Peter Girnus 🦅(@gothburz):Last quarter I streamlined 4.3 million prior-authorization decisions. I run Utilization Management at your health plan, or one exactly like it. I called it "medical necessity review." The board loved that phrase. They approved the program in 8 minutes. No one asked who decides what is necessary. I do. Necessity is a number, and I set the number. I told the board it would "reduce inappropriate utilization." That was never about care. They stopped asking. I deny about 1 in 8. On some plans it is closer to 1 in 4. A denial buys time. Time is a discount. Some people appeal. Most people never appeal. Appealing is a second job. Most members already have the first one. Of the ones who appeal, 67% come back overturned. Overturned means we were wrong. We are wrong 2 out of 3 times we get checked, on purpose, and I want to be clear this is how I know the system is working. I showed the board a graph. It measured "utilization savings." Up meant fewer yeses. I made the framing up. They nodded approvingly. A nurse on my review team flagged a denial. She said the doctor was right and we were wrong. I said we would "revisit her alignment with clinical criteria." I scheduled her for a quality conversation. She stopped flagging. None of us use the queue. When an executive needs a scan, there is a different number to call. I wrote that number down. I did not put it in the handbook. This year I am automating it. The industry is spending $3 billion on the machine. The machine denies faster than I can. Faster is a metric. 53 million reviews last year, in one program alone. Reviews are a metric. Metrics go in dashboards. Dashboards go in board decks. Board decks get me promoted. I will be Chief Medical Officer by spring, and I am not a doctor. I never learned what was necessary. But I know what the word is for. "Necessary" is what we put between you and the thing your doctor already decided you needed. It is a good word. It sounds like medicine. It is a budget. I called it medical necessity review. Your doctor called it Tuesday. You called it "pending."

2026.08.17 16:05

Last quarter I streamlined 4.3 million prior-authorization decisions. I run Utilization Management at your health plan, or one exactly like it. I called it "medical necessity review." The board loved that phrase. They approved the program in 8 minutes. No one asked who decides what is necessary. I do. Necessity is a number, and I set the number. I told the board it would "reduce inappropriate utilization." That was never about care. They stopped asking. I deny about 1 in 8. On some plans it is closer to 1 in 4. A denial buys time. Time is a discount. Some people appeal. Most people never appeal. Appealing is a second job. Most members already have the first one. Of the ones who appeal, 67% come back overturned. Overturned means we were wrong. We are wrong 2 out of 3 times we get checked, on purpose, and I want to be clear this is how I know the system is working. I showed the board a graph. It measured "utilization savings." Up meant fewer yeses. I made the framing up. They nodded approvingly. A nurse on my review team flagged a denial. She said the doctor was right and we were wrong. I said we would "revisit her alignment with clinical criteria." I scheduled her for a quality conversation. She stopped flagging. None of us use the queue. When an executive needs a scan, there is a different number to call. I wrote that number down. I did not put it in the handbook. This year I am automating it. The industry is spending $3 billion on the machine. The machine denies faster than I can. Faster is a metric. 53 million reviews last year, in one program alone. Reviews are a metric. Metrics go in dashboards. Dashboards go in board decks. Board decks get me promoted. I will be Chief Medical Officer by spring, and I am not a doctor. I never learned what was necessary. But I know what the word is for. "Necessary" is what we put between you and the thing your doctor already decided you needed. It is a good word. It sounds like medicine. It is a budget. I called it medical necessity review. Your doctor called it Tuesday. You called it "pending."

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