{
 "standard": "data/how-medicine-works.json — institutional-mechanics explainers. Each answers one question in layers: a 60-second answer, how the system works, who controls the decision, where it fails, the governing law, what physicians experience, what patients experience, and where to read further on this site. Every explainer synthesises pages that already exist; none introduces an unsourced fact.",
 "asOf": "2026-09-01T21:00:00-07:00",
 "entries": [
  {
   "id": "why-credentialing-takes-months",
   "q": "Why does credentialing take three months?",
   "short": "Because the same licence, diploma and training record are verified from scratch by every institution and every payer you encounter, and each verification waits on a third party — usually a medical school or a former employer — that has no deadline.",
   "how": "Credentialing is primary-source verification: the institution contacts the issuing body directly rather than accepting your copy. Licence, degree, postgraduate training, board status, malpractice history, references and any adverse actions each go to a different source. The file cannot close until the slowest source replies, and nothing obliges that source to reply quickly.",
   "who": "The institution’s medical staff office assembles it; a credentials committee and then the governing board decide. Payer enrolment is a separate process with its own timeline, run by each plan.",
   "fails": "Two places. A single unresponsive source stalls the whole file, and nobody in the chain is accountable for the delay. And because no institution relies on another’s verification, a physician who moves has the identical work redone at full length — which is duplication, not scrutiny.",
   "law": "Institutional bylaws and accreditation requirements drive the process; adverse actions reach the National Practitioner Data Bank under federal law. Nothing requires reliance on a prior verification performed to a standard.",
   "physician": "Weeks of unpaid limbo, often after a start date has been agreed. A physician can be fully licensed, board-certified and unable to see a patient or bill for one.",
   "patient": "A post stays unfilled and appointment availability does not change, for reasons no patient is ever told.",
   "reads": [
    [
     "/policy/why-credentialing-takes-months/",
     "The detailed treatment"
    ],
    [
     "/reform/credentialing-modernization/",
     "Why duplication, not scrutiny, is the constraint"
    ],
    [
     "/policy/credentialing-privileging-enrollment-licensing-four-processes/",
     "Four processes routinely confused"
    ],
    [
     "/dossiers/credentialing/",
     "The full dossier"
    ]
   ]
  },
  {
   "id": "who-decides-whether-an-mri-is-approved",
   "q": "Who decides whether your MRI gets approved?",
   "short": "A utilisation-review process inside your health plan, applying the plan’s own medical-necessity criteria. On a medical-necessity denial in California a licensed reviewer with appropriate expertise must make the determination — but an automated system may be involved before that point, and no rule requires you to be told it was.",
   "how": "Your physician submits a request with clinical documentation. The plan checks it against internal criteria, which may be licensed from a vendor or built in-house and are frequently not public. Simple approvals can be automatic. Anything ambiguous escalates. A denial can be appealed internally, then externally.",
   "who": "The plan sets the criteria, and the criteria decide most cases. That is the part patients and physicians consistently underestimate: the reviewer is applying a rule someone else wrote, and the rule is where the real decision was made.",
   "fails": "Delay is the common harm rather than outright refusal — an approval that arrives three weeks late has already changed the clinical situation. Automated involvement is not disclosed. And a physician who appeals successfully receives no signal that the underlying criterion was wrong, so the same denial recurs for the next patient.",
   "law": "California sets response timeframes and the licensed-reviewer requirement for medical-necessity denials. Federal rules impose decision timelines on certain plans. Neither fixes how long an approval lasts nor bars automation from producing a final denial.",
   "physician": "Unpaid administrative work per patient, repeated at each renewal, with no mechanism to fix a criterion that is generating wrong answers.",
   "patient": "A test your physician thinks you need, waiting on a determination you cannot see the criteria for.",
   "reads": [
    [
     "/policy/prior-authorization-a-patient-and-physician-guide/",
     "The patient and physician guide"
    ],
    [
     "/dossiers/prior-authorization/",
     "The full dossier"
    ],
    [
     "/policy/claim-denials-and-the-appeals-ladder/",
     "The appeals ladder"
    ],
    [
     "/reform/proposals/prior-authorization-duration-and-algorithmic-denial/",
     "What KPSGILL would change"
    ]
   ]
  },
  {
   "id": "what-happens-when-someone-complains-to-a-medical-board",
   "q": "What actually happens when someone complains to a medical board?",
   "short": "A complaint opens an investigation, and the investigation is where most cases are effectively decided — before any of the protections a physician imagines having actually attach.",
   "how": "A complaint arrives, is screened, and may be closed or assigned for investigation. Investigators gather records, may interview the physician, and may obtain a medical consultant’s review. If the board proceeds, it files an accusation; only then does the formal administrative-hearing machinery begin, with clear and convincing proof required at hearing.",
   "who": "Board staff control the investigative phase. A physician’s answer to the first letter, and an interview she may not know is decisive, are frequently the most consequential moments in the whole matter.",
   "fails": "The pre-accusation phase carries no specific notice of the allegation, no advice of the right to counsel at interview, no closing-or-charging clock and no separation of investigative from adjudicative functions. An unresolved investigation is itself reportable and career-limiting, so time alone is a penalty.",
   "law": "The Administrative Procedure Act governs hearings; licensing statutes authorise investigation, compelled examination and interim suspension. The investigative phase is largely ungoverned.",
   "physician": "A letter that reads as routine, answered without counsel, that later turns out to have framed the case. Solo and small-group physicians have no institutional counsel and answer alone.",
   "patient": "A complainant may wait a very long time for a disposition and receives little explanation of the process.",
   "reads": [
    [
     "/policy/the-mbc-complaint-letter/",
     "The complaint letter"
    ],
    [
     "/policy/investigation-is-not-discipline/",
     "Investigation is not discipline"
    ],
    [
     "/reform/proposals/medical-board-due-process/",
     "The KPSGILL model statute"
    ],
    [
     "/policy/the-central-complaint-unit/",
     "How complaints are screened"
    ]
   ]
  },
  {
   "id": "why-an-emergency-visit-generates-several-bills",
   "q": "Why does one emergency room visit generate several bills?",
   "short": "Because you received services from several separately billing parties in one building: the hospital bills for the facility, the emergency physician group bills for the physician, and radiology, pathology and anaesthesia bill for themselves. Each may have a different relationship with your insurer.",
   "how": "The facility charge covers the room, equipment, nursing and supplies. Professional charges cover each clinician’s work. Diagnostic services bill separately again. Whether each party is in your network is a separate contractual fact, which is why one visit can produce both in-network and out-of-network liability.",
   "who": "The hospital sets facility charges. Physician groups — frequently contracted rather than employed, and sometimes owned by a staffing company — set professional charges. Your plan’s contracts determine what each is actually paid.",
   "fails": "A patient who deliberately chose an in-network hospital can still be treated by an out-of-network physician there. Federal surprise-billing protections address much of this, and the arbitration mechanism behind them determines who absorbs the difference — a fight the patient does not see.",
   "law": "The No Surprises Act and its independent dispute resolution process; state surprise-billing law where applicable; facility-fee rules and price-transparency requirements.",
   "physician": "Little control over billing structure, and blame for charges she did not set.",
   "patient": "Several envelopes, unclear duplication, and no obvious way to tell whether the total is correct.",
   "reads": [
    [
     "/policy/surprise-billing-and-the-no-surprises-act-idr-process/",
     "Surprise billing and the IDR process"
    ],
    [
     "/policy/facility-fees-in-outpatient-care/",
     "Facility fees"
    ],
    [
     "/policy/ground-and-air-ambulance-billing/",
     "Ambulance billing"
    ],
    [
     "/policy/hospital-price-transparency-compliance/",
     "Price transparency compliance"
    ]
   ]
  },
  {
   "id": "who-decides-what-medicare-pays-a-physician",
   "q": "Who decides what Medicare pays a physician?",
   "short": "Congress sets the annual update to the conversion factor; CMS sets the relative values through rulemaking, with heavy input from a specialty-society process. The update is not linked to practice-cost inflation, and budget neutrality means one specialty’s gain is another’s loss.",
   "how": "Each service has relative value units for work, practice expense and malpractice. Multiply by a geographic adjustment and the conversion factor, and that is the payment. Changing any relative value triggers a budget-neutrality adjustment that reduces the conversion factor for everyone.",
   "who": "Congress on the update; CMS on relative values; a specialty-society committee whose recommendations CMS accepts at a high rate on the valuation inputs. Representation in that process is therefore consequential.",
   "fails": "The update has run below measured input-cost growth for successive years and the gap compounds. And redistribution decisions are made without published specialty and practice-size impact at the proposal stage, so a practice can discover the effect only after it is final.",
   "law": "Statute sets the conversion-factor update and requires budget-neutrality adjustments. The Medicare Economic Index measures practice-cost inflation and does not drive the update.",
   "physician": "A payment schedule that falls behind costs in real terms, with periodic redistribution shocks a small practice cannot cross-subsidise.",
   "patient": "Participation decisions, panel capacity and appointment availability follow from this arithmetic.",
   "reads": [
    [
     "/reform/proposals/physician-payment-conversion-factors/",
     "Fix the update, then fix the redistribution"
    ],
    [
     "/reform/briefs/physician-payment-conversion-factors/",
     "The one-page brief"
    ],
    [
     "/policy/site-neutral-payment/",
     "Site-neutral payment"
    ],
    [
     "/policy/compensation-models-and-incentives/",
     "Compensation models and incentives"
    ]
   ]
  },
  {
   "id": "why-a-strong-img-may-not-match",
   "q": "Why does an IMG with excellent scores sometimes fail to Match?",
   "short": "Because scores are a screen-in factor, not a differentiator — and several of the filters that eliminate applications operate before anyone reads a score: visa category, year of graduation, and whether the programme sponsors the visa you need.",
   "how": "A programme receives far more applications than it can review. It filters — often by visa sponsorship, graduation recency and exam attempts — then reviews what remains for specialty coherence, U.S. clinical exposure, letters from people who actually supervised the applicant, and research the applicant can discuss. Signals and geographic preference shape which programmes look closely.",
   "who": "The programme director and selection committee, working within institutional constraints on visa sponsorship they may not control.",
   "fails": "Money spent on applications to programmes whose published policy already excluded the applicant. A strong record assembled without regard to visa feasibility. Letters from senior figures who barely know the applicant. And publications the applicant cannot explain in an interview.",
   "law": "Not law — institutional policy plus immigration constraints. The J-1 route runs through a single sponsor; H-1B depends on employer willingness and, for most foreign medical graduates in patient care, on Step 3 and state authorisation.",
   "physician": "A candidate who did everything the internet told her to do and never checked whether the programmes on her list sponsor her visa category.",
   "patient": "Shortage-area posts go unfilled while qualified physicians are excluded by constraints unrelated to competence.",
   "reads": [
    [
     "/img/pathway/",
     "The sixteen-stage pathway"
    ],
    [
     "/img/visa/#before-eras",
     "Verify before you spend money on applications"
    ],
    [
     "/img/us-experience/",
     "What counts as U.S. experience"
    ],
    [
     "/img/red-flags/",
     "What cannot be guaranteed"
    ]
   ]
  }
 ]
}