Wednesday, December 1, 2010

You're Kidding, Right?

(Another of David's rants about insurance companies)

I've written many times about the absurdities I've encountered dealing with insurance companies.  I've had another experience that I'd like to share.

The patient came into clinic for chemotherapy.  The PA examined him and heard an irregular heartbeat.  Neither of us know the patient well, so we looked through his chart to see if anyone has ever noticed an irregular heartbeat before.  No one had.  We ordered an EKG, and it showed an abnormal rhythm.  The patient has had several EKGs in the past, and this rhythm was a new finding.  One possible explanation for the new abnormal rhythm would be if the patient's central line had moved a bit and was irritating the right ventricle of his heart.  The best way to figure out if that could be happening is to get a chest x-ray to see where the catheter tip is.

We ordered a chest x-ray, only to learn that the patient's insurance company doesn't cover radiology procedures at Johns Hopkins.  Since an abnormal heart rhythm can cause sudden death, diagnosing a cause is an emergency, so we called the insurance company for "permission" to order the x-ray.

You may think this is a "no brainer."  After all, a chest x-ray is cheap, and we could discover the cause of the patient's abnormal heart rhythm and fix it relatively easily.  The insurance company, however, needed to authorize the x-ray.  So I was told the nurse would review the case and get back to us.

Once again, I find my judgment about a case under review by someone with a financial stake in the decision.  In this case, a nurse, sitting in an office in another state, not able to see my patient, was going to decide if my decision to order a chest x-ray was justified.

No.  I'm not kidding.

But if you ask, insurance companies don't make medical decisions, they make coverage decisions.

Related Posts:
Why David Hates Insurance Companies
Not Medically Necessary


Anonymous said...

The cost to have the nurse review your request for the x-ray probably cost the insurance company more than the x-ray itself. Absurdity. And going to get worse I'm afraid.

beadr said...

nice blog, keep posting...

rlbates said...

Shaking my head ........

Dermdoc said...

Have I mentioned how much I love Kaiser lately? It's imperfect, but I don't think I could ever go back to practice outside KP after having worked here.

jerichter said...

Insurance companies are horrible... I am currently studying abroad in Spain and my heart arrthymia get worse and I had to seek treatment here. After finding out it was a ventricular tachycardia that was causing me to faint the doctor I was seeig here (who happend to be one of the best in Europe for this kind of problem)decided I needed an EP study and ablation because meds were no longer working. My study abroad insurance fought againt me tooth and nails to try and get me to to fly back to the states (because once back in the US they would not be responsable for my health care costs). My doctor talked directly to their "doctors" and told them it was ot safe for me to fly back to the states, yet the insurance company phoned me later and lied, saying my doctor had said it was okay for me to return to the states.

They were willing to put my health at risk to avoid paying my health care here that I was entitled to and needed!

Thankfully in the end it all worked out, but not until many complaints and my doctor having to speak to their "medical team" again.

Will FitzHugh said...

so how long did the review take, and what was the result? in giving the insurance perhaps more credit than they deserve, are they doing this because in some cases doctors order unnecessary tests? if that was the case then they're doing this to discourage that. you would think a good insurance company would be able to predict in advance who orders tests with good reason and who doesn't, and focus their reviews on the ones with best chance of finding an unnecessary test. then they'd save money by not doing so many annoying reviews.

Doctor David said...

Will, insurance companies often have what are called "carve outs" for services they find to be expensive. Typically these include mental health services and radiology (and bone marrow transplantation, but for most patients, a BMT carve out doesn't matter so much). A carve out means that those services can be delivered only at a finite number of locations, smaller than the number of locations where other services can be delivered. The company will have negotiated a lower reimbursement rate, which is what drives the process. Many of my patients can get chemo at Hopkins but can't get scans here. Although this may not sound onerous since, in theory, scans can be put on CD and uploaded for us to see, in practice the lack of standardization means about 1/3 of such studies can't be uploaded onto our system. Obviously, this directly impacts patient care if I can't see their scans and my radiologists can't read them for me.

In this particular case, since the patient's insurance company has a radiology carve out that excludes Hopkins, any imaging needs to be done elsewhere or approved by them to be done here. The good news is that they approved the x-ray. The bad news is it took 2-3 hours and sucked up half an hour of my time that would more productively have been spent seeing cancer patients rather than discussing the need to get an urgent x-ray with a nurse in another state.

Dermdoc... one day I can tell you how difficult Kaiser can be for complex patients like my BMT patients. But that's a rant for another day. They, at least, will subsidize housing for my patients who come from out of state for a BMT, something many other companies will not do.

Atlanta Plastic Surgeon said...

This is ridiculous though.There is not remedy either,a doctor who is regularly checking the patient would definitely know better and has to be given better respect for that.The insurance companies can drive us crazy sometimes.

Indian Medic said...

seriously that must've sucked.
Those dingbats should not to be given the right to make such potentially life or death decision.

Nice blog by the way. lots of interesting thoughts.
Keep up the good work.

viagra online said...

Can you give me an explanation about the first chart please ?

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