Have you worked for a major health insurance co.? We're expecting unrealistic? We're you asked to do potentially unethical/unsanctioned acts? How do you defend yourselt?

I work for a major health plan and I don’t feel I have to defend myself at all. My job is to summarize the case for the MD to decide if insurance is going to cover the item or not. We use Medicare & Medicaid guidelines so if they meet those guidelines we cover it. There are times it’s difficult because you know the member doesn’t meet but you have not only a responsibility to your individual patient but to ALL your patients, the insurance company needs to be fiscally responsible as well as able to see when things are not proven. Many of our cases are because the provider (Dr or company providing services) are either asking for things that aren’t medically necessary or aren’t supported by studies to show it works better than alternatives. Medicare has guidelines for a reason, just because you have knee pain doesn’t necessarily mean you need knee surgery, guidelines say to try conservative measures first, if all else fails, then surgery. Most honorable Drs will go that route anyway, but those dishonest ones ARE out there & do perform things not necessarily needed. Most patients just do what the Dr says & think they need whatever he says when it could have been fixed with say PT or an injection. I’ve never been asked to do anything unethical, in any way so if you do get asked that, LEAVE. You still have a license to guard and if they’re asking you to do things you’re uncomfortable with you don’t want to be there, just like a hospital that gives you unsafe numbers. If it were me just starting to look, I would stick with either the big companies or maybe consider non-insurance related care if you’re worried. There are other companies out there that are looking for remote or WFH nurses. Bigger companies I think have more eyes on them watching to make sure they’re following Medicare/Medicaid rule, but that is just my opinion.