1) A reader writes: “Physician orders a CT scan for patient. The powers that be at [the insurance company], refuse to pre-certify the request and deny the test. Next, patient goes to the emergency room and the ER physician orders the CT scan. Now, [the insurance company] has to pay ER fees, ER physician fee, radiologist fee and any other costs. The overall cost is now probably 1-2 thousand dollars instead of a couple hundred bucks, if the original CT request had been pre-certified.
Can I have your take on the seemingly illogical reasoning at [the insurance company]?”
This happens all the time, and shows the unintended consequences of pre-certification for imaging tests. Providers who don’t want deal with pre-certs simply sends the patient to the emergency room.
With a number emergency room physicians practicing scared, the desired study will be ordered. Since it was ordered in the emergency setting, pre-certification isn’t needed.
Requiring pre-certification incentivizes physicians to send patients to the ED for tests, resulting in higher cost care. My guess is that the insurers are banking that providers won’t resort to that, but so far, they’re wrong.
2) JCAHO is mandating better behavior in the health care setting.
This needs to be especially applied in the academic setting, where the climate is more hierarchical. Interns and residents play a critical role in patient care, so allowing them to comfortably speak out when they see errors or disruptive behavior is crucial.
As I commented in the linked piece, it’s a good idea, but it has to be enforced for it to be meaningful.
3) A reader writes: “How do you decide who makes it into the MedBlog Power 8?”
Here’s how I come up with the weekly Power 8:
i) I take a close look at all the current blogs on the Power 8 and decide who stays for the new list, and who goes.
ii) After determining who stays (normally 4-5 blogs), I go through my feeds page and e-mail suggestions for the 2-3 spots that are left. In a typical week, about 20+ blogs are considered for these spots.
iii) I review and consider every blog that is suggested to me via e-mail.
iv) As stated previously, factors I consider are how provocative the posts are, the amount of discussion it generates, and posting frequency. Blogs that are well-written, easy to read, takes a measured tone, and doesn’t ramble are favored.
Want my take? E-mail a topic or question you want me to blog about. Selected entries will be posted in the regular “My Takes” feature.
Related posts:
- Primary care: Tough re-certification is doing no favors
- Fake board certification
- Information is power
- My take: Tort reform, Curt Schilling, e-mails
- Did the University of Chicago sacrifice patient care for profit?
- Prior authorizations for Medicare?
- Mandating drug coverage makes no sense
{ 4 comments }
Great post.
When I started practice, in the 1980’s, insurance would not pay for many outpatient procedures at all. If someone just wanted a physical with lab, etc. we would admit them to the hospital for a couple of days. That way everybody got paid. The powers-that-be finally wised up.
I think we all suspect that one reason for pre-certification denials is insurance’s hope that if they give us enough trouble and hoops to go through, we will say forget it, not worth the trouble. (Then we get sued for not being “persuasive enough”).
Sending them to the ER is really the only option now. Maybe patients will complain to their providers. Who knows? That, along with the needless extra cost, might make them wise up again some day.
Regarding the above comment:
Is that like when a patient “wants” a routine chest x-ray to screen for malignancy and you write “cough” on the prescription so insurance pays for it? This type of behavior – circumventing the insurance companies – has a name. It’s called insurance fraud and it’s illegal. It’s also a million dollar problem for insurance companies who – yes, it’s true – need to make a profit. In response, insurance companies tighten the purse strings and what you end up with is a vicious cycle. While insurance companies are far from perfect, they are occasionally correct, and that CT scan you want to order isn’t actually justified based on empirical data. As a radiologist I see inappropriate studies ordered all the time – some of which actually get through the insurance pre-certification screen. It’s not only defensive medicine. There are plenty of instances where the completely wrong test is ordered (ultrasound of the abdomen and pelvis in a male patient with LLQ pain – it’s more common than you think). Insurance companies can be arbitrary, greedy and unfair, but the next time an insurance company denies your request for an expensive scan, consider that they may have a legitimate concern (particularly when we’ve recently learned that 30% of studies are unnecessary).
Most insurance fraud would be eliminated if it were actually insurance–it only paid for massive unexpected expenses that one couldn’t plan for with sensible budgeting. Third party payment presents a moral hazard for patients and doctors alike and ends up corrupting everyone,
No anonymous, it was not insurance fraud. There was no false diagnosis. This was 30 years ago and it was called a physical. It was before endoscopy so if there was unremitting abd pain of gi bleeding they went in for upper or lower gi.
Maybe you should call the physician’s office, if you think the test is wrong to ask if another test might be better, or give your referals a little written or oral education. I’m sure that most would appreciate it.
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