Rejection

IMG_4343

“Doc, his MRI was rejected. You have to do a peer to peer.”

Damn.

I hate that.

My staff had already spent half an hour getting the forms filled out and records sent over to the insurance company for the prior authorization, not to mention the time it had taken between the patient and the imaging center getting the thing scheduled in the first place.

I dialed the number and endured the automated phone tree. Finally I got a representative who informed me the phone call may be recorded for “quality assurance purposes.” Sure. Whatever.

I had to spend ten minutes telling the rep all sorts of things that they already knew. Why? Just because.

Then I was transferred to another rep and repeated the process.

“Hold while I get the doctor for you…”

Ten minutes later…

“Has he done a trial of NSAIDS?”

“Yes.”

“Does he have any documented neurological deficits?”

“Well, no…”

“Has he demonstrated treatment failure after a round of physical therapy?”

“Yes! He had physical therapy two years ago and it did not help his pain.”

“Yeahhhh…. See, he is going to have to have done physical therapy in the past six months.”

“What?”

“Physical therapy. It has to have been in the past six months.”

“What the hell? He has had cervical radiculopathy requiring two daily medications in order to function and after two years of this constant pain you are going to deny him an MRI? That is just plain stupid.”

The man had not been able to afford the MRI two years ago after he had gotten finished paying for the physical therapy.

“I know. But it isn’t my rule.”

“Fine. I will relay this information to the patient.” I made sure to relay my displeasure through the tone of my voice.

At least this guy was cordial. The last one I had to talk to was a real prick. It would be helpful if the rules were the same across the board but they aren’t. 

Advertisements

103 thoughts on “Rejection

    • Medicare is not as stupid on the MRI point (I am making assumptions on your coverage, here), which is actually laughable because it is stupid on so much other crap. Like prescriptions for test strips have to have a handwritten signature (not electronic), an exact quantity and number of refills (I cannot say quantity sufficient or as needed) and the ICD diagnosis code must be written on it to get it filled for patients.

      Liked by 1 person

  1. How do you keep your temper in check? What you have just laid out is one of the reasons why I think post-apocolyptic literature and movies are so widespread and popular. The futility of bureaucracy, systems within systems, that must be fed and adhered to, stripping people of their humanity until, like in Kafka’s “Metamorphosis” a man (or woman) is treated with such indignity that he becomes little more than an insect. The fantasy to have all these systems obliterated is a fantasy of freedom. I wonder if a society that had fewer bells and whistles might shorten or lifespan but compound our happiness during the time we are left with.

    Liked by 4 people

  2. you just perfectly described why “health care” isn’t that anymore. if i need medical treatment, there should be one decider, me, who decides with expert advice what to do. insurance is just supposed to pay for the shit that needs to be done. i really hate this reality. probably why i do not engage in the #industrialmedicalcomplex at all …. well, except, my mid-wife did send me to the surgeon to deliver my daughter …. ok, for emergencies it can be ok, as usually insurance companies don’t even get involved until after the doctor does their magic, and then usually someone else can handle the stupid way they designed a system to filter money through as many hands as possible making actual medical care and treatment an impossibility of nonsense.

    Liked by 1 person

    • It assumes physicians are wasteful and won’t follow evidence based guidelines when ordering tests and treating their patients, then pits patients against physicians and I am left feeling guilty that we didn’t get it covered. Hate it.

      Liked by 1 person

  3. Why I never, ever, ever want to work in phone customer service again. Why I never want to work insurance anything again (unless maybe doing medical coding). Depending on how interviews go I may have to stop being so picky but yup… I feel for you, the patient and the poor schmuck who has to relay stupid, lame “rules” and who has no say over anything. Been there, been yelled at, felt like crap.

    The CSRs I’ve worked with have fallen into several categories. You get truly intelligent, caring people who feel like crap that they can’t do anything. I don’t think these folks last too long. You get people who will do their job, to a point, then when it is “not my rules” they shut down, screw you. Then you get the people who really just don’t care, They are getting paid really poorly. The industry is all about numbers, not “service” yet you, the CSR on the front line, have to jump through these ridiculous hoops and EVERYONE walks away from the calls feeling like crap. Welcome to corporate America, MBAs, etc.

    Liked by 1 person

  4. At least you are able and enabled to take care of the procedure yourself. In the face of rejection or even outright failure having some control is a good thing…

    Liked by 1 person

  5. I’m whispering this so THEY don’t hear me, but I really feel at times that our insurance companies don’t care about our health and are only trying to make more monies.
    As for your patient, I’m sure he will be delighted to endure months of painful pt for no benefit whatsoever. Is it possible that the insurance will pay more for a course of pt than it would for an MRI? I can’t imagine how that makes it more affordable for them, unless they also own the physical therapy center…
    I’m just a civilian. And today, I don’t need an MRI, so I’m counting that blessing.

    Liked by 1 person

    • They probably will pay more for the physical therapy. So will the patient, which they know will deter the patient which will save them money. Then there is the cost of the patient’s time missing work a couple of times a week for several weeks…

      Like

    • Follow the money. Paying more where it doesn’t seem to make sense makes sense if you were able to track kickbacks and under-the-table payments and behind-the-door deals.

      As a systems analyst, when I first moved over to medical systems, which was when (mis)managed care was fairly new, I was given a whiteboard presentation on how it worked. The woman presenting was excellent, and I used to be a quick study. After an hour or so of drawings and questions, I said:
      “So, basically, what you’ve described for me is the ideal system to enable massive under-the-table payments, and HMO’s to change their names frequently to escape consequences, but keep their players and assets?”
      The presenter said: “You’ve got it! You understand managed care!”

      Liked by 1 person

  6. AAAHHH the old insurance game! I HATE it! We just have to realize the whole game is for them to NOT cover something. The long hold times, the repeating the story 20 times, the long hold for the medical director…they are hoping you give up and thus save them $$$$

    I work in pediatrics and I was doing a peer to peer to get an MRI of an abdomen approved for one of my patients. The doctor I was on the phone with, AFTER he said he would approve the study (yes thank you!) then berated me for 5 minutes on the phone (before he gave me the auth #) to make sure I understood that one of the rationales I gave him for the study (over a CT scan) was to avoid unecessary radiation for a young child. Told me that would NEVER hold up for any insurance company in deciding on a study (mind you he approved it). I explained to him the studies we now have on the risks of excessive radiation exposure in kids (I should have our Radiologists send him the studies) and he told me he WAS a pediatrician (help us) and that what I was saying was ALL WRONG! Really?

    I am a nurse practitioner and I have had these guys, on my OWN patients that I take care of independently, argue with me that they need to talk to a doctor because I AM NOT THEIR PEER!

    I also had one of the customer service reps, when trying to schedule a time to do a peer to peer for one of the surgeons I work with (it was about a surgery so it was best he do it rather than I) who just wanted the surgeon I work with to be ready but the phone WHENEVER the insurance doc was available. They would not let me schedule at time because, “well these are Doctors they are busy”….ummm so is the surgeon I work with…he is busy operating. What they were trying to do was call at a random time, hope he was operating and unable to come to the phone so they could just do the denial (did not work anyways).

    HATE IT!

    I will have to try the forehead to the cool wall trick!
    Does it work?

    Liked by 1 person

  7. Yup, it’s the money. That’s what makes those insurance companies so profitable. (Money for nothing – they get paid and they don’t cover it) There has to be a better way.
    Leslie

    Liked by 1 person

  8. This is really frustrating! I used to go around and around with insurance companies to allow more speech-language treatment sessions for my patients. Children who couldn’t talk because of developmental verbal dyspraxia. Basically, if I couldn’t link the condition to an ear infection, they wouldn’t pay. It’s maddening.

    Liked by 1 person

  9. I did Workers comp for a while as a medical case manager ( I call it my visit to the dark side). The only good thing was that diagnostic testing was encouraged in order to come to quick decisions about the need for surgery. Other than that, I made no friends as I kept telling the adjusters ” Open the Hartford big fat checkbook! It’s legit.” That and finding the fools that went through Oxycodone like candy… the few joys of case management!
    Sending some Bushmill whiskey your way!

    Liked by 1 person

  10. Very frustrating Victo. I feel bad for the patient. From what I have seen some of the decision weight for the doctor is knowledge of the patient. That knowledge is not available to the insurance companies. Although we have socialized health care here in Canada, there are similar problems for employees who are injured on the job and are in the care of our Workers Compensation Board. In that case the WCB determines treatment. I had one employee with a serious back injury. He got an MRI but the the WCB would not authorize an operation – they told him to lose weight. Assholes. He even brought the MRI results to the office and showed us the narrowing where the nerves were being pinched – it was obvious. They said that the narrowing was tolerable if he lost weight/ After months of pain and a lot of lost weight, the problem persisted and he had the operation. That cured the problem and he was like a new man. They could have saved him 6 months of pain if they hadn’t tried to drag it out. (We pay WCB insurance premiums from wages in case of job injury. Then WCB determines and pays for the health care to the system.) .

    It seems so subjective – one doctor will say one thing and another will have a different opinion. Naturally any insurance doctor will try to minimize costs even to the detriment of the patient. I really don’t know if there is any solution to that. I do not envy you your situation (balancing what you feel is right for the patient against what the insurance company will pay for). It must be very difficult.

    Liked by 1 person

  11. So unfair! In the past three weeks I have heard “You’re on Medicare?” Then, “Not a problem.” To cover an ultrasound on the kidneys that showed up bad stuff on an MRI for my spine that the pain management doctor requested…. But in order to get the ultrasound, my pain management doctor had to contact the urologist who had to see me to write/order the script to have the ultra sound. It’s the system, but how simple (often) the Medicare works. Now in order to get from the pain management doctor to have physical therapy, I had to see my primary for a script to have the physical therapy. Oh, the wonder of it all. Pain = $141 (Medicare paid $84); urologist = $141 (Medicare paid $84); primary =
    $141 (Medicare paid $84). MRI = $1,102 (Medicare paid $189!!!!!)

    For the readers: I had a total knee replacement ten years ago. While in England, I overdid something, and had some swelling. Where I was staying did not have an ice machine, so we had to go to a restaurant to get ice. Then I was able to get into an ER at a small neighborhood hospital. Since I did not have UK insurance, I had an apologetic physician who had to collect 25 pounds to look at me. Sent me home, with a prescription to see a neighborhood physician the next day. “Use ice.” In the waiting room next day were two lines/receptionists: No, not “colored” and “white”; but rather “insured” and “no insurance.” Another 25 pounds. I saw the physician in her examining room/office. (Cute.) She said, “Just stress and some fluid. Ice will suffice. You should see an orthopedic surgeon. When are you leaving for home?” “In a week.” “See your physician as soon as you get home. It will take four weeks or so for me to get you to see orthopedics. Go to a sports store and get a knee brace.”

    Any questions?

    Liked by 1 person

  12. I so feel your pain. We have to go through hoops for auths. And we don’t write the orders, we just execute them. So why so much crap? Try explaining home bound sometime, using the language CMS used. Crazy. Our bugaboo now is we get the auth, we visit, discharge and get paid. Then the insurance company comes in and does an audit of charts every quarter and takes back payment in huge amounts. Why? Well we have asked that several times and they come back with….because we said so. Reminiscent of parenthood. We have asked for clarification and they say, well, if your unsure of your documentation, you should call their Customer Service and talk with someone before we bill. But we write our documentation when we are in the home seeing the patient, so what do you want us to do? They just basically say one of my most unfavorite statements… “It is what it is.” Actually one brave representative said we should fight back each withheld payment and they will relinquish a portion of it without contesting it….so you can see the reasons truly are because they can. They make homecare very difficult to do which is why the largest agency in NYC is getting out of the business. Next up on the fun parade? Can you say bundles????

    Liked by 1 person

  13. That’s so frustrating. There never seems to be a rhyme or reason to these health insurance rules (other than to help their own bottom line). Denying coverage over strange rules is always a scary concept to me, even scarier though is when they deny something altogether, no matter what hoops you offer to jump through…or the lifetime $ limits of healthcare. Scary stuff.

    Liked by 1 person

  14. oohhhh i totally understand how you feel! i spent a total of an hour on the phone today, trying to do a PA for a Rx (i got transferred 4 times before i talked to the right person!) it’s so aggravating!

    *breathe in* *breathe out* *reminding myself to calm down*

    =) btw i really enjoy your posts!

    Liked by 1 person

    • Thank you! Prescriptions are worse because there are so many of them and the covered meds change every year, just because. Now I am going to have to go find my bit of cool wall to press my forehead against again…

      Like

  15. Thank you for “speaking out” about this stupidity, for we will not go quietly…….. Is there some kind of organization that fights against bureaucracy like this? If so, I hope it’s simple.

    Liked by 1 person

  16. I can’t imagine how frustrating it must be for you as well as for your patients. In Australia all taxpayers pay a 2% levy on their taxable income. Because I am a pensioner I pay $0.00 . If I earned over about $80,000 I might have to pay an extra 1%. But it mean that my brother who is quite well off and I could share a twin room in a public hospital for a by-pass for free. But if my brother wanted to pay extra for some private insurance he can go over the road to St John of Gods private (commonly known in Ballarat as St Jack of Jesus)and choose his own surgeon and have a glass of wine with his meal. And although we are almost as anti socialist as Americans are we don’t seem to make much fuss. Now for example, I am in the process of getting a full dental plate. If I go to a private dentist I am up for a few thousand dollars. But if I am prepared to wait a bit I can get one made, but I pay $16 per visit irrespective of what they do. But if I am prepared to let the dental students do the work (practice on me) it is ALL totally free. But I do have to pay to put money in a parking meter. And the students are good because they have very senior supervisors and they are using some of the newest technology. But it does take time.

    Liked by 1 person

    • See….. Dental, not covered. You have to have separate policies for that and even then you will end up paying through the nose. AND good luck finding a glass of wine with your meal at any hospital!

      Like

      • And I don’t see why good dedicated doctors who bash their heads against the bureaucracy don’t start looking seriously at working in Australia. As a country town general Practitioner they would throw a party for you and make you honorary president of all the local sports clubs and maybe even throw in a house.

        Liked by 1 person

  17. Pingback: My Article Read (3-26-2015) | My Daily Musing

  18. This was really interesting to me. I’ve never thought of a doctor being involved at this level: Not involved in the specifics of these calls, because there is staff for that, but even more, not as emotionally involved. (Many autoimmune folks have had negative experiences with many doctors before and even after getting diagnosed–I’ll be blogging about mine).

    Do you think your level of caring is typical? (I applaud you for it, and sympathize with you. And the patient!)

    Liked by 1 person

    • I think that 95% of the physicians I know really care deeply and try very hard to take care of patients well. I am so sorry you have had bad experiences. Patients don’t know this sort of thing is going on behind the scenes which is why I blog about it. We ALL have to deal with it. The ones that care are more likely to get burned out, though. When you deal with this sort of thing day in and day out it tends to rob you of your soul.

      Liked by 1 person

      • Even though I HAVE had a number of caring doctors, I am surprised at your high estimate. That means either I have seen a statistically fluke-ish number of outliers šŸ˜‰ or the same number have done a good job of hiding their humanity–which they may have been taught under the old-school med school approach.

        (Whereas today’s touchy-feely approach sometimes results in the opposite: A young doc who thinks s/he is qualified to assess you psychologically and focus your first visit on mental shrinkage to the exclusion of your chief physical complaint.)

        I very much understand the “rob your soul” aspect, for I live this daily. I DO deal with it day in and day out, and have for years and years, for my own medical care. It is a soul-sucking nightmare, indeed. And we, the patients, wind up repeatedly in Collections when the various entities err, which is something you doctors do not need to face.

        Liked by 1 person

      • You are correct that old school docs hide their humanity and the younger ones are often too touchy feely. Insurance companies change the rules on us all of the time and we don’t hear about it until patients call upset about a bill. What would it hurt to send a notice to physician offices that accept your plans to say “Hey, this or that is changing…”? It is an us against them thing with patients caught in the middle.

        Liked by 1 person

      • I’m sure most is simply incompetence, but: Reference the other comment, too, about “follow the money”. It is in the interests of parties who bill and insure to keep obfuscating rather than clarifying. You can’t hide the pea if there are no rapidly-moving cups.

        Liked by 1 person

  19. There are so many more layers in health care than ever before…this breaks down to more and more salaries/bonuses/executives eating up the money that should be going to the patients. It has become big business rather than health care…

    Liked by 1 person

    • I could not agree more. CEOs making tens of millions of dollars across the country. Physicians are actually at the bottom of the income bracket which is maddening on some level. There are people with masters degrees making more than I do after four years of medical school and another three years of residency and really my job is what makes it happen for them. THEY never have to take call or go in in the middle of the night. I could go on but perhaps that is better saved for another post!

      Liked by 1 person

      • It worked best when the doctor’s ran the system and health care was the focus. Once the lawyers/accountants/insurance people figured out they could make money on it…they ruined the system. It should all be not for profit then there would be more than enough money for doctors and their patients. They need to eliminate the middle man/woman that stands in between and produces nothing but a justification for their positions.

        Liked by 2 people

  20. I know a chiropractor who does not deal with insurance at all except to give you a statement in case you want to try to file yourself. Her fees are significantly lower than those who do file insurance for you. She figures she doesn’t have to pay support staff to do the insurance paperwork. I wonder if there are any other doctors who work that way. Of course chiropractors are different because a lot people don’t have health insurance policies that cover chiros anyway.

    Liked by 1 person

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s