(Snippets from the frontline)
Holding ‘denied’ accountable
Doctors are trained to make medical decisions caring for patients. If something goes wrong, they are responsible for their decisions.
These days, an insurance company physician might overrule your doctor’s decision and deny care.
I have a California license to practice medicine, and should I develop a pattern of making wrong decisions, the state Medical Board can revoke my license. Decisions made by insurance doctors though are by law considered “utilization” and not subject to review by the Medical Board.
So if a neurosurgeon feels an MRI of the brain is necessary, but an insurance physician denies the study and later the patient has a tumor, that insurance doctor is off the hook.
Who really needs brain surgery here?
Gene Uzawa Dorio, M.D.
Is it possible to rate companies regularly in this regard? H
I see both sides of this dilemma almost daily in either my business or personal life. As a employee benefits professional who helps companies solve their healthcare problems, we advocate on behalf of patients with insurance companies, physicians and pharmacies. Although there is no easy answer and every situation is different, medical protocols and insurance guidelines are intended to be in the best interest of the patient. The challenge is generalities do not fit every specific instance.
Not all “insurance doctors” are the same. I am one of them and my associate and I try to work with the PCPs to help them practice in a cost effective way. In this day of commercialism and widespread advertising of medications on television, some of our PCPs have requests from their patients for the “latest and greatest” drug they saw advertised on TV. New drugs are sometimes not any better than established ones, but they are always more expensive and sometimes exceedingly so. It is hard for many practitioners to say “No” to their patients so they let us do it for them. I would always call the prescribing physician to talk about the situation before denying a prescription which I think is a good practice and promotes the concept of cooperation rather than obstructionism.
If the patient complains, they have the right to file a complaint, and contrary to what Dr. Dorio says, if my decisions were overturned by the insurance company on a regular basis, I would be fired. The Department of Managed Care also oversees our process and denials are looked at carefully. A pattern of inappropriate denials would result in a penalty for the healthplan and possible disenrollment.
I find my medical treatment and the refill of my long term medications are being controlled by utilization review doctors and they are denying my treatment and medication. Thank you for writing this. Patients are as frustrated as the doctors