Why would any payer cover something when they have only the slightest intention of doing so?
“It is not surprising that insurers are carefully scrutinizing the care of patients treated with biologics, which are among the most expensive medications on the market. Biologics are considered specialty drugs, a class that includes the best-selling Humira, used to treat arthritis. Specialty drug spending in the U.S. is expected to reach $505 billion in 2023.”
“When United refused to pay for McNaughton’s treatment……his family did something unusual. They fought back with a lawsuit, which uncovered a trove of materials, including internal emails and tape-recorded exchanges among company employees. Those records offer an extraordinary behind-the-scenes look at how one of America’s leading health care insurers relentlessly fought to reduce spending on care, even as its profits rose to record levels.”
Can you imagine the pressure that would surely be brought to bear on a self-funded plan sponsor in a situation like this one when a stop loss carrier denies a claim on similar grounds or completely lasers out the risk on renewal? There’s a better, more humane strategy than The Indian Giver method of risk transfer –The Hot Potato Method