Today the doctors ask, “Are insurers liable when they make medical decisions?”
They ask, “Are doctors liable when they allow an insurer to make a medical decision on their behalf?”
They ask, “Who the heck is in charge of this? State medical boards? Courts? The Dept of Commerce?”
Doctors are accountable for the medications and treatments they prescribe—or choose not to prescribe. Whether or not they’re working under a prospective payment system doesn’t excuse a bad prescription. On the other hand, a doctor isn’t on the hook for insurance company decisions. What an insurer decides to cover, or not cover, falls entirely on the insurer.
Everyone owns their own choices. Can a doctor’s judgment and an insurer’s payment policy exist on separate tracks? Absolutely. Usually, insurers lean toward the cheapest option, while physicians aim for what actually works best. You’d think this would cause constant tension, but in reality, their choices often align—sometimes perfectly.
But what about those times when they don’t? That’s where the appeals process comes in. An insurance appeal isn’t about what’s medically necessary or allowed—it’s about what the insurer will pay for. Insurance, at its core, is about the money. So pretending that one cancels out the other just isn’t true. The doctor’s prescription makes treatment possible; insurance approval decides if it’ll be paid for. These are two distinct, often intersecting, but not required to be intersecting steps in the process.
I agree a Dr is responsible for his recommendation. After that, it gets decidedly more complicated. I think it’s a shared responsibility depending on who’s involved and their actions: doctors, nurses, hospital policies, the patient (or those acting on their behalf) and their knowledge level at the time action is taken. Responsibility for implementation of a recommendation is somewhere between all the people involved. Before I knew anything about diabetes, my doctor dx’d T2 based training he received donkey years ago; he was wrong, but it took nearly 10 years for he and I to figure it out. Since dx as T1, I’ve educated myself and no longer “leave it to the doc” regarding just about anything. For example, I had surgery and a doctor failed to modify standard post surgical instructions for a dextrose drip (pretty standard for all surgery). But based on my T1 status, I had provided written instructions T1 status be considered, specifically cartoonish against dextrose use. I’d discussed it with the day nurse, who followed my verbal/written guidance (I’d had it posted to my chart), the night nurse followed the Dr’s order (replaced saline with dextrose). I woke up high and going up, the night nurse hanging a dextrose drip, ordered immediate removal, threatened to rip the IV from my arm, she complied. Who was responsible? It took the hospital over six months to figure it out and finally apologize for what happened. I hold we all had some responsibility: as a knowledgeable T1 I advised the doc, wrote instructions to the doctors and hospital, had it posted to my chart, discusssed it with the day nurse. The doctor successfully operated, but post surgery instructions failed; the day nurse did the right thing, but should have called the doctor to reconsider his order; the night nurse failed to read my chart, just followed the doctors order, assumed the day nurse erred (didn’t report it), also should have called the doctor to resolve conflicting guidance; the hospital policy failed to provide guidance on doctor/patient conflicts, said nurses should follow doctor guidance. My point: The level of responsibility shifts due to each person’s knowledge level, action taken, and the situation. Some say its better to be deaf, dumb, and blind, leaving most/all responsibility to the medical community, I say its better to be an informed active participant, if not captain of the team, and alive. It takes time and effort and depends on the topic and risks involved.
So, this is a doctor asking who’s doing some interesting policy work.
The doctors will complain that they spend a large proportion of their time fighting with insurance companies and only a small proportion of their time treating patients. (That leans into the prior authorization complaint everyone talks about on TV.)
The docs complain that their decision making about which medication they can prescribe is completely subjugated by the rules the insurers and PBMs (who are a branch of the insurance company) make about what drugs are on the formularies and how the insurers have negotiated those drug prices. The insurers put the most expensive drugs on the formularies so that the docs can’t prescribe generics that they think are more effective.
The doctors complain that whatever medical decision them make, it gets run through a business personal on the insurance side who has no medical training and is essentially doing the medical decision making.
So, I ask them the following:
The doc respond as follows:
@Eric Niiiiiiice! I’ll bet allergies get more attention! 
It’s still on there, to this day!
Anytime I go back there, they say, “So you have a dextrose allergy…” when they are looking at my records. 
I will definitely use that one. Every medical provider always asks about allergies.
Yup. It’s part of their SAMPLE history.
S = Signs & Symptoms
A = Allergies
M = Medications
P = Previous/pertinent medical history (surgeries, etc.)
L = Last meal
E = Events leading up to the incident
