A few weeks ago, I saw a patient some gastro issues. So far, nothing newsworthy here since I am a gastroenterologist. I ordered a CT scan colonography, a special CT scan that is designed to view the colon in detail. It’s the CT scan version of a colonoscopy. Why didn’t I simply perform a colonoscopy, which, unlike a CT scan, would contribute to my retirement fund? That’s an easy one. Care to take a guess?
- The patient refused to undergo a colonoscopy.
- The patient had no insurance, and I don’t work for free.
- The CT scan was a better tool than colonoscopy to explain her symptoms.
I expect that my discerning readers can identify the correct choice. I ordered the CT scan, which the insurance company summarily denied. I called and spoke personally to the physician reviewer and explained my rationale, but his decision was immutable. I asked if there was additional recourse available to me, and he advised that I could request a peer-to-peer discussion, when I could discuss the case with another physician. I had this conversation today with a doctor, whom I suspect, doesn’t treat living, breathing patients anymore. I felt as if I was talking to a guy who was reading off insurance company cue cards. He projected less humanity than is present in the ubiquitous mechanical utterances of, “Your call is important to us. Please listen carefully as our menu options have changed …”
I will summarize the conversation in the following two bullet points.
Insurance company tool: “We can’t approve the test as you have not provided any objective evidence that there is a problem in your patient’s colon.”
Me: “I agree. That’s why I am ordering the CT scan. If I knew in advance what was wrong with her colon, then I wouldn’t need to order the test. Get my point?”
He then issued denial #2. Had I recommended that my patient undergo a colonoscopy — not the best choice for her — it would have sailed right through. But, for reasons I ask readers to trust me on, this wasn’t the right choice for her. This patient will be seeing me later this month, and I look forward to updating her on how her insurance company’s mission is to protect her health.
If insurance companies care only for profits, then they should at least have the decency to tell the truth. Look the patient in the eye, the person who’s been paying premiums for medical coverage, and tell her that you won’t pay for the test because their box-checking process has determined that it is not medically necessary. What would happen if the patient decided to stop paying premiums because it wasn’t “fiscally necessary”? Since the insurance company denied medical care to a paying customer for care that her own physician believed is necessary, then I assume that they would continue her medical coverage even if she stopped paying her premiums. Should there be one standard at play here? You may start laughing now.
Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.
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