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Old 04-29-2013, 08:57 PM
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Harrison Harrison is offline
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The Insurance Intelligencer
4/29/13

The Insurance Warrior is back, ready to fight for truth and justice ...

Doctors who work for insurance companies

When I needed a complex lifesaving surgery -- one which required special training, skill and experience -- my only question was, "Who is the most qualified surgeon, with the best longterm outcomes?" I assumed that this would be first priority for everyone. I was wrong.

For most patients -- the first question is not, "Who is most qualified?" but, "Who will my insurance company allow me to see?" For me, checking with the insurer about where to go for treatment is like conferring with the fox about how to guard the henhouse.

Patients look to their insurers when making medical decisions. This tells me that the American public believes that ...

• Insurance companies would never be deceptive.
• Insurers have our best interests at heart.
• Insurers are great repositories of scientific and medical knowledge.

One of the powerful ways that insurance companies persuade us of their medical knowledge and good intentions is to employ doctors -- and to use these doctors to interface with both you and your treating physician. Who are these doctors, and what is their real job at the insurance company?

What does a "medical director" direct?

Remember the Ministry of Truth in George Orwell's novel "1984"? It was the propaganda machine that taught the people that war is peace, ignorance is wisdom, and obedience is power. And so it is with insurance companies. Insurance company words always mean the opposite of what they appear to mean.

The denial letter from your insurance company is signed by a "medical director." This title is meant to make him sound very medical and very important. It fools patients, and it fools the most sophisticated doctors. It is meant to create the illusion that an expert and important medical executive has really burned the midnight oil studying up on your requested treatment. After all of this due diligence, he has determined in his infinite wisdom that the treatment is just not safe or right for you. In other words, the treatment which your doctor has requested is either "experimental," or "not medically necessary."

Your doctor has requested the treatment. So the insurer pits doctor against doctor. And their doctor is more important, because he is a "director." Makes him sound like he is in charge of the Mayo Clinic, doesn't it?

Well, guess what? Medical directors don't direct anything. They are the peons of the insurance world. And the denial letters which they sign are boiler-plate, identical, generated by computer. There is no due diligence, the emperor has no clothes.
As a matter of fact, they don't even "direct" their own decisons. A medical director once confessed to one of my helpees, "You will get another denial -- but don't worry about it. As a medical director, I am not authorized to do anything but state the insurance company's position."

Whoa. Think about that for a minute. Your so-called "medical director" is not authorized to reverse denials. Any dealings that you have with him are a waste of time. Most medical directors are part-timers at the insurance company. They simply rent out their name and title -- to be displayed on denial letters.

The peer-to-peer review

How do insurance companies get doctors to give up medical decision-making power -- and to deny based not on medical judgement, but on the wishes of the insurance company? They begin by hiring doctors who are not qualified to render an opinion on the treatment which has been requested. Hey, if the doctor had any knowledge or experience with any of these treatments, they might be tempted to approve them.

99% of insurance company doctors are family practice physicians. Family practice physicians have no particular area of specialization -- and are not experienced in or knowledgeable about the treatments which they deny.

So, when you hear that the medical director at the insurance company is calling your doctor for a "peer-to-peer review" -- he is not a peer, and it is not a review. He is calling to tell your doctor all of the reasons why the insurance company isn't going to pay for your treatment.

The "outside expert"

After the insurance company doctor denies your treatment again, they will send your case to an "outside expert." The insurer will tell you that there is a panel of medical experts at the independent review organization which will carefully examine every aspect of your case.

Newsflash: There are no medical experts, there is no panel, there is no examination.

Our entire medical system ultimately rests on independent review organizations. This is your court of last resort. Guess what? These review orgs are private companies which are not licensed, certified or regulated in any way. They rely on a stable of the most questionable doctors imaginable. Hired guns, as it were.

I once had an "outside reviewer" on one of my appeals for brain surgery. This doctor was supposedly a neurosurgeon. When I searched for him, I found no office, no phone number, no nothing. A current medical license, and that was it. I went on a hunch, and searched his state's Bar Association. Indeed, he had been a neurosurgeon. Not a brain surgeon; he had done back surgeries once upon a time. But it gets worse. Twelve years prior, he had gone to law school. He had been an attorney for twelve years, just keeping the medical license in order to do appeals for review organizations.

*******

When it comes to insurance company reviews -- I have seen pediatricians reviewing complex cancer surgeries, podiatrists reviewing craniofacial surgery. This is not about a good faith effort to review medical treatments. It is about using doctors to create the appearance of medical expertise -- where none exists.

You, the patient, are the only one who can overturn an insurance denial. Win it within the insurance company, before it ever gets to independent review.

Is the reviewer absurdly inappropriate and unqualified to pass judgement on your lifesaving treatment? The more unqualified, the better -- it will be very motivating to your insurer, when you point this out in your appeal.

*****

Dr. Jerome Zacks has been so troubled by the use of doctors as "denial-tools" by insurance companies that he has created a petition. This petition asks Congress to hold insurance-company doctors to the same standards as doctors who treat patients. Take a look, and sign if you want to send a powerful message to insurance companies:

Link to the petition follows:
SignOn.org - Uniform Standard of Care for Physicians

Happy and peaceful Insurance Warrior-ing,

Laurie Todd
health insurance help
__________________
"Harrison" - info (at) adrsupport.org
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
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