Medicare Advantage plans process 50 million prior auth decisions a year. When patients appeal, payers overturn their own denials over 80% of the time. The initial denial layer is calibrated to something other than clinical accuracy.
Medical necessity is not a medical concept. It is a contract term interpreted by the payer. A physician can be 100% right that a treatment is standard of care and the plan can still deny it, contractually.
One documented system bulk-denied roughly 300,000 claims over two months at about 1-2 seconds of physician attention per denial. The signatures were real. The review was not.
The incentive math is almost perfect for payers. Patient abandons care: claim cost goes to zero. Denial gets overturned on appeal: payer pays what it would have anyway, months later, with no penalty. There is no outcome where denial costs extra.
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