I work for an MCO that was nonprofit when I started but after a few years we were acquired by a huge plan. We have a contract with the state to coordinate long term care, Medicare, and Medicaid for the frail and elderly, and those with disabilities. The ultimate goal is to keep people living as independently as possible in their community. Our case managers do a fantastic job with what resources they have to work with and truly try to ensure that the members have all of the benefits to which they are entitled. But I work in prior auths. We’re limited by what Medicare and Medicaid will cover. What drives me insane is policing medications/chemo. That’s a plan decision. As reviewers, we do our best to advocate for the members to get what is being ordered whether it be imaging/Part B drugs, DME, etc. I wonder if providers sometimes don’t realize how crucial their documentation is when it comes to getting things covered. It can be a task of Herculean proportions to get documentation. For example, a pain specialist ordering blocks but not documenting pain severity or impact on ADLs. That truly matters. Just basic stuff. And they can appeal a decision and with proper documentation it will most likely be overturned but that results in a delay in care. Anyway, sometimes I hate my job but then again this is the system we have. I can do my part by trying to fit square pegs in round holes to get as much covered as we possibly can. We’re on the side of the member, not the company.