>inappropriate care by catching unsafe or low-value care, or care not consistent with the latest clinical evidence
Part of the issue is that doctors use clinical guidelines as baseline best practice document (but then have to care for patients who do not fall neatly within the parameters of the guidelines), while insurers use clinical guidelines as a ceiling for care (but then use the attributes of patients which don't fall neatly within clinical guidelines as a reason to deny coverage).
Yes for 80% of situations, the effect is the same. But for the 20% of situations which fall outside of that it's a rough scene.
Part of the issue is that doctors use clinical guidelines as baseline best practice document (but then have to care for patients who do not fall neatly within the parameters of the guidelines), while insurers use clinical guidelines as a ceiling for care (but then use the attributes of patients which don't fall neatly within clinical guidelines as a reason to deny coverage).
Yes for 80% of situations, the effect is the same. But for the 20% of situations which fall outside of that it's a rough scene.