Sorry to drag up an old topic, but I came across this while reading some back postings and couldn't resist!
I have worked in case management for several years, both on the provider side and the payer side. It's interesting to see the vast differences in viewpoint.
Yes, there are gajillions of regulations governing denial of coverage for medical care. Most come down to either not meeting criteria for medical necessity or else the request is for services specifically excluded in the member's certificate of coverage. When a denial is issued, there are complex policies and procedures to be followed, a Medical Director reviews and cosigns every denial, and I then call the patient's doctor, Case Manager or Social Worker, and the member, or their designated contact, to discuss why the service is noncoverable, what their appeal rights are, and encourage them to exercise those rights. I give them my name and phone number, so the information isn't dumped on them by some impersonal big business entity. They are also sent a letter with the information in writing to refer to later, letter sent by courrier, if the urgency of the situation warrants it. In some states, the member can sue for damages related to negative outcomes caused by a decision of noncoverage. We don't have that in MN yet, but I have a feeling it's coming. Nobody has anything to gain by a "bad" denial; it just causes the patient's condition to worsen, causing more trouble and expense for eveyone.
Please remember, the insurance contract is one entered into voluntarily by the member, and they share some responsibilities for understanding its terms and conditions, just like any other contract a person might sign.
Insurance is also business, and although I don't make millions of dollars a year (trust me, I don't!) the executives of insurance companies have the same opportunities as big business execs anyplace else. Does the name Bill Gates ring a bell?
In relation to the original question regarding multisystem failure in the elderly... In the absence of the ability to improve or cure, they have the right to maintain their level of health and function (whatever that level may be) or, if that's not possible, to be assisted through a comfortable and dignified death. If your patients do not have a Case Manager at the insurance company assigned to them, I would encourage you to help them get one. These Case Managers know that what's good medicine is generally what's most cost effective, and they also are generally pretty knowledgeable about other resources out there. One of the frustrations I have is being contacted by providers late in the decision making process. If I know early on what's going on and what plans and options are being considered, I can help more than if I'm not called until the day of discharge.