Who are the physicians that make the decision to deny care?

A phone conference had been arranged.  They wanted to talk to me about a denial for payment on a portion of a patient’s pre-authorized procedure after the fact.   Its participants: the regional medical director of a large insurance company, his female assistant administrator, and me.

He cordially introduced himself as a pediatrician by trade from a large well-known (and highly respected) academic institution with impeccable credentials responsible for our region of the United States.  It was clear we must remain professional.  I listened.  I was told there are proper ways to discuss claim denials – proper steps to follow – websites to consult.  We all must follow protocol.

Yet I had just learned by separate letter that my second request for the claim approval had already been denied.  I mentioned this.  It was unfortunate, but I was assured the the claim was re-reviewed by a specialist in my field.  Remaining professional, I wondered silently if that specialist still practiced. Then I pleaded my case once again on the phone to no avail.  I would have to submit my patient’s claim a third time to an “independent” centralized reviewer, quietly please.

So I hung up and another letter was drafted.  This time a highlighted copy of our guidelines was included for  review.  “Standard of care,” I thought, as if that would matter.  Guidelines for care mean little for payment when they are trumped by corporate policy directives.

We’ll see.

* * *

For unclear reasons, a few members of our own traditionally underpaid or politically well-connected physician tribe are elevated  to work for insurance companies. Who can blame them?  Decisions must be made and who better than one of our own?  Whether a medical director of an insurance company or a member of an Independent Payment Advisory Board, these individuals must be carefully chosen. They must believe with all of their heart in the process.  They must believe the siren song that helping people achieve their “best possible personal health and wellness” rightfully sidelines the real-life costs of care that patients endure through no fault of their own.  Most of all, they must never, ever, speak of the money.

Then they are crowned the guild-masters, the rest of us, mere journeymen.  To them, it’s about clipboards, corporate policy directives, and cost savings.  To the rest of us, clinical reality.  Increasingly, we we will be finding ourselves facing these modern-day Inquisitors – where principles for the “common good” supersede the needs of the commoner.

Medical decisions made by email, phone or fax.

No faces, please.


Wes Fisher is a cardiologist who blogs at Dr. Wes.

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  • http://twitter.com/darbsnave darbsnave

    In Fahrenheit 451, firemen made fires. They did not put them out. Count me as odd, but since then I have always felt that the line between making fires and putting fires was very thin. Fahrenheit 451 made sense to me.

    Similarly, the line between providing care and denying care is also very thin. Who’s to say that, after another turn of the screw, doctors won’t be the ones who deny care, instead of people who provide care? As Dr. Fisher relates, there are doctors who already feel comfortable in the role of denying care, on pretty flimsy grounds.

  • Rob Burnside

    Very well-written and very disconcerting, Dr. Fisher. How easy it is to “pull the trigger” from a safe, electronic distance. Bless you for going back a third time. Your patients are fortunate, indeed!

  • buzzkillerjsmith

    Pts are not able to pay for a lot of expensive care out of pocket, so third parties have to pay. That means corporations or the government. Neither are especially warm and fuzzy, to docs or to our patients.

    I loathe health insurance companies, always have. They are parasites.I don’t loathe the government, but my neurology friend in CA tells me that MediCal (CA Medicaid) pays him $19 for a followup level 3 visit. Scylla and Charybdis.

    • kjindal

      medicaid in NY is not much better. Only a couple of years ago an acute visit to see a medicaid pt in a NY nursing home setting paid $7.50!

  • Homeless

    I wonder who the doctors are that provide $210 billion of over treatment.

    Why is the one that says it’s not necessary wrong?

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      People throw numbers like this one out there, and then repeat them often enough until they become accepted truth. There is no evidence that Americans, on average, see doctors or use hospitals more than people in any other countries. Sure, there are a handful of particular expensive tests and procedures that are used more here than in other places, and there may be some doctors that order more stuff here and there, but is this a systemic problem?
      In another thread here there is mention of amputations. The surgeon indeed gets only a few hundred dollars, but the hospital gets tens of thousands more, so yes an amputation does cost as much as the President said, only it is not the doctor that “benefits” from that.
      So when we talk about over-treatment and “waste” in general, perhaps we should look at where the money is really going, and in this case where the money is staying, and ask why it is that we are willing to transition clinical decision making, from patients and their doctors, to entities that are in this solely for the cash.

      • Cris

        Well said, Margalit Gur-Arie.

      • Homeless

        If recommending unnecessary tests and procedures isn’t a problem, why does the Chose Wisely campaign exist.

        • LeoHolmMD

          All sorts of things can be framed as “waste”. For instance doing colonoscopy on all sorts of people with nothing wrong with them. A bunch of unnecessary procedures, right?

        • PoliticallyIncorrectMD

          So do the ghost hunters…

  • disqus_mmpOofx73c

    Thank you for this article. I’ve been on a quest to procure a hearing aid accompaniment (FM system) for my son, and was denied twice so far, by doctors who haven’t had the slightest training in audiology or any related subject. And yet, they have the authority to deny my son the ability to hear his teacher.

    • trinu

      If you have the money, you might want to look into hiring a lawyer, or just getting a lawyer friend to call them.

      • disqus_mmpOofx73c

        Thank you, we are actually working on that right now. So far we haven’t gotten anywhere; at the end of the day we will spend more on lawyer fees than the actual cost of the FM system.

  • drgh

    yes it is frankly chilling. the insurance is impervious. No MD or patient can get through to them and they take as long with their decision as their guidelines allow. No matter. And the doctor to doctor conversation is meant to wear down the ordering MD so they will never want to order that again and go through that all again.
    What is especially remarkable is that there is a catch phrase that a procedure is experimental. now it amy not really be “experimental”. I personally was denied for these reasons. What was odd is that they had previously authorized it and it had been successful. But the start of a new year they decided it was experimental this year. I guess last year it was not experimental. Furthermore, the success rate was 75 percent and has been around for well i would say at least 10 years so i am not sure where they are coming from. It almost like the movie Casablanca when they say “round up the usual suspects”.
    It is chilling that i would say they have so much power and are above the law far removed from the actual clinical situation. I am sure this is costing lives. That is the real cost.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    I usually ask the denying medical expert what states he is licensed to practice medicine in. If in fact it is not my home state then I conduct the Department of Professional Regulation and my state board of medicine and claim he or she is practicing without a license. You would be surprised how quickly you get service. If the physican is licensed in your state complaining to his county medical society and state board of medicine works wonders as well

    • LeoHolmMD

      Are you serious? This works? Inappropriate denial of care is totally out of control. I thought about turning some of these insurers in to the state Board of Insurance.

    • kjindal

      Yes I have gone a similar route: once I have the name of the physician-administrator I’m speaking to, I can quickly google their state & license #. I alert them that I’m documenting our discussion in the patient’s record, with their credentials noted, and if applicable, the fact that they’re a pediatrician deciding against, e.g., inpatient cardiac stay for my adult patient.
      This works too. And the more civil and cordial the discussion (ie. passive agressive), the more satisfying it is.

      • southerndoc1

        Adding that the patient’s lawyer has requested this information is frequently helpful.

  • buzzkillersmith

    Slightly off topic, but an interesting experience.
    Today we had a woman come talk to us about a detox center that opened up. There’s a chain of these apparently, based back east.

    They only take opioid cases and alcohol detox and the opioid cases have to have titrated down to a sufficient level. No meth, cocaine, benzos. Inpatient therapy for 3 to 5 days.

    How lovely to skim the cream, right up CorpMed’s alley. Profits to be made, as with the insurance companies.

    Meth and cocaine are quite messy, but a little Librium or Ativan and the alcoholics perk up quite nicely and then they’re out the door. There might or might not be any community followup. And she warned us quite sternly that sometimes pts that we dumb family docs try to detox as outpatients actually do somewhat poorly! Nice of her to tell us that. Apparently an outpt opioid taper is something that even we fools can manage.

    This woman wasn’t a doc, wasn’t a nurse.

  • http://www.dpsinfo.com LaurieMann

    I always remember the story of a little boy with chronic leg pain. They did a test or two and couldn’t figure it out. The boy’s mother kept pushing for one more test, and she was denied. It turned out the boy had bone cancer, and, luckily, “only” lost his leg.

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