Insurance denials: the law of the land

It all started out with Malaysian methimazole, and didn’t end until two highly trained medical professionals sat on opposite ends of a telephone call, scratching their heads and wondering how two digits being transposed could lead to so many problems.

Those two transposed digits caused a thyroid uptake scan to become a bone marrow scan (whatever that is). But look at all it took to get there.

Mystery illness, mystery medicine

It started when a new patient came to see one of my colleagues with a mystery illness, and a medication in a pill bottle with a label in another language.

After figuring out what this medicine was, my colleague planned a thoughtful, step-by-step, appropriate workup to figure out what was going on, how to best take care of this patient.

At each step of the way, she was thwarted.

Everything she ordered was being denied by the insurance company, and they demanded more and more documentation, ultimately requiring her to get on the phone to deal with this in person with a representative from the insurance company’s medical team.

We all deal with this every day, we order a medication, a test, a procedure, and it gets denied, and then we have to work through a series of ever escalating efforts, each one more complicated and annoying, to get our patients the care we think they need.

This is just more of the same, more of the ways we as healthcare providers have relinquished the control of the care we want to provide our patients to someone who really should have no business in the middle of the healthcare of our patients.

Because for them, it’s just business.

Denial is the law of the land

Every few months our patient’s medications change, because their pharmacy benefits manager gets a better deal on a different ACE inhibitor, a different antidiabetic agent, a different pain medicine.

We order home care services, and they get denied. We request an increase in the number of hours to care for an elderly patient who is desperately trying to age in place and stay safe in their home, and it gets denied.

Order some imaging? Doesn’t meet their own guidelines. Denied.

Sometimes these denials make sense. At our institution, when I order an imaging study, a radiologist reviews it and may contact me and change to what they think is a more appropriate imaging study, often engaging in a discussion to help me understand their logic and make sure I’m okay with the change.

When this happens at the level of the insurer, what we often just get is “denied”.

I’m almost always okay if I order a CT scan and an insurance company tells me that an MRI is a much better study and they’ll pay for that one. But for the most part, I want to be able to get to the answer I want, that I think my patient needs, that I think after using my clinical brain is the best course for them. Whatever it takes.

Doctors have little control

Of course, we can have endless discussions about overuse of testing, overusing imaging. There have been convincing studies that have shown that most patients presenting with acute lower back pain don’t need an MRI. And once we see this data we tend to learn our lesson and change our ways.

But this continual denial of the things we order, the services requested for patients, is emblematic of how little control we have on the healthcare we are trying to deliver to our patients.

As you will recall, many years ago there was a scandal with a major insurance company whose in-house policy was essentially to say no to everything that physicians ordered, and then make the process of getting approval so painful that they hoped everyone would simply give up.

I sincerely hope that this does not go on any more, but the responses to our requests often seem so capricious that it feels like the job of the people who are getting these requests is still to just turn them down.

In the case of this mystery patient my partner saw, her initial request was denied, she appealed, again it was denied, they requested she submit records, again it was denied, and when she appealed it went to a peer-to-peer review, where after following a long contorted phone tree she was finally connected to a physician, and that’s when things got even murkier.

My colleague tried to explain why she ordered this test, and the physician on their end kept insisting that the test she had requested was not indicated.

Somehow, in the course of discussions, it came out that they were talking about two different tests.

My colleague had ordered a thyroid uptake scan, looking for a hot overactive thyroid nodule which may have been causing this patient’s problems.

Somehow, through a series of errors, and the transposition of two digits in the computer, the test that the provider for the insurance company had declined was something that they called a bone marrow scan.

What’s a bone marrow scan?

No thinking involved

The most troubling part of this is that it was quite clear from the initial request, the subsequent appeal, and the complete documentation that my partner sent over, that we had no interest in looking at this patient’s bone marrow whatsoever.

And yet the insurance company’s only response was to decline a bone marrow scan.

Never once did they use their clinical brains to say wait a minute, something’s wrong here, why are we denying a test that isn’t even related to what this doctor seems to be looking for.

If I send a request for an MRI of someone’s liver, but it makes it to their desk to approve an MRI of the knee, with the clinical context “history of cirrhosis, rule out hepatocellular carcinoma,” wouldn’t you think that they would be scratching their heads, and maybe pick up the phone and ask me why I was ordering this bizarre test for a part of the body so far removed from the liver?

Our jobs are hard enough, and the lives of our patients are hard enough, our efforts on the path to get them to better place of health so littered with so many barriers, that we’ve got to make things better.

We need to rebuild our systems so that we are the ones deciding what our patients should get. We went to medical school; we trained to diagnose and treat; we have the experience taking care of patients out here on the front-lines.

When I start ordering daily labs, weekly CT scans, screening total body MRIs, or bone marrow scans on all my patients, then I’m willing to take some advice and some gentle nudging, to see the guidelines and recommendations and the standards of care that I may have strayed from.

But otherwise, let me choose the medicines I want them to have, and let me get my patients the tests I think they need.

If you’re not going to give me useful advice, then don’t give me any advice at all.

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home.

Image credit: Shutterstock.com

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