Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

How an insurance company auditor tried to destroy a physician’s career

Niran S. Al-Agba, MD
Physician
February 6, 2019
7K Shares
Share
Tweet
Share

It’s no secret that in today’s health care market, insurance companies are calling the shots. As a pediatrician in private practice for almost two decades, I’ve seen insurance companies transform into perhaps the single most powerful player in today’s health care landscape — final arbiters whose decisions about which procedures or medications to authorize effectively end up determining the course of patient care.

Decisions made by insurers, such as MassHealth, have arguably killed patients. But it was only when I got caught in the crosshairs of an insurance company auditor with a bone to pick that I fully appreciated their power to also destroy physicians’ careers.

My nightmare began around two years ago, when my late father, also a physician with whom I was in practice, and I opened our Silverdale clinic on a Saturday. It was the start of flu season, and we’d just received 100 doses of that year’s flu shot. Anxiety about the flu was running high following the death of a local girl from a particularly virulent strain of the virus a year before, and parents were eager to get their kids immunized as soon as possible.

Under Washington law, adults don’t even need to see their doctors to get flu shots. They can get them at Walgreens, directly from pharmacists. But because children under nine are more susceptible to rare but life-threatening allergic reactions, they must be immunized by a physician. This meant that, for convenience sake, parents often scheduled their kids’ annual checkup on flu shot day, thus allowing them to condense much of their routine care into a single visit.

That particular Saturday went off without a hitch, with my father and I seeing and immunizing around 60 patients between the two of us over a 12-hour day.

Three months later, a representative from the insurance company requested to see some of the patient charts from that flu clinic as part of an audit. Aimed at rooting out insurance fraud by cross-checking doctors’ records, these audits have become a routine fixture in medical practices today. To incentivize their auditors to ferret out the greatest possible number of irregularities, and thus boost the corporate bottom line, auditors work on commission, being paid a percentage of the funds they recover.

The auditor in charge of my case failed to turn up any irregularities in our documentation. But, still, she issued a stern admonition to my father and me, ordering us not to open our clinic on Saturdays to administer flu shots.

This struck me as an outrageous restriction, considering our clinic is a private entity where we set our own hours and schedule accordingly, and so I called the auditor. But instead of backing down, she ratcheted up her rhetoric, saying she was also forbidding me from examining my patients before immunizing them; clearly a bid to save her employer even more money. I was shocked. Her directive amounted to practicing medicine without a medical license — which is, of course, illegal in the state of Washington and many other states across the nation.

I shot back that immunizing infants and small children is a serious undertaking, requiring proper caution and care, informed her there was no way I would be complying with her mandate. Following this brief exchange, she took it upon herself to report me to the Medical Quality Assurance Board, the government-backed body charged with shielding the public from unqualified or unfit doctors. The accusation levied against me? Not following an insurance company mandate which, in her opinion, amounted to unprofessional conduct.

It didn’t matter that the charges against me were ludicrous. The potential consequences were only too real, and potentially catastrophic. Had the State Medical Board decided against me, I could have lost my license. I hired a lawyer, sinking more than $8,000 into legal fees. I was cleared last month by a unanimous committee vote. But other physicians facing similar situations may not be as lucky.

The 18 months of excruciating stress that followed my altercation with the auditor made it patently clear that insurance companies wield far too much power. Bureaucrats are making life-and-death medical decisions without a single minute of medical training, and their auditors are terrorizing physicians, by coercing state medical boards to act as their henchman. Unfettered by any consequences for enforcing policies that fly in the face of rules protecting patient safety, insurance companies will continue to harm doctors and patients alike if no one can stop them.

Niran S. Al-Agba is a pediatrician who blogs at MommyDoc. 

Image credit: Shutterstock.com 

Prev

Practice at the top of your license: What does that really mean?

February 5, 2019 Kevin 0
…
Next

How can we really stop obesity?

February 6, 2019 Kevin 5
…

Tagged as: #Instagram, Pediatrics, Practice Management

Post navigation

< Previous Post
Practice at the top of your license: What does that really mean?
Next Post >
How can we really stop obesity?

More by Niran S. Al-Agba, MD

  • Is there hope for COVID with home visits?

    Niran S. Al-Agba, MD
  • A tale of two epidemics: COVID and obesity

    Niran S. Al-Agba, MD
  • Delivering health care at a retail clinic isn’t something to be proud of

    Niran S. Al-Agba, MD

Related Posts

  • A physician’s addiction to social media

    Amanda Xi, MD
  • Pursuing a career as a physician: A reminder why

    Sangrag Ganguli
  • Understanding professional liability insurance in physician employment contracts

    Elizabeth Shubov, JD
  • What is the application process for physician long-term disability insurance?

    Bob Bhayani, MBA
  • How social media can help or hurt your health care career

    Health eCareers
  • Here’s why health insurance is different from other insurance

    Joseph Crisp

More in Physician

  • The power of self-appreciation: Why physicians need to start acknowledging their own contributions

    Wendy Schofer, MD
  • Skydiving and surgery: How one doctor translates high-stress training to saving lives

    Alexandra Kharazi, MD
  • Don’t be caught off guard: Read your malpractice policy today

    Aaron Morgenstein, MD & Laura Fortner, MD
  • The dark side of medicine: an urgent call to action against greed

    Don Gaede, MD
  • Dr. Glaucomflecken for president!

    Aaron Morgenstein, MD & Amy Bissada, DO & Corinne Sundar Rao, MD
  • What is driving physicians to the edge of despair?

    Edward T. Creagan, MD
  • Most Popular

  • Past Week

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Healing the damaged nurse-physician dynamic

      Angel J. Mena, MD and Ali Morin, MSN, RN | Policy
    • The struggle to fill emergency medicine residency spots: Exploring the factors behind the unfilled match

      Katrina Gipson, MD, MPH | Physician
    • What is driving physicians to the edge of despair?

      Edward T. Creagan, MD | Physician
    • Deaths of despair: an urgent call for a collective response to the crisis in U.S. life expectancy

      Mohammed Umer Waris, MD | Policy
    • Beyond the disease: the power of empathy in health care

      Nana Dadzie Ghansah, MD | Physician
  • Past 6 Months

    • The hidden dangers of the Nebraska Heartbeat Act

      Meghan Sheehan, MD | Policy
    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
  • Recent Posts

    • The power of self-appreciation: Why physicians need to start acknowledging their own contributions

      Wendy Schofer, MD | Physician
    • The endless waves of chronic illness

      Michele Luckenbaugh | Conditions
    • Skydiving and surgery: How one doctor translates high-stress training to saving lives

      Alexandra Kharazi, MD | Physician
    • Telemedicine in the opioid crisis: a game-changer threatened by DEA regulations

      Julie Craig, MD | Meds
    • How this doctor found her passion in ballroom dancing [PODCAST]

      The Podcast by KevinMD | Podcast
    • Surviving and thriving after life’s most difficult moments

      Rebecca Fogg, MBA | Conditions

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 54 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Make the Diagnosis: This Bump on His Nose is a Tricky Diagnosis
  • CRT Regimen Boosts Complete Response Rate in Unresectable Vulvar Cancer
  • Fla. Doc Charged With Murder; McConnell Exits Rehab Facility; BPA on Store Receipts
  • FDA Faults Next-Gen Olympus Duodenoscopes
  • CDK4/6 Inhibition Active in Recurrent Low-Grade Serous Ovarian Cancer

Meeting Coverage

  • Ankle Sprain Physical Therapy Doesn't Shift the Pain Elsewhere
  • Use of EMR Directive Tied to Reduced Opioid Prescribing After Spine Surgery
  • CRT Regimen Boosts Complete Response Rate in Unresectable Vulvar Cancer
  • CDK4/6 Inhibition Active in Recurrent Low-Grade Serous Ovarian Cancer
  • Switch to IL-23 Blocker Yields Deep Responses in Recalcitrant Plaque Psoriasis
  • Most Popular

  • Past Week

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Healing the damaged nurse-physician dynamic

      Angel J. Mena, MD and Ali Morin, MSN, RN | Policy
    • The struggle to fill emergency medicine residency spots: Exploring the factors behind the unfilled match

      Katrina Gipson, MD, MPH | Physician
    • What is driving physicians to the edge of despair?

      Edward T. Creagan, MD | Physician
    • Deaths of despair: an urgent call for a collective response to the crisis in U.S. life expectancy

      Mohammed Umer Waris, MD | Policy
    • Beyond the disease: the power of empathy in health care

      Nana Dadzie Ghansah, MD | Physician
  • Past 6 Months

    • The hidden dangers of the Nebraska Heartbeat Act

      Meghan Sheehan, MD | Policy
    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
  • Recent Posts

    • The power of self-appreciation: Why physicians need to start acknowledging their own contributions

      Wendy Schofer, MD | Physician
    • The endless waves of chronic illness

      Michele Luckenbaugh | Conditions
    • Skydiving and surgery: How one doctor translates high-stress training to saving lives

      Alexandra Kharazi, MD | Physician
    • Telemedicine in the opioid crisis: a game-changer threatened by DEA regulations

      Julie Craig, MD | Meds
    • How this doctor found her passion in ballroom dancing [PODCAST]

      The Podcast by KevinMD | Podcast
    • Surviving and thriving after life’s most difficult moments

      Rebecca Fogg, MBA | Conditions

MedPage Today Professional

An Everyday Health Property Medpage Today iMedicalApps
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

How an insurance company auditor tried to destroy a physician’s career
54 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...