The doctor at Carecore who issued the denial was not a radiologist or surgeon. She was a family practice physician who had graduated from a Mexican medical school about 5 years ago. She was board-certified in family practice, but from what I could tell, she had never worked as a primary care doctor, but had only worked for the insurance company. And she was able to override the opinion of my ENT, who’s on the faculty of a medical school and has been doing surgery for 20 years.

I informed the HR manager at my company of this chain of events. The manager was unaware of Carecore’s practices. I’m not certain what, if anything, the manager did about this.

I was able to work out the situation by telling the radiology technician who did my neck scan, what my problem was. She said that they always got some of the upper chest even with a neck scan, so she’d see what she could do. Luckily, my ENT was able to see what she needed from the (extended) neck scan. Problem solved.

Companies like Carecore aren’t hiring radiologists. They’re hiring bargain basement doctors with so-so backgrounds.

The refusal to pay for an expensive procedure, known to be out of the reach of the patient’s ability to pay, is the same as the cancellation of a procedure. That is the practice of medicine. Canceling an order or prescription is the same medical act as writing one.

That cancellation may have been done 1) without a direct exam and history of the patient; 2) by someone less qualified than the clinician to decide, either by training, experience, board certification, or knowledge of the specific patient; 3) by someone without a license in the state of the patient.

I would be interested in testing the filing a licensing complaint against the doctor reviewer and against his supervising medical director (for suborning and failing to restrain the unauthorized practice of medicine) every time a procedure or prescription is denied. The complaint could be for unauthorized practice of medicine. If the reviewers are licensed in the state, but of a different specialty, the complaint might be for unprofessional conduct in the form of clinical decision outside one’s scope of competence. If the reviewer has the same specialty and the proper state license, then the complaint might be, being a disruptive physician by interfering with the care of patient the doctor has never met.

From the AMA’s CEJA (Ethics) Report:

“(1) Personal conduct, whether verbal or physical, that affects or that potentially may affect 43 patient care negatively constitutes disruptive behavior.”

From line 42 here:

http://www.ama-assn.org/ama1/pub/upload/mm/369/ceja_2a00.pdf

If I were the doctor working for an HMO, I would require lawyer representation, at HMO expense, for any licensing matter. If I have 100′s of complaints lodged against me in many state licensing boards, carefully crafted by knowledgeable peers, and none is frivolous, there is some chance one will stick.

I am also interested whether treating doctors can bill their standard fees for forensic (medical-legal) work for the time spent on pre-auths, minute by minute. Then, bill the insurance company since the time was spent for their benefit, in an implied contract, and to avoid their unjust enrichment from theft of professional services. When they refuse to pay, try to take them to small claims court. As corporations, they may be required to hire a lawyer to defend themselves.

Lastly, patients suffering from second choice, cheap care should complain to their employers about the insurance company, without revealing details of the medical condition. The employer is the customer of the insurance company, and is likely the most influential party of all.

Any report of the result or the real world experience with such responses would be appreciated. None of these responses complain about damages to the patient, nor do they sue for denial of care, something immunized by ERISA, and upheld by the Supreme Court.