MD Whistleblower

Last week, I opined about a decision by Anthem to deny paying for Emergency Room (ER) care that it deemed to be non-emergent.   My point was that insurance companies should not be obligated to pay for routine, non-emergent care, recognizing that we need a fair and reasonable method to define a medical emergency.    In my view, payment should not be denied to a patient who reasonably believes he needs ER care, even if the symptoms are (hopefully) found to be innocent after a medical evaluation. For example, if a patient develops chest pain at 10 o’clock p.m., and is worried about an acute cardiac issue, he should call 911.   If the ER determines that chest pain is simple heartburn, it would not be reasonable for Anthem to deny payment for this ‘non-emergent’ condition.    We’re all a little smarter after the fact once we know the outcome. Some medical complaints, however, are never medical emergencies.   If you want ER care for a runny nose, a cough or a sore knee, and you proce

We live in an era of demonization.   Political adversaries are not opponents, they are villains.   Commentary that contrasts with our views is labeled ‘fake news’.    Presumption of innocence?   R.I.P.   Civil discourse has become a quaint memory.   Why would one debate respectfully when today’s tactic is to talk over and demean your adversary?   On the morning that I prepared this post, I read an article reporting that one of Ohio’s largest insurance companies, Anthem, is denying payment for non-emergency care provided at emergency rooms   (ERs).    In my view, this article was slanted, unfairly tilting away from the insurance company, an easy target to attack.    I think that a typical reader would conclude that the company was greedily trying to claw money away from sick customers.   An anecdote was offered describing a denial of payment for emergency care for abdominal pain that did seem improper, although there were no medical facts provided. I felt that the journalist did

Reasonableness is like pornography - hard to define, but we know it when we see it.  (with a nod toward U.S. Supreme Court Justice Potter Stewart.) It’s interesting how folks classify themselves on the political spectrum.  Most individuals regard themselves as moderate, independent and reasonable, regardless of their views and positions.  Try asking an extremely  partisan political conservative how he classifies himself and you will hear terms such as ‘family values’, ‘mainstream’ and ‘pro American’.   A politician on the far left is more likely to describe himself as ‘Progressive’, rather than as a 'liberal fanatic'. The point is that unreasonable people believe that they are reasonable. I read an account of an episode that occurred last week in Cleveland that hinged upon the legal meaning of the word reasonable.   A 16-year-old boy with various allergies joined several friends at an expensive restaurant.  Without providing advance notice to the restaurant, the young man

In our practice we have an open endoscopy system, as do most gastroenterologists. This means that other physicians – or patients themselves – can schedule a procedure with us without seeing us in advance for a consultation.  Of course, we are always pleased to see any of these patients for an office visit in advance, but many patients prefer the convenience of accomplishing the mission in one stop.  This is reasonable for patients who truly need our technical skill more than our medical advice. Our office screens these procedure requests in advance to verify that no office visit is necessary.  While this process works very well, it is not infallible.  There have been times when a patient arrives to our office poised for a colonoscopy with accompanying medical issues more complex than we had expected. No vetting procedure is failsafe.  Have you seen the TSA statistics when they are tested in identifying dangerous items hidden in luggage?  Even though our trained personnel vet the

In our society, there are absurdities that simply defy reason.   In the past week or so, I have read about an individual who was denied the ‘right’ to bring a peacock on board a plane for comfort.   Just this morning, I read of a women who was cruelly denied to fly with her comfort animal – a hamster.   Readers are invited, if they dare, to use their preferred search engine to discover the tragic denouement regarding this hapless hamster. 'Let me comfort you.' * If a person needs a peacock, a snake, a pig, a kangaroo or a pterodactyl for airborne support and comfort, then perhaps flying is not for you.   The rest of us have some rights also.   Rent a car. The medical world has its own exhibits in the Theater of the Absurd.   Here’s our latest performance. Our medical practice received notice last week from The Centers for Medicare & Medicaid (CMS) that we owed the federal government money.   Apparently, according to federal brain trusts, we had billed a

Since the infamous memo released this week by the chairman of the House Intelligence Committee has taken up so much oxygen, other newsworthy events were relegated to a lower priority by the media.  In my view, many of these second tier issues deserve Page 1 coverage, but our media in general has decided that potential or actual scandal must lead their coverage.  Can anyone defend, for example, the prominent and repeated coverage that Stormy Daniels has received?   If CNN received a lurid videotape of Stormy and the president on the same day that North Korea declared that it wanted to denuclearize their country, which would be the lead story?  The editors would be agonizing! Tell the truth, would your rather be reading about Stormy?* A bombshell announcement in health care came this week when when 3 titanic corporations stated they aimed to reform health care coverage from within.  Amazon, JPMorgan Chase and Berkshire Hathaway will combine their resources, ingenuity and

How often do we read or hear, “I have a right to …”   Everyone wants to have his rights respected.  Gun owners, prisoners, civil libertarians, union members, non-smokers, protesters and ordinary citizens all want our rights to be validated and respected.  What happens when the exercise of my rights encroaches on yours?  It is these questions that occupy much of our judges’ time and attention.  These are not easy calls to make.  The fact that so many of our Supreme Court decisions are decided by a 5-4 vote indicates that these issues are controversial, complex and vexing. While we all pride ourselves here in America on our individual rights, these may be at the expense of our community’s rights.   I don’t envy societies such as China or Russia where the state’s rights are paramount.  But, there is no consensus, even here, as to where to draw the line between protecting an individual and society at large.  Consider how vigorous the debate has been on the tension between protecting i