Health ReformPolicy & Law

Insurance Coverage Denials: Private versus Public

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The people behind the coming denials: The people behind the coming denials:

[Centers for Medicare and Medicaid Services] has fewer than twenty physicians on its coverage staff and fewer than forty total clinicians once pharmacists, nurses, and other health care providers are counted. While this isn’t a precise surrogate for sound decision-making, it gives insight into how well the agency informs its decisions. Most of its physicians are generalists. It doesn’t have a single oncologist on its staff, and has just one nephrologist despite the fact that it pays for the vast majority of dialysis performed in the U.S. To give a basis for comparison, private health plans—which exercise far fewer authorities to set prices or coverage rules—have more clinicians by order of magnitude on their staffs. Aetna has more than 140 physicians and about 3,300 nurses, pharmacists and other clinicians. Wellpoint has 4,000 clinicians across its different businesses, including 125 doctors and 3,180 nurses. United Healthcare employs about 600 doctors and 12,000 clinicians across its health care business.

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