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.

View 20 Comments >

Most Popular

Get KevinMD's 5 most popular stories.