In California, these doctors are not required to be licensed within the state, and have the power to veto any diagnostic or treatment plan by a patient’s primary physician.
Worse, they cannot be disciplined:
A huge snag in the system is that utilization review doctors without California licenses cannot be disciplined by the Medical Board of California for unprofessional conduct because they aren’t under board jurisdiction. Neither can they be prosecuted in the states in which they do have licenses, because those states don’t have jurisdiction in California.
These hired guns have a huge say in treatment and diagnostic decisions, and cannot be held accountable.
What a scam.
Related posts:
- Malpractice caps = more doctors
- Tort reform working in Texas
- Free = more utilization
- Fake board certification
- Prison doctors
- Chiropractors want to do anesthesia without CPR training
- Be careful what you promise
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The licensing almost never acts. It will certainly not insert itself into a controversy, only to be sued by the losing side.
These doctors are subject to insurance bad faith claims, and to civil RICO actions. This is what organized medicine is for. They are nowhere to be found. They get all intense if an optometrist wants to prescribe eye drops. Yet, they are nowhere to be found in the face of massive unauthorized practice of medicine.
The cancellation of a prescription is the same as the writing of one. It is the practice of medicine. As to the argument, we are not canceling anything, but merely declining payment, that is just a pretext, and a form of bad faith.
In several cases, the Supreme Court has given presumptive validity to clinical decision making. The most famous is Roe v Wade, where a law that interfered with clinical decision making got struck down.
To comply with these SC decisions, the burden of proof should rest with the insurance company doctor, not the other way around. These denials have never been challenged on such grounds.
I don’t think that it is just a pretext. Choosing to prescribe a medication is practicing medicine. Refusing to pay for it is a financial one and a matter of coverage. Doctors and the public have been spoiled by third party payment to the point that they feel helpless to take care of themselves when it isn’t there.
Whether they are acting in bad faith or not isn’t a judgement that any reasonable person can make in such a sweeping fashion as that is individual and case specific. The individual making that accusation is apparently showing himself not to be a reasonable person.
If the denial is a financial decision, why must an experienced, specialist doctor make it? Why not an accountant or clerk? The doctor knows the patient will never get the expensive drug otherwise. He has legal scienter that he is canceling the prescription, despite not being licensed by the patient’s state board.
Let’s face it, doctor’s aren’t Gods. Some are greedy and dishonest and order the care most profitable to themselves and others are too lazy to do their job. They bear watching as much as anyone else–and those who think that they are Gods find it an unbearable imposition.
He doesn’t know whether the patient is going to get the script filled or not any more than most of them know what the word scienter means.
The insurance company ought not to be paying for care that is pointlessly wasteful or that just plain sucks, and an accountant can’t tell that. I don’t give a fig whether they are licensed by the state of California or not. They do not however have a doctor-patient relationship with the patient however and have no legal obligation to that patient. They are consultants to the insurance company who advise the company regarding whether the documentation of the care provided meets their guidelines that they write to reflect what they believe that they are legally and contractually obligated to pay.
If those guidelines are in error, are unfair, or are in conflict with the attending physician’s opinion is not what they are contracted to address. If the treating physician finds that to be a problem, he needs first and foremost to attend to the quality of his documentation. Does he actually document the evidence supporting his decision? or only cryptic judgements unsupported by data?
A doctor has never seen a patient. A doctor becomes a multi-millionaire by denying care, fired for approving it. There is no correlation between documentation and quality of care or patient outcome. The demand for transcript like records is pretextual make work, similar in punitive effect as having to write 500 times in the 7th grade, “I will not yell out without permission in class, anymore.” The insurance doctor is a traitor to clinical care, should be investigated and shunned from all professional societies, social groups, openly denounced in their churches by sickened, damaged patients. Their families should be approached by damaged patients to ask for explanations of how it came to be these heartless doctors came to be so inhuman.
Your personal remarks just show frustration in the argument. If the care under review is wrongheaded, harmful, or unnecessary, let the insurance doctor carry the burden of proof before an arbitrator. He has the less knowledgeable and the more conflict of interest position. The assumption is that the denial is self-serving, and not based on patient interest. If he has good evidence for the denial, let this traitor to clinical care persuade a finder of facts in the appeal process. Meanwhile, because the SC supports the clinical decision, it proceeds until denied after an appeal.
I am suggesting civil and criminal RICO charges should be tried, along with claims of insurance bad faith directed at the doctor personally. Because insurance bad faith is an intentional tort, and is not the practice of medicine, the doctor’s personal assets should be claimed. I am suggesting getting injunctions to proceed with the clinician care until the insurance doctor proves his denial has validity, in accordance with several holdings of the Supreme Court.
Reporting to licensing boards is a duty when a doctor comes across unprofessional conduct. Although, nothing is likely to happen, I urge doctors to obey their instincts and consciences if they feel another doctor has acted unprofessionally. Canceling a prescription without the personal examination of the patient is unprofessional conduct. Canceling a prescription without a patient doctor relationship has to be some kind of criminal assault, especially if the patient deteriorates. I would like doctors who have had patients harmed by the denial of another doctor to approach their local district attorneys to see if criminal charges of battery can be brought before a grand jury. This is like turning off a respirator without the consent of a patient. Denying a life saving medication or a diagnostic test, how is that different from pulling out an IV or pulling the plug on a respirator without consent?
While the lawyer has granted the insurance company absolute immunity in ERISA, the limits of other, more imaginative claims should be tested in both civil and criminal charges. Your preposterous arguments would be good questions for many downtown juries across the nation.
The insurance companies are also government contractors, carrying out government functions. They must obey the laws the government must obey. Most of the time the denials are for expensive treatment for dark skinned patients. There is never a dispute over generic drugs for example. So the insurance companies should also be investigated for having a disparate impact on minorities. Their conduct may be a factor in racial disparities in the health statistics.
I have not given this much thought, but it is worth sitting down with a Constitutional law expert to review what recourse short of violence exists.
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