Physicians, Insurers Clash Over Medical Necessity in CA
While Health Net is the focus of the litigation, LACMA says it aims to end wrongful conduct of "all California health insurers" that prevents doctors from providing proper treatment for patients. Thousands of health insurance claims are routinely denied every year based on insurers' definition of medical necessity that conflicts with California law, according to Delgadillo.
"Health Net is dictating medical care from the boardroom," Delgadillo said in a press statement. "Patient care should be decided by doctors, not business suits."
In a conversation the other day, he elaborated: "We can no longer sit back and wait for other people to solve problems where patients don't have the economic might to solve them, and neither do physicians. But collectively we can. We have to stand up for the rights of patients and that's what physicians have taken an oath to do."
The issue of patient needs for innovative, life-saving procedures is at the heart of the LA case, Delgadillo says.
One of the plaintiffs, Robert Mendoza, 59, was diagnosed with a rare form of prostate cancer, adenocarcinoma with signet ring cells, and his chances of survival were deemed very low. His was one of some 50 cases in the world, Delgadillo says.
- Hospital Groups Strike Back at Hospital Rating Systems
- AHIP: Enormity of HIX Challenges Sinks In
- The Secret to Physician Engagement? It's Not Better Pay
- 5 Hot Healthcare Ideas from SXSW
- Another SGR Patch Likely, Lawmaker Says
- How Succession Planning Boosts Employee Retention Rates
- 4 Reasons PCMH Principles Aren't Going Away
- Two-Midnight Rule Must be Fixed or Replaced, Say Providers
- Don't Underestimate Emotional Intelligence
- Evidence-Based Practice and Nursing Research: Avoiding Confusion