Sunday reruns

It's been 2 years since I put this up, and I must say that one (but only one) of the insurance companies I deal with has significantly improved in that time.


I'm not taking sides in the health care debate, but I do want to clarify something.

I see people on the news screaming that they don't want "bureaucrats" between them and their doctor, and are afraid that's what government health care will bring.

WTF? THAT'S THE WAY IT IS NOW, PEOPLE!!! I hear my assistant Annie on the phone all day trying to get approval from non-government insurance companies for tests, medications, physical therapy, ANYTHING that I order.

Look at your insurance card. Doesn't it say things like "in-network" and "formulary"? Who the hell do you think came up with those? Not us docs. Dat be dem dere byoo-row-kratz!

Look back at some of my posts (like this, or this). I routinely have medications (both brand name and cheap generics) and tests refused by insurance companies. For an excellent commentary on this from the pharmacy side, this was written by FranticPharmacist.

So if you don't want bureaucrats between you and your doctor- TOO BAD. They've been there for years. THE ONLY PEOPLE WHO DON'T HAVE THIS PROBLEM ARE PAYING CASH FOR EVERYTHING!

In fact, for those of you who don't want the government running this, THEY ARE ACTUALLY ONE OF THE BETTER ONES TO WORK WITH! Just ask Annie. Medicare doesn't question the majority of my tests, or meds. Yes, they don't cover everything, nor should they, but they don't fight with me over stuff like MRI's on stroke patients. Uncle Sam (unlike Aetna, Cigna, Humana, and many others) tends to leave these things to the doctor's discretion. Annie prefers Medicare patients for this very reason - they make her life easier.

So what happens to you the way it works NOW, with your non-government insurance?

You come to me for some neurological issue, which requires further work-up. So I order, say, an MRI and MRA of your head.

Annie gets the order, and calls Bozo Insurance, Inc. (BII) to schedule it. BII refuses, saying they want more information. So they fax us a 5 page "pre-auth" form, which Annie spends 20 minutes filling out and faxes back. Then they say the form wasn't enough, and they also want copies of your office notes, so we send those, too (yup, when you joined BII you agreed that they can read your medical records).

So a few days go by. BII will claim they never got our fax. Or that we filled the form out wrong. Or that they don't cover Capricorns when the moon is in Pisces. And we don't know this until Annie calls back after a few days, because they're hoping we forgot about it.

Eventually they'll deny the whole thing, on the grounds that you don't meet criteria for an MRI and MRA. This decision is usually made by a non-medically trained person with a minimum of a GED. They do this because they want to see just how badly I want the test.

So they tell me I can appeal this via "peer-to-peer" review. Which means I need to personally call their "physician reviewer" to argue with them as to why I want the study.

So, during my insanely busy day at the office I have to call them. I'm promptly put on hold for 10 minutes, before finally reaching the reviewer. This person is a doctor- but NOT necessarily in my specialty. In fact, it's usually something like a retired dermatologist, who hasn't done neurology since medical school in 1938. Or an OB/GYN who hated his job, and is doing this now instead. Or some doctor who immigrated from Lower Swazbodiaczk and can't get a U.S. medical license (but your insurance company hired him to decide what medical care you need). But it's almost NEVER someone actually in my field, who might understand why I want the study.

So after telling your life history to Dr. Denial, one of 2 things will happen. They'll deny both studies, and want you to try medication or physical therapy or psychotherapy or holistic reflexology or whatever, and if you fail that THEN I can try to resubmit a request for the test. OR they will flip a coin and say they will cover the MRI, but not the MRA. Or vice-versa. They'll say that if the first test is fine, THEN I can start over trying to get the other covered. Maybe.

And many of these companies actually pay these "reviewers" bonuses based on HOW MUCH MONEY THEY SAVED THE COMPANY BY DENYING TESTS.

This can at times become comical. One of my patients is a doc who works part-time as one of these insurance company "physician peer reviewers". And when he needed an MRI, guess what? HIS OWN COMPANY DENIED IT! He paid out of pocket for it (and yes, it was abnormal).

So how did I get on this tangent? Because yesterday I was walking by Annie's office, and heard her losing it over the speaker phone. And, as always, she was totally awesome.

Annie: "I'm calling because you people denied an MRI on a stroke patient?"

Pinhead: "Before we discuss this, I have to inform you that this is a recorded line."

Annie: "Oh, good, hopefully someone will actually be listening to me then. Thus far it hasn't happened."

Pinhead: "Let me look up the tracking number... Okay. I have to inform you that we are unable to approve this study. Your doctor will need to make a peer-to-peer call."

Annie: "Oh, now THAT's a surprise."

Pinhead: "What do you mean?"

Annie: "Is this line really being recorded?"

Pinhead: "Yes. It's to improve customer satisfaction."

Annie: "Oh, goody, because I'm sure not satisfied, and neither is the doctor, or the patient. Your company, and whoever is listening, never approves anything. In fact I can say that 100% of the time you require peer-to-peer review."

Pinhead: "We do this to save our customers money on unnecessary testing."

Annie: "Okay. Then let's just stop wasting each others time. Forget the intake coordinator, forget you. Since your only job is apparently to tell me that my doctor needs to call your doctor, couldn't your company save money by firing you?"

Pinhead: "Um, I hadn't..."

Annie: "Think about it. You have benefits and a salary, right? I mean you're not doing this as a volunteer job, are you?"

Pinhead: "No, but I..."

Annie: "So wouldn't your company save money by firing you and instead getting a computer that automatically denies every damn test and sends a fax telling us to call for a peer-to-peer review? Then we can just let the doctors talk directly to each other from the beginning, which is what you bozos want anyway. Think of the money saved by cutting all of your jobs."

Pinhead: "Oh, but you can't mean that?"

Annie: "Oh but I do mean that. And I'm glad we're being recorded. Let's consider the current situation. You are basically a worthless automaton. A computer could do your job for far less. And at this point you've incurred the wrath of all the medical professionals in the country as well as the patients. You and all of your superiors ought to be out of a job due to your blatant inefficiency. And don't think we don't save your denial forms, and your names, and document it all in the chart."

Pinhead: "I..."

Annie: "Nothing personal you understand, just a suggestion. I'll have my doctor call your doctor. Have a nice day".

Pinhead: "No, wait! I..."

Annie hung up.


So bottom line here: if you don't think bureaucrats are currently between you and your doctor- THEY ARE! GET REAL! IT'S BEEN THAT WAY FOR THE LAST 10 YEARS OR MORE!