Originally Posted by M Levac
I am not a lawyer, nor did I read any of it. Nevertheless, my opinion follows.
Medicare is insurance, and like any other insurance, claims can be decided in court, and the court has its own rules. In the documents (which I did not read, but whatever), it seems there's two aspects to consider. First it's the method prescribed to conform (i.e. be eligible for coverage), and second it's the outcome required to obtain compensation. These two aspects can be further distinguished. For the first, the pertinent part is "conform", not "method prescribed", meaning that if one conforms regardless of method, one is eligible. For the second, the pertinent part is "outcome", meaning that if one produces prescribed outcome, one is entitled to compensation.
In the event a claim is made by the insured, if "method prescribed" was not followed as written, and since that's not the pertinent part yet can still be enforced, the rule here is what's called demonstrably justifiable, i.e. one has to demonstrate that one's method is justified (i.e. effective in conforming, but more specifically equally effective as whatever is prescribed by the clause) and this must be done in court. Ya it's a hassle but the good news is that for this clause (method prescribed) to be ruled invalid, only a single case needs to be argued successfully, then it creates a precedent. As a bonus, this can then be used to refute pretty much all the BS coming from the official guidelines and whatever else gets in the way of whatever alternative method is in fact demonstrated to be successful.
A parallel can be drawn with theft insurance where certain clauses can prescribe specific methods to make it harder for thieves to steal your crap, in order to be eligible for coverage and subsequently for compensation in the event of theft. We know all about theft and thieving methods and methods to prevent theft, so those clauses are pretty much standard, but there's still some who will try to put in absurd requirements, which the court is only happy to shoot down. Personally for example, I remember an insurance claim by a youth club way back, where stuff was stolen, but the insurer didn't pay, because the theft did not occur during a fire, which is what the insurance clause stated should occur in order to conform and be entitled to compensation. In other words, the place was not insured for theft nor fire, but only for theft during a fire. To illustrate the absurd. In order to conform to that clause, somebody would have to start a fire when he was being robbed, but then that would make him a fraud because arson is a crime. On the other hand, it's possible to be robbed during a fire since everybody (besides the thieves, of course) would get the hell out and nobody would be looking out for thieves.
Finally, whoever thought it would be a good idea to invade Medicare to push his own low-fat agenda, it's all gonna blow up in his face, because now it ain't just talk, it's the Law they're dealing with, and when it comes to Law, the court rules.
Anyways, until such hypothetical court ruling, here's what's gonna happen.
Whatever happens, low-fat will remain king on paper. People will try to conform, but will fail, so won't get coverage or compensation - Medicare costs less - success at the legislative level, i.e. look, we reduced health care costs! And, patients will be blamed for that failure precisely by pointing out they didn't follow prescribed method, which is "evidence-based" after all so it must be true! That's a bit of irony because failure of the prescribed method will be held as proof of its validity. Whoever will succeed with prescribed method will be held as proof low-fat is king.
Again, I am not a lawer, nor did I read the documents. Nor am I going to read them. No point.