Who Knows Best: Third Party Payers or Physicians?

June 3, 2011

Certainly physicians are not all-knowing and there are times when the needs of the patient does not correlate with the assumptions of the third party payers, namely the insurance companies.

As I reflect on yet another busy week in private practice, I can say that this week was not too bad. To start the week off, we had a holiday on Monday as our nation honored our past and present men and women in service. On Thursday, I took the day off to go with my nine-year-old daughter's class on a field trip to the zoo. 

However, the days in between were above average in terms of the amount of time that I have spent in dealing with third party payer rejections and non-approvals of orders and medications for my patients. Certainly physicians are not all-knowing and there are times when the needs of the patient does not correlate with the assumptions of the third party payers, namely the insurance companies. I will describe three instances (out of many) in which the insurance company's red tape forced my staff and myself to spend extra time in getting approvals of tests, prescriptions, permission for inpatient length of stay increases, etc. and ultimately my patients all had excellent outcomes.

A 65-year-old male complained of dyspepsia and was prescribed the appropriate proton pump inhibitor on his insurance formulary last year. When his symptoms did not improve over the expected time course, a medication change was requested and ultimately rejected. The patient went on to have negative laboratory testing, negative diagnostic radiology testing, and had an initial EGD that showed diffuse erosive gastritis and duodenitis. When the prior authorization was completed and the peer-to-peer discussion with a physician reviewer was completed, the medication change was approved. The patient went on to have a follow-up EGD recently that showed complete resolution of the prior gastritis and his symptoms are completely resolved. The patient would have had the endoscopy anyway, but my point here is that he was uncomfortable for an excessive period of time while I jumped through the insurance company's hoops to get the medication approved that I prescribed for him.

A 40-year-old female recently admitted to the hospital with symptoms of biliary dyskinesia and ultrasound showing a small gallstone with HIDA scan showing a 3 percent ejection fraction. She ultimately went on to have a laparoscopic cholecystectomy and her symptoms have completely resolved. However, she was very sensitive to the effects of the anesthesia given and when she was not able to spontaneously void after two days post-op, I had to contact her insurance company to get their permission to keep my patient in the hospital an extra day to insure that her symptoms resolved appropriately. Complete nonsense!

A 55-year-old male complained of persistent low back pain. He had minimal degenerative changes on his lumbar films and had progression of pain radiating into his right posterior thigh with numbness. When I ordered an MRI of the lumbar spine, his insurance company rejected and asked me to send him to physical therapy first. I politely objected and asked for a peer-to-peer review and pleaded my case for suspecting a possible lumbar disc herniation. This was rejected and my patient politely went on to PT as requested. Of course his symptoms did not improve and when he came back for his follow-up visit, a second attempt was made to get approval for the lumbar spine MRI. It was finally granted and the patient was found to have a large right sided posterolateral disc herniation with compression of the thecal sac. He was then referred to neurosurgery and had a wonderful outcome with his surgical decompression.

I have described only three cases out of several in which the insurance company's direction of treatment allowed or permitted did not adequately resolve my patients' problems. Of course there has to be cost saving measures employed. However, there are many other cases like these in which we as the physician complete our history and physical examination and then formulate the appropriate plan based on our assessments.

I think the insurance companies need to appreciate and understand the decisions we make for our patients, because at the end of the day, the decisions are for our patients' best interests and outcomes.