Insurance denies pt’s therapy: because the insurance company guidelines are out-of-date

AITA for Pointing Out to the Insurance Company That I’m the Expert on My Patient?

https://www.medscape.com/viewarticle/976690

I (48, F) had to do one of those “peer-to-peer” calls with an insurance physician (undisclosed-age, M). I know, it’s a commonplace task now, what’s the big deal, etc., but let me explain.

From the start of the conversation, tons of red flags. First of all, he won’t tell me what specialty he is. And I’m like, “Okay, that’s kind of weird, but can you at least tell me if you’re an oncologist?” Then he asks, “Why does that matter?” So I say, “It matters a lot because I’m an oncologist and this is about a person with cancer. It’s literally a matter of life and death because your insurance company denied their cancer treatment.”

He finally says, “No,” he’s not an oncologist.

“So then, what’s your specialty?” I ask.

He clears his throat and says he isn’t allowed to say. Then he reminds me that this call is being recorded for quality assurance purposes.

“Excellent,” I say. “Then it’s being recorded that you’re the one obstructing my patient’s access to lifesaving treatment.”

Then he says there’s no reason to be rude and calls me “Miss.” I ask him to please refer to me by my title of “Dr,” and he drops the “Miss” but instead starts using my first name as if we’re old friends or something.

At this point, I’m not making any progress in getting my patient’s medication approved, so I let the first name/untitling go and ask him to explain why the insurance company denied the medication (let’s call it X).

I hear him shuffling papers, and then he says it’s because we didn’t try medication Y yet.

I tell him it’s correct that medication Y used to be the standard-of-care first-line therapy, but as of 6 months ago, the FDA approved medication X as the more effective therapy. I explain to him the insurance company guidelines are out-of-date. Any board-certified oncologist would know this. Which he, inconveniently, is not.

Then he tells me there’s often a lengthy delay in updates to company guidelines, which he can’t control. To which I respond, “That’s why I, as the patient’s doctor, should be in charge of what treatment is approved,” not him or the insurance company.

He says he doesn’t disagree with me, but it’s not in his power to approve it. Because the company hasn’t updated its guidelines, I’ll have to talk to an oncologist at the insurance company to get an override.

It seems obvious to me it would have made more sense to do that in the first place, but in the interest of time, I keep this comment to myself and tell him, “Fine, please transfer me to their oncologist.”

Then he says, “Oh no, I can’t do that. You’ll have to set up another phone call.”

At this point, I’ve had another patient in an exam room waiting for over 15 minutes so I ask him to please hurry and set that up.

I hear papers shuffling again, and he says they can set me up for that phone call at 4:42 AM the next day.

When I ask for a more reasonable time, he says because they’re in a different time zone, that’s all they can offer, and if I don’t take that time, then my patient’s case will be closed, and I’ll have to start all over with the appeal from the beginning — which means talking to someone like him again.

Because there’s no real choice, I take the offered time. The following morning, the insurance oncologist immediately approves medication X.

So AITA for pointing out that if the insurance company had trusted that I, as a board-certified oncologist, was doing the right thing for my patient from the get-go, we could have saved everyone a lot of time and frustration (and sleep)?

Their response? “This call is being recorded for quality assurance purposes.”

One Response

  1. I question whether these doctors who are denying treatments, imaging, etc., have ANY experience at all! I think they are fresh out of medical school (if they are really a doctor), plus, they are going strictly by scripts written for them to read from the policies of the insurance company and don’t take into consideration any extenuating circumstances (so not treating the patient as an individual and instead they are using a one-size-fits-all policy). They don’t read the supporting documentation the doctor sends with the request for a PA for sure!! They will deny something due to xyz but if they had read the documentation, they would see that xyz had already been done! I have so many examples but won’t bore you with them. Also, at least Anthem BCBS no longer allows additional documentation to be sent or a peer-to-peer review for many of the denied PA’s (especially for imaging requests, even if previous imaging, an EMG, etc., showed a serious problem)! The SECOND STEP after denial is an appeal now and if they make the same mistakes (not reading the documentation, etc.), with the appeal, then the case is closed! They also aren’t following the rules on the amount of time allowed to come back with a decision on the PA’s! I recently waited 6 months for a PA on a CT scan (despite previous tests showing serious issues & my current problem was causing intractable pain and numbness)! It’s time these insurance companies are reported and if enough people do this, maybe they will finally get fined enough that they will be more reasonable!

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