Wednesday, March 20, 2013

Our New Inquisitors

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.   It's 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.




Dan said...

I'm not a doctor, but "a denial for payment on a portion of a patient's pre-authorized procedure after the fact" sounds like they authorized the procedure, then afterwards decided not to pay for it. Surely they can't do that, can they? How could they possibly justify that? Isn't it, say, theft of services?

DrWes said...

Dan -

Check your policy. Almost every insurer out there requires pre-authorization of services for elective procedures and has a clause (like this one, for instance) that says something like: "Preauthorization ensures that care and services will not be denied on the basis of medical necessity. However, preauthorization does not guarantee payment of benefits. Benefits are always subject to other applicable requirements, such as preexisting conditions, limitations and exclusions, payment of premium, and eligibility at the time care and services are provided."

Hope that helps.

W.O.R.M. said...


What a travesty that you should have to plead and beg to be justly compensated for work that you performed and was pre-approved (fine print stipulations aside, as noted in your comment to Dan).

This is just one example of physicians being steamrolled by large, politically connected entities grabbing for a bigger piece of the healthcare dollar "pie". In part, a consequence of organized medicine's fragmented and impotent leadership. Let's not even mention antipathy from the government and legal profession.

DEMAND an independent review. You might just get a fair shake. As Ed Koch said, "You punch me, I punch back.I do not believe it's good for one's self-respect to be a punching bag".

Call upon your "inner engineer", with his well honed critical thinking skills to formulate and articulate a convincing argument as to why the procedure was appropriate and deserving of compensation. Don't give a second thought to the "impeccably" credentialed medical director. Odds favor him as a typical former [information] spoon fed medical student who would be hard pressed to think his way out of a paper bag. Give'em hell!

Anonymous said...

When a family member ended up in ER recently, it was a brand new world for all of us. When the bills rolled in, they had all been submitted to the secondary first instead of the primary. Hours of phone calls later, that was " fixed" and all bills were resubmitted. Then came the big surprise. Some MD from the insurance company deemed the patient's hospitalization for her brand new, never before experienced heart event as " medically unnecessary." Although we were told not to pay the hospital, that is was THEIR responsibility to justify the treatment, I was livid. That hospital and staff had put my family member back record time and with little waste that I could detect. Of course, I sat down at once and wrote a two page narrative of the patient's pristine medical history and subsequent change in health status. I don't know if that helped the hospital to get paid quickly. But a. it made me feel that I had helped in some way and b. it made me sad to think of all the frail elderly and the poorly educated in our country who are overwhelmed by insurance paperwork, stipulations, jargon, and shenanigans.

CodeMonkey said...

Two things to think about
(from a medical coder/biller)
1) Let the patient know they are on the hook for the medical care. Once they know how expensive it is, it becomes a major incentive to live a healthy lifestyle. (as one of my MDs told a pt. "you can buy a lifetime gym membership for half the price of one CABG.)
2) Point out how cheap their current insurance company is, and if possible, investigate other carriers.
(bonus: If a carrier does this twice to one of our MDs, we drop out of their network. Why be in network if they won't pay us?)