatment to provide? Clerks with a high school diploma getting their marching orders from insurance or HMO executives?

As I understand it, PAs must work under a physician's supervision. However, whether or not they have full discretion to authorize treatment, they are the ones seeing the patient whereas the claims person in the insurance company is not, but is making the final decision.

[Treo]

35. The question asked was

it is illegal for anyone other than a doctor to practice medicine, right?

The answer is No, you're wrong

[unblock]

33. you and your doctor are free to choose between the $20 monthly meds or the $800 monthly meds

or between having that $15,000 procedure or doing without and risking an early death.

the choice is yours and you doctor's, don't let the price tag influence you in any way. your health comes first, you know.



no, the insurers are not in the business of practicing medicine. they're in the business of bankrupting sick people and hoping their sick customers hurry up and die already, or at least can't keep up with their premiums.

[jberryhill]

38. They are not telling people what to do or not - they are telling people what they won't pay for

[Mimosa]

41. What they won't pay for could kill an insured patient

Say I have symptoms which possibly indicate cancer or maybe not. Say my doctor wants me to see a specialist and have specialist order an MRI. Though I have a BC/BS $10,000 policy deductible 70/30 plan I just can't afford to follow my doctor's instructions because I'd have $3,000 to pay out of pocket. I do not have $3,000. Yet I'm paying 400 buck a month for health insurance. Something's terribly wrong with this system. :(

[aint_no_life_nowhere]

43. A doctor wrote a book on this very issue

Practicing Medicine Without A License, by Don Sloan, M.D.

http://www.whitecloudpress.com/product.asp?specific=jnqserl8

In the first chapter, he describes working for an HMO and seeing the daily erosion of his ability to handle patient care in the way he wants, as the HMO directs his activities, what he can and can't do.

On June 21, 2004, the Supreme Court led by Clarence Thomas ruled that patients cannot sue their HMOs in State Courts anymore and must proceed under federal law according to ERISA. The result is that patients can't sue HMOs for negligently altering care or denying it and recover a variety of damages such as punitive damage. They can only sue in federal court to recover the cost of the medical procedure denied to them. John Nelson, then President of the American Medical Association called this ruling the permission for HMOs to now practice medicine without a license.

The OP is not the first to raise this issue. In fact, it has been raised many times regarding the way HMOs and insurance providers actually affect the course of treatment that physicians are able to offer patients in this country.