I have to admit it: I'm a little biased.
While I am sure that from time to time, insurance companies are presented with authorization requests for services that are either inappropriate or not medically necessary, these type of requests are in the minority. I also am aware that sometimes insurer guidelines can help a patient get appropriate care, and that insurance companies are not social service organization that can operate at a loss.
However, I am writing here to document how, with increasing frequency, health insurance companies are delaying and denying care in a manner against common sense medical judgment. These denials, which are made to favor profit margins, and which go against the recommendations of the treating physicians, are made to the detriment of patient health outcomes. Though I will show on this webpage selective cases to illustrate this abusive and inhumane behavior of insurers that I am seeing as a provider, I am also writing to hopefully instill in patients and healthcare consumers a degree of anger and a will to appeal and fight back. Regardless of what anyone else says, my experience as a physician has taught me:
--As for-profit businesses, the insurance company serves their shareholders, not patients or doctors.
--The insurance company superpower is SHAMELESSNESS.
--In reality, insurers are never penalized for their bad behavior.
--Due to insurer ability to influence politicians, there is no political will to change anything.
--For health insurers, preventing care is much more profitable than providing care.
--Insurance contracts are "take it or leave it" deals, leaving patients with no power.
Here is a video essay from NY Times from 3/14/24: "Medical Injustice Disguised as Paperwork," about the onerous process of prior authorization, used by insurers to deny care and inflate profits.
Every year, I spend more time fighting ridiculous and inappropriate denials and insurer delay tactics than ever before. I am not alone in my impression that health insurer policies reduce access to care.
I’m seeing more instances where the patient is being thrown under the bus by the insurance company at their most vulnerable time, when they are sick and hurting. Additionally, many patients are reluctant to complain about their inappropriate treatment for fear of losing their coverage altogether, despite the poor quality of their coverage. For the examples below, I feel certain that if the patient were the friend or family of an insurance executive, when it comes to providing timely and effective care, would also find that the denials and delays of the insurer, who has de facto control of healthcare (not the doctors!!), would also find the situation unacceptable.
It seems to me, as noted by this article I found online, that regarding insurance companies, "their job is not to pay for healthcare, but to avoid paying for healthcare. It is a terrible system.” There is an inherent conflict of interest, since for every bandaid or aspirin covered by a for-profit insurer, there is less money for them. And they need the money.
I am sharing challenges I have had in getting care approved for my patients with examples below. Though due to HIPAA regulations, I can’t share all of their details, but all the patients involved in the cases I mention would be glad to corroborate how insurers denigrated the quality of care they received, and how care was delayed or denied, all inappropriately. Also, I have learned that the patient is not actually the client of the health insurance company. The client is the entity paying for the policy, which in most commercial cases is the employer, or for government coverage, state or federal government, with thoughts echoed in this enlightening video about why health care customer service is so bad: they don't need to care about patients.
Apparently, the only basis on which to sue a health insurance provider would be on a contract dispute, and the terms and agreements for any person signing for insurance coverage are so heavily weighted towards the insurer that these suits almost never are filed. And like with justice, medical care delayed is medical care denied, and the insurer saves bundles by avoiding medical expenditures.
Probably I need to just be quiet and accept that what is occurring here is the new world order. Just as this video shows how Amazon with their near monopoly of online sales is driving up prices with unfair practices, and exorbitant drug prices are caused by another layer of middlemen called pharmacy benefit managers, what is more obvious to me over the last few years is that the corruption has become an inherent element of the entire healthcare system. Despite having the most expensive health care system, the United States ranks last overall compared with six other industrialized countries. I guess we DO have this shining example of American exceptionalism.
Given that the business model of insurance is to take in premiums (their income) and then have as little outflow of money as possible (their expenses), insurance companies are highly incentivized to be as obstructive as possible in order to maximize their profits. Just by their administrative involvement, care is delayed processes, and quality is compromised. The insurer has de facto control of what happens to patients, which means that they are practicing medicine without a license. And, due to healthcare insurers being able to contribute essentially unlimited amounts to influence lawmakers, I have little hope that things will change.
However, I at least want to be clear about what I am seeing as a provider. We are not fighting on a level playing field, and the other side that is willing to use unethical and immoral techniques in their battle to gain larger and larger profits for their involvement in the delivery of healthcare, even stressing hospitals. More and more, when I see patients staring back at me asking how their care can be denied, I share my impression that the insurer could not care less. I often share my thoughts that we are not dealing with respectable adversaries.
Here is another article with a corroborating opinion that when insurance is running the show, both doctors and patients lose.
So, here are the new rules:
The insurance company is your doctor, and they could not care less about what happens to you.
(Though this page is quite long, and probably should be a book or e-book, I'm sharing here my anger about how poorly patients are treated these days in the intersection of capitalism vs caring. Spoiler: caring loses. While I would like to think that some change will be coming, or that there's hope for improvement, these days with those in Congress more concerned about getting viral social media exposure, and with politicians always needing money (institutional corruption), our leaders instead just keep kicking the can down the road.)
🙁
If you bought a car, or a large appliance, or anything really, you would want to have a sense of the quality of the product you are buying. Is this car going to stall in the middle of the highway? Will this refrigerator need to be replaced in two years? All reasonable questions, but with insurance products, not the case. By design, what they are selling, which is the opportunity to participate in a contract (written by them, to favor them) is so complex and vague that it's essentially impossible to understand. Plus, which patient knows what kinds of conditions are going to afflict them in the future?
Maybe a solution would be to have more clarity for patients who would be consumers of insurance products to know that they are buying. I would like to have a hope that a government agency will make them accountable for selling faulty insurance products. Then again, it would be interesting also to see pigs fly.
I recall generations ago, car accidents more often than not caused significant injuries. Ralph Nader, American lawyer and consumer advocate, published his book in 1965: "Unsafe at Any Speed: The Designed-In Dangers of the American Automobile" As a result of his exposition of the problems with American cars, change did occur. There was pressure on Congress so that safety standards were made mandatory. Translation: cars had to have seatbelts and lives were saved.
While I would like to think that maybe a basic standard could be implemented to allow the doctors to be the doctors, so that patients could actually get care in a timely, appropriate, and cost efficient manner, I think we live in a different world now. Insurance companies with their lobbyists (and the effects of their donations on politics) are too strong. According to this article, healthcare insurers as a whole spent $713.6 million lobbying federal policymakers in 2020, compared to $358.2 million in 2000. Norms are gone, members of Congress have to spend a disproportionate amount of time raising money, and many of our leaders spend more time trying to be social media stars than working on any common sense policy. We live in a world where we can't agree even who is the president. For all intents and purposes, there is no penalty for insurers to conduct themselves in an immoral and inappropriate fashion, and therefore their first priority is profits. I have examples below of how insurer actions degrade the quality of care.
At a minimum, the healthcare insurance marketplace would be improved if there were more clarity about what insurance products patients might be purchasing, as even the names are deceptive. I have a great example with an insurance product that, due to its poor quality coverage, has been losing favor with providers in Georgia, despite the great sounding name:
Ambetter. Look at the happy people on their webpage! Should be great, right? You even fell better saying the name!!
However, I have a whole webpage where I document my frustrations with this super low quality insurance product: drwolgin.com/ambetter.
On this page (drwolgin.com/ambetter), I have details of the tremendous amount of push back and obstruction I faced to get approval for a patient who was getting paralyzed due to her spinal condition. I literally had to go on Twitter just to get a response, and the total time required between myself and my staff, time on hold, time writing letters, no less than six hours:
Other examples: I would see a patient for back pain. I would order physical therapy (PT). Ambetter denied the therapy. I would see the patient back and since they had at least access to some exercises on my website (drwolgin.com/lumbar-exercises-core-strengthening), and since they are getting worse, I ordered an MRI.
Ambetter denied the MRI...because they hadn't had PT.
It's a perfectly hermetically sealed system! Insurer takes in money, then denies any expenditures that could cost them money! And they can't be sued! Beautiful!!
I agree with what one patient said to me after having nearly everything denied, “they should be called AmWorse.” Though this company is widely known to provide very little coverage to patients I have seen, at least we can feel relieved since their CEO made over $13M last year, and they can still find the money to advertise at Nascar events. Apparently, I am not alone with my frustrations with this company as apparently as of July '23, a class action lawsuit was filed alleging Ambetter has a pattern of racketerring and a scheme to defraud its customers across 26 states including GA.
If the plans were appropriately named, the consumer could make an informed choice. Ambetter? AmWorse? Wouldn't it be more honest if the patient presented for care, and right on the card, it said something like "Garbage Insurance."
At least having an appropriate name would be a good start. This company is one example of marketing that is not honest.
Bottom line/Summary: with details below, due to the actions of the insurer's subcontractor Carelon, hired to "optimize" (i.e., deny) care, due to the denials and delays, this patient not only suffered unnecessarily for a prolonged time, but also had a clinical result that is below community standard, which is essentially insurer-induced malpractice, all of which could have been prevented by timely treatment (blocked by insurer).
Though a spinal bone was involved, the end result is no different than allowing any other fracture to heal in the wrong position, when timely treatment could have prevented a poor outcome. Most frustrating:
The insurer can't be held liable for the negative impacts of their non-justifiable decisions.
Patient LH (MRN 370340, BCBS insurance) was on her riding lawn mower 10/22/23, and a large tree branch weighing about 60 lbs fell on her. With the deforming force on her lumbar spine bending her forward in fraction of a second, she sustained a compression fracture of the vertebral body of T12 as noted in this schematic to the right -->
(and with her actual X-rays below)
Though not every compression fracture requires surgery, and though the patient did not have any neurological deficit (weakness or sensory changes of the legs or genitals), one of the indications for more aggressive intervention is intractable pain. Since the location of the fracture is between the stiff thoracic spine (the spine region stabilized by ribs) and the mobile lumbar spine, practically everything this patient would do would aggravate her pain.
One of the commonly used treatment options (and for which LH was a candidate) is a minimally invasive surgery called kyphoplasty, with a schematic of this procedure to the left. The patient is put to sleep, and through two small incisions, one on right and one on left, done with X-ray guidance, a needle is placed into the bone, through which a balloon is placed that will increase the height of the compressed bone. The balloon is removed, and then bone cement is placed in this area created by the balloon. This cement looks like toothpaste when it is introduced, but is a quick drying plastic that hardens in about ten minutes. Usually, much of the height of the compressed vertebra is restored, and the patient has immediate relief. Despite the risks, this surgery very often results in a happy patient.
As a surgeon, I don't sell surgery, and I note that the only guarantee is no guarantee, and that there are risks. With all these warnings, LH chose surgery. Even with pain medications, she found the pain intolerable.
Consider for a minute the subjective state of intolerable pain. Though we cannot cure everyone's pain, in this situation with a T12 compression fracture, the options are physical therapy (PT), medications, and sometimes bracing. If you have a broken bone, how much is PT going to help, especially when any movement aggravates her pain? In fact, none of these treatments were giving any relief. As an illustrative example, imagine you had a clamp on your finger, or a vice on your head, and you couldn't get it off. Do you think you'll be able to get any rest? Can you ignore it? You would likely go to great efforts to get the pain relieved, and for LH, the cause of the pain was right in the middle of her spine.
Appropriately, the patient was offered kyphoplasty, so we submitted the request for the surgery. I'm sure you can guess the answer:
Denied.
We appealed, and I had a chance to speak with their physician reviewer, a neurosurgeon, and explained the situation. At the beginning of the call, he noted that he could not reverse the decision (umm, so why are we talking??). However, he stated that he totally agreed with my plan, but that her particular policy had guidelines which included a “carve out” (sorry, we don't cover that!) for spinal trauma. Unbeknownst to apparently the patient, her husband (whose employer purchased their insurance), the benefits manager, and the branch the husband's city government employer handling benefits, none were informed that the "guidelines" of her insurance plan had an exclusion for spinal trauma.
I asked, since this physician reviewer is on the inside, can he start the appeal process? Get this: No. Not only couldn't he start an appeal, but he directed me to tell the patient to start that process by calling the number on the back of her insurance card. So, yes, here is a patient, LH, in intractable pain, who now gets an opportunity to go through the phone tree and endless time on hold and being shuttled around, and being told that the recommendation for surgery was "not medically necessary," that "the doctor's office had not submitted adequate documentation," (not true) that I was both in and out of their network (I am in), and any number of other reasons why the surgery could not be done.
I am not making this s*%# up.
There is a lot to unpack here.
--First, I am reminded again that insurance companies subcontract or outsource the dirty work of saying "no" to patients by hiring companies to do their medical benefits management (MBM). These companies "manage" the care with one common theme: delay or deny as much as possible. Like a mafia Don hiring out the dirty work to a hit man, insurers hire these MBM companies to say "no." Just to clear up any confusion, since I have been in practice since '93, never once has an insurer had a suggestion to actually help a patient. Like a one year old, they have learned the power of saying "no," and by definition, these insurance companies literally could not care less about the patient. For this case BCBS uses a company called Carelon to do the dirty work of the (inappropriate) denial. (I mentioned above about how an insurance company Ambetter who does their best to deny everything. Ambetter uses a company called Turning Point, and with their criteria here, since any submitted medical records have to meet all their criteria, which happen to be written to find something wrong with any case, since all medical records have to meet all of the criteria outlined on two pages, this other MBM for example technically can deny every case.)
–If the case reviewer spinal surgeon can't apply common sense medical judgment to a clinical situation, and approve a treatment, why was I even talking to him? Unless proven otherwise, the insurer was paying a surgeon to tarnish his own MD credentials to recite to me the rationale for denial with which their own reviewer even disagreed (below-standard care produced by insurer denial).
–If the insurer has a carve out or exclusion for spinal trauma, how was the patient supposed to know this detail? Was the purchaser of the insurance plan (the patient’s husband’s employer) made aware of this deficiency in coverage when they decided which plan to purchase? Did they say to their employees that they have great coverage, but just don’t break your back!! I'm sure that tucked into the fine print was language noting that they would follow "guidelines," but which patients know what conditions they will get, or have the bandwidth to ask for an research the guidelines? And would Carelon even give them out? I have asked, and they would not share them with me, and I even understand medical things!
--How is the failure to disclose gaps in medical coverage not deceptive marketing by the insurer?
–The neurosurgeon reviewer referred to the word "guideline," but even that word is a lie. Since apparently, the application of medical judgment is prohibited to get past the "guidelines," and since the insurer has de facto control of medical care and is practicing medicine without a license, a more appropriate word would be the "laws" of medicine.
–How is it appropriate that the patient has to start the appeal process, when she is not medically sophisticated, and in intractable pain? Could the insurer be more obstructive? Would they think this recommendation would be appropriate if LH were their sister or mother? Does the insurer have more information than I do, given that I am not only seeing the patient in front of me, but have to be held to a community standard of care? Again, could the insurer care any less? Time being of the essence? They couldn't care less. How is this activity not illegal?
Wait, there is more to the story.
One of the issues with compression fractures at the thoracolumbar junction of the spine is that the alignment of the spine changes...for the worse. When viewed from the side, the center of gravity of most people is over their hips. If you put a bend in the spine, the center of gravity moves forward, basically putting the patient at risk of a lifetime of pain from the backside (posterior) muscles working harder and working overtime to keep the patient upright, to correct what is/was, when treated properly, a correctible problem. However, with the care being denied by their MBM Carelon, the for-profit insurance company demonstrates their conflict of interest, with their priority being on preventing medical care.
During the time that the patient's surgery was denied, she did in fact become more deformed (kyphotic = increased forward bend) at the T12 segment. This deformity could have been avoided or at least mitigated.
When the patient returned in December with the increased forward bend, kyphosis, we requested the surgery again, and again, surprise!!...it was denied. I asked our surgery scheduler to demand an expedited escalation of this case to a practicing spine surgeon.
I had on 12/19/23 a chance to do a peer to peer with Dr. AC, neurosurgeon, for Carelon MBM. First I had to assure whether he had the ability to apply common sense or could change the denial and initially he did not answer. He noted that the previous denial was because the patient had not had 6 weeks of therapy. (For the record, this explanation for the denial is not true. As noted the denial was that they excluded spinal trauma.) Since the option for actual appropriate care was in the hands of this reviewer, I did not want to argue, but the six week delay was not the reason given to me, nor has LH been able to tolerate any therapy. Simply, the insurer delayed any care for an additional six weeks (of patient suffering). Either way, I explained the situation and we were able to get an authorization number.
Should I be thanking the heavens that I as a spine surgeon can actually help a patient with spine surgery? Can I actually be the spine doctor on this spine case? Apparently, in this one hard fought moment, yes. And also apparently, I am being again taught that regarding medical decision making, the rules have changed.
But wait a minute: The plan as a carve out for spinal trauma, but now they are approving a case for spinal trauma? The approval goes against their own internal logic. How is this delay not purely bad faith?
I shouldn't have to be doing this, but I left this comment in the medical record of LH: "I also have to state for the record here in case there is any third party review, the delay by the insurance company was excessive, inappropriate, and caused unnecessary suffering. I strongly believe that if any of the personnel from the insurance company were subjected to this standard of delay and obstruction, they would find it unacceptable and would agree with my opinion. Clearly, profit over patient for the insurance company."
For the record, officially, the stance of the insurer is “Doctor, you can do whatever you want, but we’re just not going to pay for it.” Convenient for them, but most patients are reluctant to go into bankruptcy to face the financial risk of proceeding with medical procedures when they have medical insurance, feeling like they will be stuck with the bill. Again, the medical insurer controls how care is delivered.
Since the patient had thought she was covered with health insurance, to cover any issues that arise with her health, and since there is no way she could have predicted that she would either have a spinal fracture, or that her insurer would not cover this particular procedure, this action by the insurer, in my opinion again, reeks of bad faith, with some additional info from this link to a law firm that works in GA to provide some clarity. Also, again my opinion, not disclosing to their insurance clients that this insurance product doesn’t cover things like a broken back is a detail that reeks of deceptive marketing practices. I suspect that the insurer is technically covered, as in the reams of fine print that a potential customer either signs or doesn’t get insurance, there is language to cover their actions with vague terms written in favor of the insurer, but the spirit of the agreement is immoral.
Much like before 9/11, nobody would ever think that jet airplanes are actually bombs, why would LH think that her insurance wouldn’t cover her for a broken back?
I even wrote my own complaint on her behalf to the GA Insurance Commissioner: click here.
Not surprisingly, the GA Insurance Commissioner wrote back a contradictory response, that since there was no insurance plan, they had no jurisdiction. Huh.
Then, the next page had a response...from the insurance plan!!!!, with of course no acknowledgement of the fact that their delay caused irreparable harm to LH. By omitting the detail that their plan had an exclusion for spinal trauma, and last I checked omitting key details is a form of lying, the insurer is trying to defend the indefensible. And the regulatory agency does nothing.
Click here to see their responses and my responses to their responses.
And, as of 1/30/24 appointment, there is further update on her progress:
the forward bend in her T12 segment, that was 2 degrees on the October 30, 2023 MRI,
that was noted above to have increased from 9 to 13 degrees of kyphosis (forward bend)
was noted today to now be 24 degrees.
I even wrote in the medical record for this patient that this result, which is below standard of care, is generated by the behavior of the insurer...and nobody will ever hold them responsible for their actions.
Bottom line/summary: Details below. As patients can and often do have more than one thing wrong with them, the insurer used the fact that this patient had other conditions to incorrectly and inappropriately deny the second stage of a two part treatment plan, using reasons that were irrelevant, as the first stage was successful. Even their own physician reviewer could not explain why. Denial is arbitrary and inappropriate.
Again, no insurer penalty for this inapproprate and below standard of care blocking of treatment.
For patient JS (MRN 215920, Aetna Life Insur/Medicare Advantage plan), the carrier denied care after we had started our treatment process...because the patient might also have some other problems (who doesn't??)
This patient, JS, was being treated for facet arthrosis, which is pain from the two small joints on the posterior aspect (back side) of the spine. Normal treatment (described briefly here) involves using a small amount of lidocaine (numbing medicine) either in the suspected facet joints, or to numb the small nerves to the joints, and if the patient has even temporary relief, that result is evidence that those particular facets are causing the pain.
Most insurance companies required these blocks (called facet or medial branch blocks) be done twice before approving the longer lasting procedure called radiofrequency ablation (RFA) which involves using a needle to burn these small nerves and give 3-12 months of relief.
On patient JS, we did the first block in the lumbar region, and the result was successful. The patient has great relief for a day, which shows we blocked the right place. If the pain were from L45 and we blocked L5S1, we would not have had a successful result, as we would have missed the target to prove the source of pain. Of course since doing the second block is like putting one foot in front of the other when walking, we requested the second block. But, as you are probably guessing:
Denied.
I had a "peer to peer" conversation as a result of our appeal of the denial, and the notes I left in the medical record for this patient after that phone call tell the story:
"This note is made after a "peer to peer" phone call from a Dr. JR, a pain specialist, made as a "courtesy" since the request for medial branch blocks has been denied irrevocably. Dr. JR started the phone call with the disclaimer that the denial cannot be overturned (Umm..., why are we talking then?) and she could not make any change in the denial decision. Dr. JR noted that the case did not meet their guidelines.
I asked what the reason was for denial because doing a second block is standard of care, required by insurance companies, and is part of the treatment algorithm in these cases. Dr. JR noted that one of the issues was that their company had tried to contact our office on 11/7, leaving 3 messages, and that hearing no response, there was an automatic denial. Interesting. I learned after the phone call, when we checked our logs, neither my assistant nor our surgery scheduler had received any messages about this patient on that day. As far as I know, someone at the insurance company could have whispered my name in a soft voice in their office, and with my not answering (technically a failure to respond), processed the denial. Is the insurance company behavior acceptable? Could they care less?
I asked if that's how things go these days, that if we don't answer the phone in a certain amount of time that requested procedures are automatically denied? Dr. JR noted that answer was "yes." I also noted that I had no confidence that they actually called. I related that I have had times where a reviewer called our office when I was in surgery, the reviewer was advised that I was in surgery, and then we received a denial with the stated reason for the denial (letter sent to the patient, which patient shared with me) being that I did not answer their phone call. It would be hard for me to conjure up a better example of doing all they can to prevent health care, and their actions to me seem to be pure bad faith. Dr. JR noted that she was not going to debate whether or not the calls were actually made to our office. (Thank you, Dr. JR!!)
I changed subject to what Dr. JR suggests that we should do to actually HELP the patient. Although Dr. JR is a pain specialist and we were discussing a pain management procedure, she offered no suggestions. I noted that this type of interaction is typical for insurance reviewers. I noted that insurance companies only say "no" and though they are essentially practicing medicine without a medical degree, they never do anything to help the patient. Dr. JR noted that the patient has some evidence of radiculopathy with pain down into the leg and weakness and that those problems needed to be addressed. I noted, "Great! Dr. JR, what do you suggest?" Though I noted that patients can have more than one thing wrong, and that since Dr. JR was in the same specialty and since she has likely seen hundreds of similar patients, Dr. JR said "I will not answer that question."
I asked the Dr. JR what she would suggest if she were actually treating the patient and if she really has no suggestions, why she went into medicine if not to actually help people. Dr. JR noted she was not going to enter a discussion about why she went into medicine personally and then Dr. JR decided to end the phone call.
This conversation is another example of how the medical benefits manager (MBM) of the insurer for patient JS is assigned only one task: to deny care. I wonder if a deeper dive would reveal that Dr. JR would be dismissed from her position for insufficient levels of denied procedure requests. If the insurer cared about the patient at all (and their actions say the opposite), they would act differently. If any insurance executive were treated this way, they would have a seizure about how inappropriate this denial is/was. This case is another illustration of the conflict of interest between the for-profit insurer and the patient with medical needs and a treatable problem.
Here, by denying the second block, they also deny the RFA procedure, so it's like the insurer had a coupon: two denials for the price of one! That deal was one they could not pass up!
Also, hiring a doctor to speak with me is perpetuating a fraud, since the "peer to peer" process, is for show only. Why did they need a doctor to talk to me if the denial was irrevocable? These denials disrupt the doctor patient relationship, and are built in by design, putting profits above actual delivery of healthcare, and I hope the patient makes a complaint to the insurance commissioner (although I doubt they will do anything either).
Denials by a for-profit insurer instead of helping patients receive care appears to be the new world order, and another exercise of the shamelessness of the insurance industry."
I should not have to write this s*#@ in the medical record.
Bottom line/Summary: Part of the proposed surgery to address the problem involves use of spinal hardware/implants, to allow the L34 segment to fuse. Though my description and all progress notes described use of pedicle screws, the insurer wholly made up a reason for denial, saying I was going to use a spinous process clamp (both pictured below). The insurer conjured up this false reason to support their denial: totally inappropriate.
**Apparently, the insurer can just make up any reason they want to deny surgery.
The insurer faces no penalty, no repercussions, no consequences, for this bad faith action.
(And btw, GA Insurance Commissioner, with regard to having any control of GA medical insurance for GA residents, responded that they can't help. Click here to see their response. And since they said I should complain to the Mississippi Insurance Commissioner, I did)
This case concerns a patient JM (MRN 254780, BCBS) who had a herniated disc on the left at L34. He had a re-herniation that requires treatment, but the insurer is making up ridiculous reasons to deny JM treatment.
Anatomic info: The disc is the cushion between the vertebral bones, and has a structure that can be thought of like a jelly donut with a rim and a center. Sometimes, the rim will tear, and either bulge out to touch a nerve, or some of the center (nucleus) material will get extruded. Either way, a common way that this condition is treated is with discectomy, where through the posterior (back side) of the spine, a small amount of bone is removed to allow access to the bulging area to remove the disc and relieve pressure on the nerve. The procedure is illustrated below.
While in most cases, more disc does not come out of the opening in the annulus to cause recurrent pain, in the case of JM, it did. JM had relief for several weeks, but then his pain returned. Further imaging revealed that he had recurrent herniated disc material.
We unsuccessfully tried everything we could (PT, injections, nerve blocks) to avoid a second surgery, but none worked. Given that a focal nerve block gave him good relief for a day (diagnostic result to confirm the surgical plan), JM decided to proceed with revision surgery. .
However, the revision surgery would be more involved. On the first surgery, we had to remove some of the facet joint to get in to do the decompression as shown here -->
To go into the same location, I can't remove more of the facet joint because only half of it is left as it is, so I would have to remove all of it, which would make the spinal segment at L34 unstable.
When we think of spinal stability, one can think of the model like a three legged stool, or a tricycle. If you take away one leg or one wheel, the structure becomes unstable (doesn't work right). We would gain stability at this L34 segment by fusing together the L3 and L4 vertebral bones. This fusion/stabilization is integral to the success of the surgery, and is a commonly done spinal procedure. The fusion is stabilized with pedicle screws (procedure code 22840) which is standard of care.
This information was submitted to the insurance company and since I’m sharing the details of this case here, you can imagine the response:
Denied.
The insurer explanation was that the code 22840 was judged as investigational, which is hogwash. On their own, the insurer decided to use the procedure code 22840 to describe a different type of spinal stabilization, a clamp that goes between the spinous processes, which I never mentioned in either my request for surgery, nor in my office notes.
To review some anatomic details (as illustrated to the left), the spinous process is the part of the bone you can feel when you run your finger down your back. The pedicle, which is the strongest part of the vertebral bone, is the tube of bone that connects the vertebral body to the anatomy on the posterior (back side) of the spine.
There is also a fundamental difference between pedicle screws and a spinous process clamp, as illustrated below with these two modes of fixation being clearly different.
I re-submitted the request for surgery again, even with these important clarifying details, and again:
Denied.
Their reason offered for the denial, which was the same reason, is complete garbage and a demonstration of bad faith. Though stabilization is essential for the case, the insurer would not approve this part of the procedure. It would almost be like, if the insurer had to authorize changing a flat tire, authorizing removing and changing the tire, but not re-applying the lug nuts. Ridiculous.
Nowhere in my request is there a mention of a spinous process clamp. Additionally, spinous process clamps are used and are not investigational, but are within the standard of care. Medicare covers them. Does the insurance company know better than a practicing spine surgeon how to treat JM's problem? Did they have any alternative treatment suggestions? Of course they don't. Just for him to get lost.
I think the insurance company would at least be more honest if their logo was a middle finger. As is the theme of this screed, they literally could not care less, except about preventing healthcare. The denial of this code is arbitrary, ridiculous, inappropriate, and immoral. Though my letter of complaint to the GA Insurance Commissioner was sent, as noted by their response (here along with my complaint to the Mississippi Insurance Commissioner, as directed by the GA officials) they have never helped a patient in my experience. I think they are the Commissioner For Insurance, not charged with helping patients or providers.
As of the time of this writing, the patient is still suffering with what is a treatable problem. At least the shareholders of BCBS are happy.
Bottom line/Summary: Even though there is no orthopaedic surgeon who will read a report and then operate on a patient with out seeing the images, and even though there are no radiologists who do orthopaedic surgery, the insurer will believe only the radiologist's report of the imaging.
Though no insurance physician reviewer could explain the logic of the above statement, this rule is used to further delay procedure approvals in a manner that only protects profits, and prevents care from being given, again, with no consequence to the insurer this this inappropriate behavior.
Do radiologists have the expertise to know what details would affect a surgical outcome? Of course not. Have radiologists ever missed a finding? Of course they have. But no matter to the insurer. Any technique to throw in a delay or denial is pure music to their ears.
This case is another example where care has been delayed, and as of this moment, remains effectively denied. The case involves patient DC, a 62 year old disabled female (MRN 395070, Aetna Life Insur Medicare), who has failed conservative care, and who has an unstable spine, and surgery is denied.
First, a minute about what is an unstable spine? The spinal column has a number of segments, and for each level, there is a vertebral body in front, and two smaller joints in the back, called facet joints.
Inappropriate denial for surgery in a patient with spinal instability:
In the spine, the connection between two spinal bones, which includes the disc in front, and the two facet joints in the back, can be represented by a tricycle: big wheel in front (though on its side) and two little wheels in the back. Clearly, a tricycle without one of the little wheels in the back (without a facet joint) would not work right. The connection between two spinal bones would therefore have abnormal spinal motion at that segment. This abnormal motion is called instability.
As it turns out, my patient DC previously had surgery by another doctor, who removed the facet joint at L45, as illustrated in this schematic. This unstable segment is a textbook indication for a spinal fusion.
Not being 100% correct every time, in this case, the radiologist failed to note this finding. After speaking with him, he did amend his opinion, and document the lack of facet joint, but approval remains delayed. Also, the insurer wants this patient, with an unstable spine, to complete six weeks of physical therapy, even though the patient feels worse after every visit. Probably a more apt requirement is that the insurer wants the patient to complete six weeks of physical torture. However, even a hundred weeks of therapy are not going to make this segment stable.
I was able to arrange a review with their physician (because of course I have tons of extra time!) and made these notes in the patient's chart after this discussion with their reviewer. In these notes, I mention some of the points discussed above, and except for abbreviating name information, this text is copied directly from the patient's chart (except for my comments in parentheses). The reviewing doctor noted their decision was unfortunate (yes, it's unfortunate that I ran over your dog. My bad.), and as noted below, they approved only part of the surgery.
Wait...what? How is that decision any different than repairing only half of a damaged roof?
This note is made after a "peer to peer" conversation with Dr. K.C., neurosurgeon. Apparently, Dr. C is unable to apply any logic or give any explanation why the surgery should be denied, and instead hid behind the "guidelines" as if they are immutable laws of medical care, which for all intents and purposes, they are. Though to me, "guidelines" are broad recommendations (don't chew with your mouth open), they are instead apparently immutable hard stops in the decision making process. I wondered why we were even talking if there is no room for any logic to support my surgical plan. There was not. The insurer assesses the case to be either within guidelines, or not. The insurer has no interest in allowing the doctor (me), who is seeing and examining the patient, who is seeing films and who would be responsible for the result, to have any input. Instead, any opportunity to deny care is taken immediately.
Dr. C noted that even though I had documented that the patient has gone through physical therapy, and that the patient was only made worse by physical therapy, my documentation of this detail was not sufficient. I needed a discharge note from physical therapy. In other words, more roadblocks to helping the patient.
Dr. C noted that our office needed details about the proposed instrumentation which I provided for her in the phone call. Were they going to approve the hardware from one company but not another?
I noted for Dr. C that the patient at L4-5 was missing the inferior facet joint bone, indicating spinal instability. To be super simple for anyone reading this since apparently a neurosurgeon was unable to use this information to help get approval for this case, a spinal segment is like a tricycle. There is a big wheel in the front, which is the disc (which is actually horizontal and not vertical), and 2 little wheels in the back called facet joints which add stability to the connection where one spine bone connects to another. In this case, given the patient's previous surgery, the inferior facet on the right has been removed. This example is like a tricycle without one of the back wheels. By definition this segment is unstable. However, Dr. C would only accept the reading of there being an absent facet joint if she read it from the radiologist, as apparently my reading is not credible nor am I competent to read a CT scan. More options for the insurer to deny care.
Dr. C also noted that this insurance company policy was unfortunate to believe only radiologists, even though no radiologist actually ever made an incision on a person, and even though no surgeon would ever just read text on a paper and then did surgery on a patient. (Pure obstruction.)
Dr. C noted that they could only approve part of the surgery. I noted that that type of answer was ridiculous. Would any surgeon just do half the surgery? To think for a second, with this opinion coming from a neurosurgeon who at least previously practiced, that I would even consider for a minute going in and doing PART of the indicated surgery is both ridiculous and insulting. (More obstruction.)
I asked what the next process was since Dr. C was clearly is not in the business of helping the patient and Dr. C said that she cannot help but our office needs to put in a request for an appeal. (More obstruction.)
Once again, clearly, if the insurance cared for even one second about helping the patient, they would help facilitate this appeal process (as I am at this very moment trying to do) but rather, obstruction is part of the plan. Looking at the insurance business model, they take in premiums and the longer time they can delay care or deny care, the better their financial statements look, regardless of whether the patient who purchased the insurance product is getting value for the dollars they spent. The obstruction is by design. Let's at least be clear about how they function.
I will be sure to share this information with the patient and I hope they make a complaint to the Insurance Commissioner and any elected officials who will listen. Even if the insurance and healthcare system is entirely corrupt, which I expect it is, maybe this clarity can be known about how medical care is administered in this country.
I will also ask our surgery scheduler to send a request to the radiologist who read the CT scan of 9/18/23 to see if that radiologist, who will never operate on the patient and will never see the patient, will document that on the right side at the L45 level that the facet joint is missing. The radiologist, clearly is not perfect at reading studies, missed this detail. Again, great for the insurance company because they have another option to save money and deny care.
The patient DC herself at our last meeting also noted the runarounds that she got in her own request to get her surgery request appealed and approved. She noted times on hold as long as 45-60 minutes, after which the rep would somehow disconnect the call. She was told that I was in her network, and that I was not in her network (I am in her network). She was told, even after we got the radiologist report that she herself sent in that the was missing a facet that “there was not enough evidence” to approve her surgery.
I can’t make this s*&# up. If this type of insurer behavior is not pure bad faith, I don't know what is.
Short answer: Oh hell no!!!
Here's the thing: WC is not medical insurance. With typical healthcare insurance, a patient has a problem, makes and appointment with a doctor, and decisions are made about appropriate care between the patient and the doctor.
However, in WC, though maybe not physically present in the exam room, there is a third party who will never meet or see the patient, who controls all the care: the WC adjuster.
Every patient who gets their care through the WC system probably at the outset needs to get a card or brochure with the following guides to what to expect:
WHAT TO EXPECT WITH WORK COMP:
While WC coverage involves no co-pays and usually includes some temporary disability salary payments, the medical care provided is characterized by a number of significant disadvantages:
--Decisions are not just between patient and doctor, but WC controls the case (not the doctor!)
--Delays are more the rule than the exception, regardless of your pain and suffering, resulting in a quality of care that is below standard
--Even if your work caused your symptoms, patients with any pre-existing condition can expect to have to fight to get coverage
--You can't use your regular insurance
--You will remain in WC limbo until you settle your case, or get denied (controverted)
AND IT'S ALL LEGAL!!!! Great, right?
First, some background information on WC:
WC is a system that tries to address the needs between the two involved parties: employers and workers who happen to be injured in the industrial setting (on the job). As a physician treating WC patients, I am sharing here my thoughts and frustrations in working within the WC system.
The WC system was started in the early 1900's as a result of some catastrophic events (Triangle Shirtwaist Factory Fire of 1911) and a number of social and economic factors, along with a rise of the labor movement. The WC system has a number of key features:
No-Fault System: Employees entitled to benefits regardless of the cause of the injury.
Exclusive Remedy: Employees can't file WC and also sue their employer.
Compensation for Medical Expenses: Medical expenses covered.
Wage Replacement: Injured workers receive a portion of their lost wages while unable to work
Plus other benefits, such as rehab services, death benefits if worker is killed, and there are provisions in the laws to be sure employers carry WC insurance.
While all this arrangement sounds great in theory, WC is an adversarial system. Though the WC adjuster might not be physically in the room when I see the patient, the adjuster controls what care can and cannot be given, and more importantly, though they might say otherwise (that they do care about the patient), they act as if their primary objective is not to help the patient, but to minimize costs to their boss, the insurance company. While a patient and doctor are typically working together to lessen the suffering of the patient, WC acts as if their primary objective is monetary, and not health related.
As occurs with insurance companies in the health insurance business, not related to WC, where the new insurance company superpower is shamelessness, in a world where bad behavior by WC insurers is for all intents and purposes never punished, I am seeing more and more frequently patients being treated in a manner that no adjuster, WC attorney, or judge would ever stand if the patient were themself, or their family member. I am seeing substandard care be more the rule than the exception, with examples below. I note issues including these below.
–Since WC covers a specified body part, not the whole person, I often see injred body parts not being included or recognized and accepted in the claim,
–When in the course of treatment, or as a result of the WC injury, other body parts become injured (as a result of the WC injury), though these other body regions should be included (example: WC knee on right, so patient falls and twists L ankle) they are nearly always summarily denied,
–Instead of having timely evaluation and treatment, there are endless delays or denials,
–Approvals for care are all controlled by WC adjusters who will never meet or examine the patient and though I would like to see evidence to the contrary, either the adjusters are hamstrung by the inherent rules of the WC system, or they simply couldn't care less about helping the patient,
–I have seen many instances where patients are directed to receive care from providers who are either not subspecialty trained for the patient’s problem, or are biased that all WC patients are magnifying small injuries and instead of toughing it out instead choose to blame work for their own bad lifestyle choices,
–I have seen the inappropriate stopping the worker's partial salary payments with the justification of there being an upcoming settlement conference,
–I have seen endless delays that seem to be abusing details of the rules within the WC system, with delay actions by the WC carrier that would argue against WC having any pretense of wanting to help the patient. Examples: patient is informed of an upcoming settlement conference (arranged by WC) so salary payments are stopped...and then they further delay the settlement conference. Delays are baked in by WC changing adjusters, as apparently by statute, a new adjuster has 60 days to get acquainted with a new file...so nothing happens. Then...on day 59, guess what? WC changes adjuster again. More delay!! And all legal....
--These delays and denials, which are baked into the WC system, ignore the fact that their injured worker, who is a patient with a treatable problem, has a worse prognosis in many instance due to these delays, not to mention the prolongation of suffering (more evidence that WC insurers literally could not care less),
–WC provides a standard of care that (and I am 1000% sure of this point), no WC adjuster, attorney, or judge would stand for for one day if they were the patient, with WC insurers directing medical care (practicing medicine with no license and no liability) to a standard that is below standard of care, with the WC insurer subborning medical malpractice by their actions.
And probably most frustrating of all: when patients DO have regular medical insurance, they can’t use it!!
Right on their insurance form, there’s a box that is checked asking if the condition is work related…which it is. If they check that box, the claim is denied (regular medical insurance doesn't cover work related issues). If they don’t check the box, then the claim is insurance fraud. The only way to get to use their regular insurance is to either get a formal denial of their WC claim (called “notice of controversion”) or to settle their case. Since WC has all the money, and all the time in the world, and armies of attorneys to further obfuscate and delay the claim, and since apparently the judges in GA want GA to be a “business friendly” state and don’t want to give any gruff to employers having to deal with irritations like some injured worker’s claim, I almost never see…let me rephrase…I have NEVER seen a judge give any penalty to an insurance company for their malicious intent, willful neglect, endless delays, and provision of substandard (read: malpractice level) care in my practice in GA since ‘06.
But, my friends...But!!! It's all legal.
But other than that, I have no strong feeling on the matter.
I have examples below.
KH (MRN 6300, Gallagher Bassett Svcs, WC) who is a 41 yr old female, was working as a manager for a NAPA Auto Parts store in GA for over two years with no orthopedic issues. As part of her normal duties, she would regularly lift upwards of 50 lbs.
Injury occurred 11/22/22, when a large strut weighing approx 45 lbs dropped on KH's foot with direct crush and ankle inversion injury. She tried to keep working despite the burning pain in her foot, but had too much pain and swelling to function so she reported the injury and was told to go to ER, which she did next day, where she was told there was no fracture. KH was given crutches. A follow up appointment was made with an urgent care clinic in Dothan, AL which she attended, and orthopedic follow up was recommended. However, instead of orthopedics, she had another visit with the urgent care clinic January ‘23 where after X-rays, the diagnosis again was “bone contusion” (bruise). KH noted that during these urgent care clinic visits, “nobody ever touched my foot.”
Over the next few months, no follow up was arranged with the patient, despite continued pain and swelling. While a bruise would have had resolution of symptoms by about six weeks, KH continued to have so much swelling and discomfort of the L foot and ankle, and she could not put on a shoe. KH reported multiple calls to the WC adjuster, from which no recommendations were given.
(Not surprising, as per my understanding and my dealings with WC, no adjusters are orthopaedic surgeons with any experience treating patients.)
KH was sent again to an urgent care clinic again in April '23, where she was again diagnosed with a "bone contusion" (no physical exam performed per the patient...again). Becoming increasingly angry and frustrated, as patients in the WC system can't use their regular insurance for work related problems, the patient and the company human resources person made increasingly frequent and often daily calls to the WC adjuster, only to be told that WC had "lost all the emails."
(How is this corporate malpractice not criminal? Would the WC adjusters, their attorneys, or any judge feel it would be appropriate for there to be a delay of over seven months to see a foot/ankle specialist in the face of continued symptoms if they or their family member were the patient? Are the providers at the urgent care clinics smarter or better than a fellowship trained foot/ankle orthopedic surgeon, that without even examining the patient, they could diagnose that there was nothing wrong? How is it that the WC adjusters, by not authorizing care in a timely manner, are NOT practicing medicine? While the adjusters may not personally be providing medical care, they certainly are preventing it. If these adjusters did attend a medical school, is it accredited?)
KH eventually had a consultation arranged in our office June 6, 2023. On that visit, KH was noted to have bony abnormality at the base of 5th metatarsal bone, enough to warrant MRI exam and then subsequent CT exam. With further work up, the diagnoses included (which is more than the previously diagnosed “bone contusion”):
–Crush injury L foot with neuritis of superficial peroneal nerves
–Healed fracture at base of 5th metatarsal vs bone island
–L ankle extensor tendonitis
–L ankle instability
At the 8/10/23 visit, when surgery was requested for reconstruction of the lateral ankle ligaments, the course of care was further obstructed and delayed as WC arranged a second opinion…from a total joint specialist, which is, (spoiler alert), inappropriate.
(Just as I would not consider myself as a valid second opinion for an issue involving a total joint replacement, a total joint ortho is not an appropriate provider to make a second opinion assessment. Total joint orthos likely aren't going to the foot/ankle meetings, to stay up on the latest techniques, and doing total joints, they don't have their own significant volume of clinical experience to rely on. Choosing the total joint ortho for the ankle problem is an exercise of pure bad faith, and makes no sense.
However, apparently for the WC insurer, any delay is good. More delay means higher chance of the patient becoming frustrated, and considering a settlement to extricate themselves from the stranglehold of interminable delays that are part of the WC delay limbo strategy that WC pursues...all legally.
What matters more than what one says, is how they act. The actions of WC insurers are clear: Do anything to close cases and hopefully minimize costs, regardless of the damage they do to the injured patient. WC insurers care nothing about the patient. Aside from getting an appropriate second opinion, if they cared about the welfare of the patient, they would have arranged sooner evaluation with a specialist. However, regardless of what they might say, WC insurers act as if any patient under their care is worthy of the respect they would give to a pile of dog excrement that they stepped in. They want to case scraped off and to have nothing more to do with it.
Most frustrating, and I am aware that his is the new world order, WC insurers face no penalty for bad faith behavior. Though they are practicing medicine without a license, they cannot be held liable for their actions of preventing medical care. Their actions are proof that they literally could not care less about the quality and timeliness of the medical care for their injured patient.)
As of the time this section is written, the patient has had lateral ankle ligament reconstruction and is feeling better about her ankle and foot stability. Apparently, more was going on than a foot contusion, despite the seven month delay in evaluation and care services caused by totally legal WC delay.
Maybe at least it would be more honest if patients in the WC system got an introductory brochure saying:
"Welcome to Work Comp, where you will have no control of your case, our decisions will take forever, we could not care less about your pain and suffering, and the quality of your care will be BELOW STANDARD...'cause that's how we roll, baby!!"
CG (MRN 410430) was seen for an independent medical exam (IME) 12/21/23. CG is a healthy 41 yr old female who had not previously had any orthopedic issues with spine or extremities, was in an employed position for over six months doing heavy work as a machine operator. Her work involved frequent bending, lifting, and twisting as she assembled large industrial batteries, with parts often weighing upwards of 30 lbs.
Injury occurred 1/22/19. CG was doing a lifting and twisting move and had a sudden pain in her back with pain down both legs, L>R. The day it occurred, she tried to tough it out, finishing her shift, then went home, rested, and took ibuprofen.
The next morning, she couldn’t move and reported the injury to her boss, but she was written up for not reporting the problem right away (is that fair? blame the victim?). She was sent to an occupational medicine doctor, who gave some medicines and told the patient to take it easy. CG returned to that doctor a few weeks later reporting worse symptoms, so physical therapy (PT) was ordered. Though physical therapy aggravated her symptoms, PT was continued for 3-4 months.
(Most providers would consider 4-6 weeks as an adequate trial of physical therapy, especially in the scenario of a patient who says they are getting worse. Standard of care would indicate the next step to be imaging: MRI. Care delayed.)
Despite an injury date of 1/22/19, in a patient worsening with physical therapy, it took over eight months, until 9/25/19, to order a lumbar MRI.
(This delay is excessive. Would anyone not bound by the WC-controlled medical limbo, i.e,, medical jail, think that waiting over eight months to get an MRI in the face of worsening symptoms is appropriate? Would any WC adjuster, attorney, or judge think this standard of care would be good enough for them?)
After the Sept. '19 lumbar MRI, another FIVE months later, CG was referred to a neurosurgeon in Columbus, GA, who on 2/13/20, without giving the patient a diagnosis, said that the patient was too young for surgery, and that he didn’t want to do surgery.
(I have to wonder if the neurosurgeon looked at the films himself, or just looked at a radiology report. In the MRI study from Aug ‘20, noted by the radiologists to be the same as that of Sept ‘19, there is potentially surgical pathology. More importantly, the subsequent pain management interventions did not address the abnormality noted here at L34 with all of their injections directed at the two lower levels, that happen to be normal. Is it a surprise that the patient did not get better? Again, for any WC adjusters, attorneys, judges, or any humans with a pulse, is this standard of care appropriate?)
Though the only guarantee with any treatment is that there is no guarantee, it would be important to see how the patient might have responded to a transforaminal epidural injection (TESI) pictured here to the right, given at the L34 level on the patient's left side. Also, the first step to successful treatment of a problem is to accurately diagnose it.
If I were the doctor on the case, my suggestion would be first to get more up to date studies (better than three years old). Assuming for the moment that the imaging was the same, I would suggest to do a transforaminal epidural injection on the left side at the L34 level. The local introduction of steroid to the painful segment could be enough to decrease the focal swelling, but even if the patient got good relief for a day or two from the local anesthetic, she would be an candidate for a small surgery called microdiscectomy, to remove that disc bulge.
(So, just for the record, I think the patient does have pathology that correlates with her symptoms, and her care has been characterized not only by excessive and inappropriate delay, by a "below-standard" standard of care, but her treatments have not correlated with the pathology seen on her imaging studies. To my view, no further efforts have been made, prior to the independent medical exam I did in Dec '23, to see if there is anything else treatable in this patient. Is this the new standard of care?)
PP (MRN 335000, Sedgwick CMS, WC) is a 35 yr old female who stepping off a forklift at work, had an inversion injury to her left ankle 11/21/2020, so bad that she was unable to bear weight. Based on both the history and subsequent findings, PP had a complete tear of the lateral ankle ligaments, a treatment that would have healed well with non-operative care, and PP could have avoided the need for surgery, had her condition been evaluated and treated expeditiously (with a walker boot).
Below-standard care here is caused by WC delay: With WC in the driver’s seat, first referral to orthopedics was 2/23/21, THREE MONTHS later. The window of opportunity to heal the ankle injury non-operatively had closed, leaving the patient the opportunity to live with a loose/unstable ankle, or have surgery. Does WC have any liability for their causing a lower standard of care to be given? (spoiler: no!)
At my first visit with PP, which was even two months later, 4/26/21, surgical reconstruction was requested. Fortunately, the surgery was approved and was performed six weeks later (early June '21).
Although PP was better for a while, and although she was a compliant patient (followed doctor's instructions), unfortunately the repair lost its hold (no surgery is guaranteed…) and symptoms returned after several months. As we explored options, and with both of us wanting to be sure there was not a better suggestion, a request was made for a second opinion.
The recurrent symptoms occurred about January ‘22 and the request for second opinion was made about the same time, but it took until six months, until July ‘22 to approve another opinion. Unfortunately, the opinion of the second opinion doctor was “I don’t know.” (Hey, thanks for that!!). Therefore, another request was made for another second opinion (one with an actual opinion), but it took until March ‘23 to arrange that other opinion.
Is there a theme here? Delay, delay, delay...seems to be a recurrent pattern, and all legal in the WC system.
Between further WC delays in approving a new MRI and WC finally paying the second second opinion doctor, we did not get the report from this doctor until August ‘23.
Further delay.
Based on the opinions of the second opinion and my own recommendations, additional surgery was recommended, but…Surprise!!...WC denied that request.
An appeal was made, and WC promoted further delay by consulting with an orthopedist in NY who, without ever seeing PP, and with no explanation how the result would change the treatment plan, recommended an injection in the ankle. For the record, the diagnosis of instability (loose ankle) is made by physical exam, not by record review and not by injection.
Here is another point where WC is directly practicing medicine, and in doing so is lowering the standard of care.
Who in their right mind would consider consulting with another doctor not licensed in your same state, who will never see or examine you, about whether the recommendation of your in-person doctor (who has met, examined, treated, and will continue to treat you) is correct or not?
Revision surgery was finally approved Dec '23.
Though PP is still recovering, and the results are to be seen, does this story strike anyone as appropriate care?
Editorial opinion: I don’t think so.
WM, MRN 290340, Concentra WC: This patient WM is a 45 yr old female who, while working as a property manager of an apartment complex, a job that involved frequently walking around the building, lifting items, occasionally helping residents with moving items, doing this job without complaints for two years, fell down stairs with injuries to multiple body parts, the most serious of which involved her neck.
Though she had a previous cervical spine injury in 2020 (the purported reason why WC denied everything noted below), she was not taking pain meds nor seeking medical care for two years before her injury. After her fall, which certainly would believably include neck injury as one rolled down a stairway, the patient had neck pain and pain with numbness down the arm suggesting a herniated disc in the neck with pressure on a nerve root.
WC was very obstructive, taking months to even approve a cervical spine MRI. With regard to treatment recommendations, WC essentially denied everything, except the visits to me and some medications…for two years. Despite documentation in the medical record on essentially every visit documenting the relationship of the industrial injury to the patient’s symptoms, and about the clinical rationale for further workup and treatment, all requests were ignored. Referrals I made that were either ignored or denied included:
–physical therapy for cervical spine
–any suggestion of cervical injection or surgery
–referral for evaluation and treatment of a clinically torn rotator cuff
–referral for evaluation and treatment of depression and anxiety secondary to both chronic pain and being ignored.
WC did approve an independent medical exam (IME), which actually is anything but independent. They know in advance who will give them what opinion (should be called a DME: defense medical exam, to find some doctor to reliably say nothing is wrong with the patient). I documented the following in the medical record after the patient had this “IME”:
This patient, who is an African American woman, was sent for a second opinion to a spine surgeon in Columbus who, per the history she related to me, told her more than once during their interview “you look like my maid.” (Is that supposed to be a compliment?) The doctor also concluded that “you seem fine to me, like you can do your job without problems.” This doctor must be super smart, as normally, I have to examine patients, but in his case, according to the patient, the doctor was able to reach his opinions without ever touching her during the encounter (no physical exam), and was in the room for no more than 3-4 minutes.
This patient remains in a state of legal limbo, but I will still make some recommendations to hopefully get her some relief. I will note here that I am 100% sure that no person who is adjudicating her treatment, attorney, adjustor, judge, would tolerate for one second to be treated this way...or more specifically, to have treatment denied this way.
(Seriously dudes, should I have to write this stuff in the medical record?)
With her disability partial salary payments being withheld, and therefore lacking money to pay her rent or even buy food, with all attempts to get evaluation and treatment for her work related injury either ignored or denied, WM had no choice but to settle the WC claim for a pittance, for an amount less than would cover the cost of one visit to the local ER. WC literally starved her into a settlement. If needed, I am sure WM or her attorney would be glad to corroborate.
DS (MRN 398510, WC, Liberty Mutual) who was able to do his job (involving frequent bending, lifting, and twisting) for over a year with no problems, was in a shipping container on 8/15/23, , when that container with him it it was hit by a truck.
Though DS had neck and back pain immediately and has since the incident, though they approved the lumbar spine, it took the WC adjusters SIX months to approve his cervical spine.
Seriously...
Probably the WC system should list as one of their first line treatment strategies: neglect.
Summary: Medicare Advantage plans offer all kinds of goodies to seduce patients to sign up. They just deny the big things that cost more. These plans should be called Medicare Disadvantage.
First, we need to review some details about the various parts of Medicare. For original Medicare, the areas covered include:
Part A: hospital
Part B: doctor visits and outpatient care
Part D: Drug coverage
Medicare Advantage (MA) plans are called Part C, or MA or Advantage plans. These plans are advertised as providing all of Part A and Part B coverage and most include Medicare prescription drug coverage (Part D). These Advantage plans are often successful at seducing customers/patients with offerings of extra coverage, such as vision, hearing, dental, and/or health and wellness programs. These programs will tout that those who enroll can see their doctor any time for a $0 copay. OMG! Awesome, right? What's not to like? All the same Medicare coverage and even some little bit extra!!
Sorry, baby girl, but there is no free lunch. These plans are not offering these benefits to get a community service award. It’s all about the Benjamins. This article outlines many concrete examples of how, through delaying and denying care, your Medicare Advantage plan could actually kill you. The government agency that pays the bills for Medicare, Centers for Medicare & Medicaid Services (CMS) pays Medicare Advantage plans a fixed (capitated) amount every month to cover care for each beneficiary (Medicare recipient). The real savings for the Advantage plan is from denying bigger cost items, like services for evaluation and treatment. Since these Advantage plans receive a flat payment for the care they provide, they are strongly incentivized to use any trick in the book to ration the care. Not only do they deny care, but patients with Medicare Advantage will have a more limited choice of doctors and medical offices than they would with Original Medicare.
So, question: Are these MA plans in the mix because they are better than doctors at deciding what services and treatments are best for patients? These plans, where the decision maker has never, and will never meet the patient, do they know better than the providers about the best care plan? Does that idea even make sense? Come to think of it, when I was in medical school and ortho residency, I actually can’t think of one guy in a suit from a Medicare Advantage plan that was training right alongside me. However, they got the best deal. They scrape their profits off the top, they have all the control, and no consequences for their actions. One day I expect one of their executives to write a tell all book: “Throwing patients under the bus is FUN!!” And regardless how inappropriate their decisions, nor how their actions literally cause patient harm and cause below standard care to be given (also called medical malpractice), insurers have no liability for their actions. Now THAT is one world-class rigged system.
These Medicare Advantage plans, which are heavily advertised to the older segments of our population (and these TV ads are not cheap), incorporate the help of famous spokespeople (William Shatner, Mike Huckabee, J.J. Walker, Joe Namath) sound great, but patients are not getting the full story.
The devil is in the details.
What is not shared with their customers/patients is how the for-profit insurers make this business a financially worthwhile endeavor.
As a provider, I can relate my experience and frustration dealing with these programs: They apparently follow the advice of the Nancy Reagan campaign against drugs from the 80’s: “Just Say No.” They seem to find any reason to deny services, regardless of common sense or medically justifiable logic, and they seem to be getting better at it.
Think of the insurance business paradigm, as with any business: Income is money coming into the company (insurance premiums), and expenses (cost of actually providing care) are dollars going out. What is left is profit. And, insurers are for-profit enterprises.
In this article, the profit per enrollee (patients who signed up for the MA plan) is a lot. In fact, with their participation in MA plans, insurers made higher profit margins than insurers in other markets. I can tell you as a provider, my view is that Medicare Advantage is a giant con job , marketed in a way that does not reflect reality. I see at least daily significant rates of wrongful claim denials, worse health outcomes, and my staff and I have to spend countless hours fighting the ridiculous rationales offered for their denials. Here is another article detailing why Medicare Advantage plans are a giant scam.
Maybe, like cream, the truth does rise to the top. I read that more patients and hospitals are leaving Medicare Advantage plans, due to the most commonly cited reasons of excessive prior authorization denial rates and slow payments from insurers. These plans rely on the failure of Medicare recipients to do the due diligence about what they’re signing (though it's complicated legalese designed to be one sided and to confuse the signer), with insurance agents also heavily incentivized to say whatever they can to make the sale.
For full disclosure, I have some patients who have had serious conditions, like cancer and heart conditions, who have been happy with their plans, but my experience as a provider has been different. Maybe the reason is that they figure nobody will die from the pain of a spinal condition. However, when I request approval for a surgery, sometimes the plan will approve only some parts of the surgery. This partial approval is both ridiculous and inappropriate, almost like if your house had hurricane damage, and the insurer said they would cover all the repairs except the damaged roof. (Wait...what?) I have to think their actions are immoral, arbitrary, and in bad faith.
And to just remind about one other important detail, the insurer themselves doesn't do the dirty work. As noted above, insurance companies subcontract the job of preventing care to their MBM's (medical benefit managers), leaving the insurer with plausible deniability. I had a recent complaint about an insurance company I made to the GA insurance commissioner that was not addressed because the insurance company did not deny the requested service, but their MBM did. Apparently, this outsourcing of obstructing care is how we roll in America these days.
Unfortunately, I don’t see any cavalry riding in on their white horses to save the day. 🙁
I guess it all depends on the definition. An online dictionary defines a crime as “an action or omission that constitutes an offense that may be prosecuted by the state and is punishable by law.”
Ahh, more details. Since insurers hold the money (and the control) in the way much of our current healthcare system runs, and since, after Citizens United, corporations can spend unlimited amounts on lobbying politicians, our laws currently reflect that insurers can't be sued. Most folks would consider that insurance company obstruction of medical care for an insured patient, where the patient is harmed or worse due to that obstruction, to be an unacceptable action even bordering on criminal. However, the laws favor the insurers.
If someone came up to you on the street, put a gun in your face, and demanded your wallet, we would all agree that the perpetrator is a criminal. While nobody is putting a gun to the heads of patients who enroll in, or find themselves enrolled in, any number of insurance plans, I will bet a dollar that these patients also were not informed about the many deficits in coverage of the plan covering them, nor of the many loopholes for the insurer to delay or deny care.
Probably, since every covered person had to check the box that says they “agree to the terms and conditions,” each patient has technically agreed. However, these “terms and conditions” are not negotiable (no box checked? no insurance!) and are written by corporate lawyers to favor whom...the patient? Ha!! Don’t make me laugh. There is enough vague terminology with plenty of loopholes to allow the insurer to do whatever they want, along with binding arbitrations clauses (guess who picks the arbiter??) whereby the patient gives up their right to sue or to be involved in a class action lawsuit. And even if patients did read all the fine print (which nobody does), and even if there were an option to negotiate the terms (which there isn’t), how many patients would know what conditions are going to affect them in the future?
I think that denying care to a patient in their time of need, increasing their stress at exactly the worst time, is inappropriate, inhumane, cruel, and violates the spirit of offering an insurance product. Therefore, my impression is that given the way our laws are written, these acts are not technically criminal. However, I think they are.
As noted above, in the sections that discuss “guidelines,” the insurers outsource the dirty work of denials to a subcontractor (MBM, or medical benefits manager), so the insurer can say “We didn’t deny anything!” However, if I asked a guy to go kill your dog, I can technically also say I didn't kill your dog.
Insurers use their MBM’s to act in bad faith, putting profit over patients, denying care for conditions that have justifiable medical rationale, and that any patient would fail to imagine would ever affect them (see case of LH above).
If a company sold cars that exploded, there would be product liability issues. However, insurers have lobbied enough to have no liability for the defects and deficits in their insurance plans. The dishonesty in marketing is remarkable, especially for the so called "low cost" plans. These are plans that should instead be called "low quality" insurance plans.
Insurers have no liability for the damage and suffering that their denials cause, regardless of how medically inappropriate they are, and regardless of whether they would accept the same standard of care if they were the patient themselves. In other words, they literally have allowed themselves to act in bad faith based on manipulating details of healthcare and contract laws. Most importantly, as long as their bottom line improves, they literally could not care less.
Having over the years made multiple complaints to various regulatory agencies, and having a success record of basically zero over whatever the denominator is, I am not very hopeful. Part of the reason I’m even writing this is to share with patients that they are not alone in their frustrations.
I have many times made complaints to the Insurance Commissioner in GA, basically to be told that they have no jurisdiction. I have written back noting that they are the agency in charge of regulating insurance for patients in GA, working in GA, getting their insurance in GA, but apparently if the insurance company makes their office address one inch over the state line, our Commissioner is completely powerless.
Summary of some previous responses: “Dear Dr. Wolgin. Thank you for your letter. However, we can’t help you or your patient. Make it a great day!”
Apparently, there is an organization called the National Committee on Quality Assurance (NCQA), which certainly has a nice sounding name, and one would think, call me crazy, that they might possibly assure quality, and do it nationally. If you check out their website, there are good looking, smiling people, and a sense that this organization is there to maintain a level of quality to accredit health plans to be able to participate in a state. They have descriptions of what they do on this page, with a stated goal of measuring and improving quality. However, for complaints I have submitted, I got essentially no response. NCQA is a private, non-profit organization that seems to be set up to add a sheen of quality to insurance products. One online source noted that this organization had annual revenue of $231M. Their pricing plans indicate that the agencies they credential pay for the credentialing. HOWEVER...if NCQA is paid by insurance companies, why would they spank or give any negative feedback to any insurance company?
Here comes the next thought in my head: how are these not simply "paid for" seals of approval, lacking any actual assessment of quality? How is this situation any different from when the rating agencies around the time of the 2008 financial crisis gave stellar ratings to mortgage backed bond funds that were complete garbage? For any help of actually helping a patient, in my opinion as illustrated below, NCQA is a joke, perpetuating a false impression of quality in insurance plans.
Here’s a great example. I contacted NCQA with issues about an insurer (Ambetter/Centene). I outlined issues noted on another webpage I have (drwolgin.com/ambetter). I explained about the obstruction and inappropriate insurer behavior about my patient who was literally getting paralyzed from spinal cord compression. They literally responded that “Your interaction with the insurer is unfortunate. We have forwarded your issues to the insurer.”
What?
Imagine you thought you were getting ripped off by a plumber. You write a letter to the State Plumbing Board, and they say that they’re sorry that your experience was "unfortunate," and they sent your complaint to that plumber. That was their response? I wrote a letter back to NCQA and copied all of the members of their Board of Directors, each receiving their own copy, and…crickets. If you like, you can read my rebuttal here.
Another fact in favor of insurance companies is that, from a study of healthcare.gov insurers, nearly 17% of in network claims were denied in 2021, but healthcare consumers appealed less that two tenths of 1% of claims.
In other words, insurance gets away with it all the time.
Just like trying to change the behavior of a two year old, if there is no consequence for bad behavior, why would or should they (insurance companies) change?
If you do get approved for your surgery, and if you get a ridiculously high bill, there are strategies about how to negotiate (or fight) to pay a more reasonable amount as noted in this book by Marshall Allen with a review here, and an online video here to review the concepts in further detail. Though this book seems spot on in the outlining of issues in our healthcare system, including noting that employers, and not patients, are the customer of the insurance product, his points have a little different focus than what I'm noting on this webpage.
With the examples I'm showing here, I am detailing where patients are not getting medical services covered in the first place.
The examples shared above on this page of inappropriate insurance company denials are immoral and often harm patients.
But if the insurers are making money, why would they care?
Insurance profits soar while quality of care crumbles.
When I have young people ask me if I had a do-over, if I would become a doctor, I say that except for the part about helping a patient who is hurting, the rest is pure garbage. As I note in this letter I wrote to our vendor for our Allscripts electronic medical records system (it's too long to read, but just look at the length), the medical record has been corrupted mainly by the payers who look for any excuse to not pay. If we don't have every detail about how many cigarettes their Aunt Ida smoked, we get docked, so the medical record winds up being full of useless information. Though many surgeons have opened surgery centers to have better control of the quality and the patient experience, without having the leverage of a huge hospital system, insurers demonstrate more bad faith in finding hogwash reasons to avoid payment.
This doctor here discusses the mounting frustration with practicing, outlining why especially older physicians are leaving in droves. Though he focuses on Medicare and government payers (and they are guilty of making things worse), the larger thorn in my side is the egregious behavior, likely in bad faith, of insurance companies.
Even when the insurer approves something, they don't really approve it (though they have received the clinical info, and are authorizing the service, there is no guarantee of payment!!)
Patients need to be better advocates for themselves, as I can attest, insurers don't listen to me. Too many times, when I am getting the BS explanation from their "peer reviewer," and I ask that since they're with the company, if they can fast track the appeal, the reviewer literally tells me to have the patient call the number on the back of their card. Yes, they make the patient (who is not medically trained) start the appeal. Ridiculous.
Patients have to write to the insurance commissioner, to their state and local legislators, to become a tsunami of feedback to those with any option to regulate insurer bad behavior.
Sure, doctors can choose to not participate with insurers, and maybe more of us will, but that action just throws more patients under the bus.
Maybe this is the answer. Who knows. Always glad to brighten y'alls day. 🙂
mw
