It has become in-vogue for insurance “providers” to contract with a third party company to review (i.e. deny) radiologic studies, such as MRIs, for medical necessity and appropriateness. If they deem that such a study is “not medically necessary,” the process for a physician and patient to overcome it is purposefully onerous and requires a disrespectfully time-wasting amount of phone calls and paperwork.
Approximately one month ago, I saw a 40’s year-old-woman who’s main complaint was knee pain and decreased range of motion. On exam, there was a weird tender lump jutting out from the side of her knee (what I, in medical parlance, described as a “lateral joint deformity”), and I detected some degree of possible meniscal instability on manipulation of the joint. All of this would lead most people with medical training, and some without, to come to the conclusion that an MRI of the knee to specifically examine the soft tissue structures is the appropriate next diagnostic step.
What follows is the phone conversation I had earlier with the third party company involved after fighting with them for four weeks, and subsequently being denied, for the test:
[called main number, on-hold for 16 minutes]
Operator: “Hello, this is xxx, may I have your patient’s account number please.”
Me: “Hi, this is Dr. John Cmar at Sinai Hospital of Baltimore, how are you doing this evening?”
Operator: “Um… fine. You patient’s account number, please.”
Me: [account number given] “I’m calling to appeal a decision for coverage on an MRI for a patient of mine.”
[information is exchanged]
Operator: “I’ll need to locate a Medical Account Manager for you. Please hold for the physician.”
[on-hold for 22 minutes]
Operator: “Um, I’m sorry sir, but it appears that we no longer service insurance company yyyy. I can’t help you.”
Me: “Really? But I’ve been dealing with you for four weeks. When did this change occur?”
Operator: “November 1st.”
Me: “But I have a letter here from you issuing a final denial on November 4.”
Operator: “Yes… I’m sorry, but I can’t explain it. It makes no sense.”
Me: “I agree. So, what’s my next step? Start from square one and four weeks ago, and issue another referral?”
Operator: “That’s as good an idea as any. I really don’t know. I’m sorry.”
Me: “I’m sure you understand this isn’t satisfactory. Do you have a manager I can speak with?”
Operator: “Sure. Please hold so that I can locate a manager for you.”
[on-hold for 18 minutes]
Operator: “I’m sorry sir, but there’s no manager available right now.”
Me: “… really?”
Operator: “Yes, sir, I’m very sorry.”
Me: “Well… thanks for your help, then. I’ll reissue the referral to the insurance company.”
Operator: “Is there anything else I can help you with today?”
Me: “You… have got to be kidding.”
From a purely practical standpoint, that was from ~6pm to 7pm wasted on fighting futily for coverage of a medically indicated study for one patient, that has been previously delayed for four weeks and will continue to be delayed further. For me as a salaried hospital employee, that’s a personal debt in time and energy… but for a private practitioner, that would be a direct loss of livelihood, and for the patient, an inexcusable delay in specific diagnosis and accurate treatment.
I am thankful that it only took an hour of my time. Oddly, however, I happen to have more than one patient.