Are Medical Directors at Insurance Companies/PBM illegally practicing medicine?

It has been reported that ~ 75% of medical directors at insurance companies are only GP/FP/Internists, making medical decisions about what medical treatments will be paid for or not paid for… many of which are way outside of their skill sets.
We know that it is ILLEGAL/UNETHICAL for a prescriber to prescribe medication for person they have not examined first hand. It is also illegal for a prescriber to prescribe for patients that live in states other than the ones that the prescriber is licensed in.. unless the patient comes to see the prescriber in their office practice in the state they are licensed in.
Is it legal for a insurance company – via their medical director – to “de-prescribe” a certain medication or medical procedure.. that is to say that we won’t pay for X drug.. but will pay for Y drug… or we won’t pay for X procedure when Y drug – we think – will work?
Anytime that you bring up such issues.. the typical first response is that the attorneys at the insurance company will bury us in mindless legal requests, but is not the insurance company that is making and doing these decisions.. it is an employee.. a physician, nurse, pharmacist who is “calling the shots” based on their education and licensing. BUT.. if their only “contact” with the patient is reading their medical file .. which is nothing more than some lab tests and some other healthcare professional’s opinion.
Are these healthcare professional within the rights of their license? Are they practicing medicine outside the scope of their state license and their skill sets?… and just hiding behind the huge insurance company or PBM they work for?
Could patients refused payment for treatments – or will only pay for alternative treatment ..that they had been prescribed by a local MD/specialists… be able to file complaints with the state boards where these healthcare professional are licensed or in states where they have practiced “virtual medicine” on patients that they have never met, examined nor live in/around/near where the patient lives?

Leave a Reply

%d bloggers like this: