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So the way this works is that for things that are planned (like a routine surgery or an office visit) you will give your insurance card to the team that works with that physician and they will figure out if the planned services are covered. If they are? Great. Easy.
Immediately this runs into some problems.
What if you go to the office and the doctor wants to perform an unplanned mild procedure? Do you want to come back a week later after insurance has been worked out or just get it done? I have literally seen patients been given this option and then forget about it when the bill comes.
What if you didn't plan going to the doctor? Your anesthesiologist for your emergency surgery may not be in network, but this is not planned you get what is available. The insurance should be forced to pay for this, but they are lobbying to not.
Healthcare delivery is a 24 hour problem. Insurances are not generally open 24 hours. This limits the ability to contact the insurance and ask if something is covered. Plenty of practice environments are open outside of insurance hours even for routine things. Sometimes patients spend extra days in a hospital waiting for insurance to approve the next phase of care.
Now you might say "well listen, just tell me if this DOCTOR is covered." Some places will have a website that will tell you if a doctor is in network or not. Sounds great right?
Well no, just because a doctor is in principle in network doesn't mean they actually cover anything that doctor does. They might be in network for emergency care, but not routine care, or reimburse less than cost for a given procedure so performing it is not financially sustainable. It's not uncommon for certain types of procedures to just not be done in non-emergency settings because insurances won't pay more than it costs to do the thing.
Lastly even if you get something done that is covered, with a doctor that is covered, and you checked in advance with your insurance to make sure that it was covered...sometimes they just won't cover it anyway. They have all kinds of random excuses and often this can be addressed by some combination of patient and physician appeals, but:
We don't know if something is covered by insurance because 5% of the time they decide not to cover what they said they said they would.
*I don't know the true number here it is probably wildly variable on region, insurance, and specialty. United being notoriously bad about this.
You are replying to short post that included "force health insurance companies to make legally binding answers".
Yes sorry, I though you were focusing on the doctor side of things which is what the rest of this mess is on about.
If you want to laser focus on that we still have problems, even as an insurance critically person I admit it's fair for them to go "okay I'll pay for it but you have to justify it correctly" because that prevents various bad actors in healthcare provision (including doctors) from doing sketchy stuff.
It's pretty fair for them to ask us to put into our note our medical decision making and only pay if it is justified.
But then they play games with what is required to justify it.
Mandate legally binding answers and you get "yes we will pay for this service if it is documented correctly." That is necessary but has chasm wide potential for abuse (and is generally what they do now).
Even if you were to hand wave away those problems that doesn't address after hours approval, delays in approval, surprise billing concerns and so on.
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