Sunday, April 1, 2018

The Joy of Appealing a Medical Insurance Company Denial

A few weeks ago, I saw a patient with some gastro issues.  So far, nothing newsworthy here since I am a gastroenterologist.  I ordered a CAT scan colonography, a special CAT scan that is designed to view the colon in detail.  It’s the CAT scan version of a colonoscopy.  Why didn’t I simply perform a colonoscopy, which, unlike a CAT scan, would contribute to the Whistleblower 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 patient is a ‘cat lady’ and loves all things CAT.
  • The CAT scan was a better tool than colonoscopy to explain her symptoms.
Playing Cat & Mouse with Insurance Companies

I expect that my discerning readers can identify the correct choice.  I ordered the CAT scan because it was the best option for the patient, which the insurance company summarily denied.  I called the insurance company (always a fun and amusing exercise) and spoke personally to a 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.  My suspicion was that this doctor no longer treats living, breathing patients.  He seemed to be 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 CAT scan.   If I knew in advance what was wrong with her colon, thenI 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.

Comments invited. 


7 comments:

Anonymous said...

It's just terrible that a physician (you) spoke to another physician (at the insurance company) and there is this disagreement.

My guess is a CT scan costs less than a colonoscopy? Is there EBM to support your case?

Did the insurance company physician recommend another test instead of the CT colonography? How does the insurance company expect you to identify the cause of your patient's symptoms and then treat it?

Some of these questions are obviously rhetorical.

Terribly frustrating!!!

Jason Hemming said...

Nothing more frustrating than the dreaded P-P, though I’ve gotten most of the buzzwords down. That being said, I’m curious as to the details of the case where a CT-colon would be the best diagnostic option (other than sedation concerns when compared to a regular colonoscopy)

Michael Kirsch, M.D. said...

A few scenarios where CAT scan of the colon might be preferable.
(1) Prior colonoscopy was very difficult.
(2) Looking for narrowed regions which may be more obvious on CAT scan. (Severe narrowings would be seen will on either study.)
(3) Pt wants a lower risk test of the colon.
(4) No driver needed as no sedation required.

Thanks, Jason, for your comment.

Brian L. Gustin, C.P. said...

Michael, before your initial request did you review the insurance policy your patient (or employer) purchased to understand what the Limitations and Exclusions were? Did your documentation note all or some of those bullet points you pointed out, which ruled out a colonoscopy? If you did then you have an argument. Most of us in healthcare do not and become frustrated at the process. However we must realize insurance companies sell a product/service, just like we do. Those products/service (policies) have parameters, which then allow them to price those products/services, just like we do. They want to make sure they are not providing and paying for something outside of the parameters their customer (your patient) paid for, just like we do. I certainly am not trying to be an apologist for the insurance industry, but I do understand the process as it exists today. Frustrating? Yes, but it is what we have until we cause change to happen. First, we need to understand the difference between who the customer is and who the client is. Generally speaking the customer is the insurance company, they write the checks to pay us and the client is our patient; they receive our services but do not necessarily pay us, except once the main customer pays. IF we want to treat our patient and get paid we need to understand the needs, wants, and desires of our customer first. Only then can we treat our client, the patient. Learn to crack that code and your life will be less frustrating with payers. Find ambiguities in their policy language and exploit this to your advantage. After all, an insurance policy is nothing more than a legal contract, and ambiguities are construed against the party who wrote the contract. It is scenarios such as yours ACO's were created; essentially allowing payers and providers to collaborate on how best to serve the patient and at the same time be mindful of cost.

Michael Kirsch, M.D. said...

Brian, thanks for your thoughtful client. Your approach may make some sense in an academic world, but certainly not in the reality of everyday medical practice. Consider you opening recommendation to me: "...before your initial request did you review the insurance policy your patient (or employer) purchased to understand what the Limitations and Exclusions were?" Is is reasonable, Brian, for me the doctor to be requesting and studying insurance co legalese documents? I'm a doctor, not a lawyer. How would I get through the day? I think your well meaning piece of advice in that sentence, and in your response, indicates a wide chasm between a legalistic universe and the planet that I inhabit. I appreciate your point that there is a list of covered benefits and that insurance co's are businesses. However, this is difficult to apply to medicine which is practiced with artistry and judgment, hard to quantify. We are not selling assorted widgets that are easy to measure and price. In addition, when HMO's used to be popular, they would seek approval for all kinds of diagnostic testing. My understanding is that it didn't save $, but only frustrated physicians and patients. MK

Brian L. Gustin, C.P. said...

Michael, I get it. My suggestions are not why we got into the healthcare field but unfortunately before either of us can practice our "artistry" we have to deal with how do we get paid in order to continue helping people. I, and many in my field, have had to add administrative overhead to understand those policies. Most policies are similar so have your staff read a few of the major payers; they can give you, the clinician, the Cliff Notes so to speak. As a way to lessen the overhead burden perhaps you and some other colleagues could share this expense; just a thought. Spending a bit of time on the front-end of the interaction saves a boat load of time doing multiple appeals on the back-end. You are correct, the HMO's didn't save a dime and increased the frustration level for all, but the ACO model may have some traction. The ACO model, for the first time, allows payers and providers to establish benchmarks of cost and care quality. This is where you can have some direct impact on changing the mindset of the payer based on your years of experience and judgement. Providers must understand payers and payers must understand providers and all must do so with the patient experience in mind.

Vince said...

This happens every day across the nation and will go on a limb and argue some brokers, advisors, consultants or cost containment, entities in the pursuit of saving the plan money may attempt to portray the author as engaging in "over utilization" "greedy" or just wrong on medical necessity. I would also argue if most physicians understood rules and regulation that govern this profession, this would not and could not happen, while I am aware of the perception this may be a difficult or futile effort, I still hold out faith. In regards to the question raised on why insurers are not transparent to their real goals of profits before people I argue those who do not understand this are blind or in denial.

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