Insurance guidelines are not clinical guidelines—and it’s time to challenge that legally

The guidelines insurers use to deny claims are fundamentally different from those developed by clinical specialty societies. This discrepancy has serious consequences for both patients and providers—and it may be time to challenge it in court.

In “DRG Downgrades: The Clash of Medical Standards and Insurance Guidelines,” Dr. Poonacha and Lea Chamoun highlight how insurers use vague, self-serving criteria that diverge from evidence-based clinical standards.

Consider these excerpts:

• “Clinical practice guidelines are developed through a systematic process to ensure they are evidence-based… Typically, a panel of experts convenes to create these guidelines… Each author discloses any conflicts of interest… the development process is explicitly outlined… including the level of evidence for each recommendation.”

• “In contrast, the process of health insurance guideline development is often less transparent. It is frequently unclear how these guidelines are formulated, who is involved, and whether conflicts of interest exist… The divergence between insurance-driven criteria and clinical standards, such as those from CMS, leads to frequent denials of coverage… Insurance guidelines are only for specific diagnoses, not the full spectrum of health issues… This discrepancy emphasizes the need to bridge the gap between insurance guidelines and clinical standards.”

This issue extends beyond DRG downgrades and affects the entire fee-for-service system. Insurers routinely apply their own guidelines to deny payment and coverage. Giving insurers this unchecked power presents a blatant conflict of interest.

Why should an insurer—far removed from the clinical encounter—have the final say over a treating provider’s decisions?

While the authors call for “harmonizing” guidelines, a better solution is to establish independent clinical panels to review denials. The burden of proof should be on the insurer—not the provider. Clinicians, with their training and patient knowledge, should be presumed correct. Insurers should have to justify denial of care before a neutral panel.This would restore fairness and likely reduce inappropriate denials. This is not just a policy concern—it’s a legal and ethical one. Skilled attorneys should challenge the insurer’s unchecked authority. The time for reform is now.