Medical – Legal Collaboration to Improve Laboratory Stewardship

In this episode, Dr. Geoff Baird and I interview Elizabeth Pendo, the Senior Associate Dean of Academic Affairs, and the Kell-eye Y Testy Professor of Law at the University of Washington School of Law. Our topic is medical legal collaboration to improve laboratory stewardship. Dean Pendo has a broad experience in health care law that includes years of legal practice in the private and public sector, as well as a noteworthy academic career. Her legal work, teaching, and academic publications encompass perspectives of patients, providers, insurers, and government. In the podcast we cover a broad range of topics including: Federal vs. state rules governing health insurance; the role of the Affordable Care Act in supplementing earlier federal legal frameworks; The standard of care from a legal perspective; Current challenges regarding incorporating the standard of care into medical necessity determinations by private, and public, payers; Perspectives of patients, labs, and insurers as regards insurance denials.

PLUGS Website:
https://www.schplugs.org/

MTS Website
https://medtraining.org/

Chapters

• 0:00 Elizabeth Pendo's background in health law, including her work with a private insurer and as a patient advocate; Experience with coverage denials; Challenges patients face when navigating insurance systems during times of illness.
• 15:14 State Law vs. Federal Law under ERISA. ERISA's impact on insurance regulation, its preemption of state laws, and how the Affordable Care Act addressed coverage gaps by introducing appeal rights, transparency requirements, and additional patient protec
• 31:17 Definition and application of "standard of care," its legal and clinical interpretations, challenges with insurance coverage for rare or complex conditions, and the limitations of evidence-based policies in capturing real-world medical necessity
• 47:09 Inefficiencies in U.S. healthcare, the financial and clinical consequences of fragmented insurance, and the case for universal coverage—whether single or multi-payer—as a solution to reduce costs and improve access
• 1:03:34 Strategies for appealing insurance denials, emphasizing the importance of exhausting all appeal levels, presenting new evidence at each stage, and influencing future changes to medical necessity policies
• 1:18:38 Payer engagement strategies, including advocating for annual policy updates and using clinical consensus to challenge “experimental” labels. Fostering collaborative negotiations between health systems and payers to align coverage with real-world medical s