Medical Testing in the Era of Insurance Certification

This morning I started out writing an entirely different blog post but decided to go another route after a painful episode with an insurance company, namely United Healthcare. Why yes, if you read my blogs, this is the same insurance company that denied my patient an antidepressant medication that is the only one in its class. This is the company I tried without success to discuss their rationale with a medical director. However, today was a radiologic procedure I wanted on a patient and was subsequently “invited” to talk to one of their physicians to get approval for it. Does this strike anyone else as odd that I can be essentially “ordered” to talk to one of their doctors but none of them will return the courtesy of my phone calls?

In the last six months medical insurance companies have become increasingly resistant to allowing physicians to order certain studies without certification by them. If you insist that the patient needs the test, then you must have a “peer-to-peer” review in which justification of your need for the test must be made to one of the company’s physicians.

As documented in many studies, there are a lot of unnecessary tests that we physicians order for a variety of reasons. Those include liability concerns, patient requests, and concern that you might be missing a rare disease process. Recently the Foundation of the American Board of Internal Medicine developed recommendations from several medical specialty groups regarding tests or treatments which doctors should question the necessity of before ordering, in a document called Choosing Wisely.

I absolutely agree that we, as a healthcare system, are ordering too many tests. The insurance companies way of dealing with the problem is to have a majority of tests, particularly expensive ones, “certified” before they will agree to pay for them. Today I had two of them that apparently did not fit someone’s algorithm and needed a “peer-to-peer” discussion. Sighing, I called the number listed on the fax paper request from United Healthcare. Dutifully I hit #4 as instructed. This didn’t work immediately because a 30 second introduction had to be finished before option “4” could be chosen. Finally I got through and was instructed to key in the case number. Twelve numbers later, it repeated the number back to me and told me to press “1” if that was correct. Then I got a real person. Up to this point I was OK with how much time I had wasted but the real person on the line was not a doctor. It was someone who wanted to know if I was a doctor and if the patient’s name was so-in-so and if the procedure ordered was a such-in-such. Affirming that was the case I was put on hold. About five minutes later I began to seethe.

Have you heard how primary care physicians are inundated with patients, how we don’t have time see the patients that we have much less makes sure all our refills are done, referrals letters read, referral letters sent, prescription prior authorizations done, patient lab work reviewed as well as keep up with CME (continuing medical education–you want me up-to-date, right?), patient emails, and any other business of healthcare? Every afternoon there are a minimum of 75 charts to be gone through, lots more on Thursdays (because I take off on Wednesday) and Mondays look like a truck backed into my office and dumped the charts onto the desk, chairs and credenza. Don’t even make me think about when I come back after vacation. Well, apparently United Healthcare thinks responsible patient care involves me sitting and waiting on a phone for one of the “peers” to pick it up and determine if my ordering is within their guidelines. This is not something I’m willing to do–so my question to my audience is–should I be willing to? Is this now another part of my job and is it a reasonable thing? Please input, I’d love to hear. 

Please remember that the opinions written in this blog are entirely my own.

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