Patients’ Collateral Damage in Physician-Payer Tussles

October 10, 2013

Insurer denials for expensive diagnostics are often caused by physician failure to follow simple rules.

In the ten minutes before a breakfast meeting last week, I learned about how more physician requests for expensive diagnostics are approved and denied than in 40 years in healthcare.

The revelations came from a physician whose job it is to make those decisions on behalf of insurers. The anecdotes were amusing, funny at times, and ultimately disturbing.

For example, demanding approval for a CT with a single-word diagnosis of “headache” and responding to the insurer’s medical director’s request for more information as if it were an affront to the requesting physician’s competency is an exercise in futility, and unnecessarily combative. It happens all too frequently according to my source. The requesting physician digs in for battle, and the patient is left in the lurch.

Conversely, requesting approval for a CT or MRI with an obvious diagnosis from the physical exam isn’t going to get far, and asserting intellectual curiosity is not likely to help. If it has webbed feet, a bill, and feathers and it quacks, you don’t need a DNA test to confirm it’s a duck. Lots of these, too. With already high deductibles and copays, which are increasing under Obamacare, saddling patients with a big chunk, if not all of the bill, for unnecessary tests verges on abusive.

Then, there are the windy, boilerplate EHR notes that are not relevant. “There are ‘magic words,’” he said, “and they earn approvals every time. A few minutes of research on the Internet, and the approval is easy.”

There are rules that have to be followed that this former surgeon, who fought the same battles for years, has come to appreciate. “They actually make sense,” he said. They contribute to the patient’s clinical and financial well-being as well as the insurer's. Nonetheless, all too many physicians refuse to order a few simple and inexpensive blood tests that can indicate or rule out more extensive diagnostics that benefit their own patients, instead choosing to fight, relegating their patients to collateral damage.

“I want to, and am encouraged to…" approve diagnostic testing because it is ultimately in the patient's and insurer's best interest. Early diagnosis, and confirmed diagnosis, is far less expensive to treat than trying to manage undiagnosed symptoms, allowing the condition to progress in complexity.

The problem commonly stems from the perception that someone who has never seen the patient is exercising control or second guessing according to this doctor. Remembering our Shakespeare, Hamlet to be exact, when Queen Gertrude famously said, “The (lady) doth protest too much, methinks,”may have a relevant lesson.

I have little tolerance for mindless rote, and less for insurer shenanigans, but, at least with this sample of one, that is not the case. And especially disturbing at the expense of patients.