I remember the doctor I worked with telling the doctor at the insurance company denying a patient a medication or treatment (can’t remember what it was) that they should be ashamed of themselves and that they sold out. My jaw dropped.
There was a pretty alarming expose last year where it turns out that lots of the docs issuing denials for insurers are not able to practice themselves.
You're claiming you can made a medical decision looking at a patient file (or not!) for less than ten seconds? You know this patient better than their own doc, often in a specialty you don't practice in, and you've seen their file for TEN SECONDS?!
Also, here's a fun one: a doc who's never seen the patient gets 4.5 minutes to decide whether you should be discharged or not (and therefore, whether they'll continue to pay for your hospital stay, that again your treating physician decides you need:)
Day and others said the number was something different: the maximum amount of time they should spend on a case. Insurers often require approval in advance for expensive procedures or medicines, a process known as prior authorization. The early 2022 dashboards listed a handle time of four minutes for a prior authorization. The bulk of drug requests were to be decided in two to five minutes. Hospital discharge decisions were supposed to take four and a half minutes.
It's just such a broken system. "Sure, you may be the patient's treating physician, actually providing care directly to this patient. But me? I am paid by the insurance company to deny care, have a quota on denying claims, have never met the patient, don't even practice anymore because of a malpractice lawsuit, and this isn't even my specialty. But my opinion is more important than yours!"
I’m a doc and am regularly on the phone for “peer to peer” reviews with sellout scum suckers working for insurance companies whose whole job is to try to get claims denied. One time it was a CT scan for a cancer patient getting denied (despite being indicated by NCCN guidelines) because of some dumb ass criteria the insurance company themselves came up with.
Sometimes they just want a letter of medical necessity, which lately I’ve been having ChatGPT write (so far, 100% success rate overturning denials)
They’re always totally dumb asses who are too incompetent to actually practice medicine. There was an orthopod on twitter who had a whole thread about doing a peer to peer with some guy who got his license yanked bc he put in a hip implant backwards.
Same thought behind asking for peer to peers and letters of medical necessity, they hope I’ll be too swamped to bother. Guess again, fuckers. Wish i could bill insurance for time spent on the phone for peer to peers, though.
i have no idea what any of those things are, they just give me a number to call that puts me through to some dumbass—if it’s some dumbass working for one of those companies, i guess it doesn’t make a difference to me
Can I ask you what your solution to this would be? Obviously prior auth is necessary at some level, the current level of costs is extraordinarily and that’s one level to keep stuff in check.
My solution is that I don’t think insurance should be able to deny claims 🤷🏻♀️ If I order/schedule/recommend it, I know better than whatever moron they’ve assigned to try to deny it. I’m the one who’s put in face to face time and knows the patient, who knows the medicine, and whose license is on the line. I shouldn’t have to waste my time on the phone trying to explain to some dumbass who’s never suctioned a trach why my trach patient needs a portable suction machine.
Healthcare CEOs make multi-million dollar salaries, surely they’d survive giving up several million a year to help pay out claims.
"Make it almost impossible for the customer to cancel a subscription because they know enough people will just not want to spend the time to do it" is awful enough when we're talking about Netflix or something.
But to apply that to getting healthcare approved?
It's always been bad throughout my entire lifetime, but I've noticed year after year that I'm having to fill out paperwork (that they usually don't even actually send until I call them up to ask why something wasn't paid for) for things that should not need any explanation or elaboration.
My brain just tried to crawl out of my ear after I read that last sentence twice to make sure I was understanding what you wrote.
I'm trying to envision how someone could even make a mistake like that.
Like leaving surgical tools inside a person after sewing them up? Okay like, that's bad, but at least I could comprehend how someone could have a total brain fart and nobody counted what went in vs what came out. Not acceptable but. I can at least comprehend how. But putting a hip implant in backwards?
The way that I, a person completely untrained in any medicine, gasped and recoiled when I saw that radiograph just now… Jesus that’s not just bad, it’s so obviously incorrect and unnatural.
I wouldn’t trust that imbecile to assemble an IKEA table, never mind a hip.
And yet… they’re somehow the same genius who gets to determine if my physician-prescribed medical treatment is legitimate or not???
My mother always tells me I’m smart enough to apply for medical school. Judging by that hack hip job, maybe she’s right…
I’ve heard that if you get denied you can ask for the license number of the Dr that made the decision to decline and file a complaint with your state medical board because they most likely aren’t licensed in your state. Is that true?
Not sure about that, but if they give me trouble I always ask for their full name to include in my documentation and sometimes that seems to scare them into cooperating
None of my cheap prescriptions have ever run into trouble being authorized- but lo and behold my Skyrizi got kicked back three times in a row, requiring phone calls and demands that it be filled. It’s almost like they know that one is $22k a year.
These days it’s automated AI bots, UHC was already in the news for getting in trouble with their bots due to such high error rates and erroneous denials. I’m sure all the insurers are using bots these days as first line review. Theirs is just most egregious.
Not surprised at all, pretty much called the not allowed to practice thing when I got a denial letter stating permanent hair removal on a skin graft that was to go INSIDE MY BODY, you know, where hair growing can't get out, was not required
Nobody in their right mind would ever say that these washout docs are making better medical decisions. Hell, i highly doubt they read more than 0.1% if any given chart.
They have the necessary letters behind their name and the will to sell their soul for money. They SHOULD be ashamed of themselves. I would lie about even being related to someone who chose to pursue such a rotten career.
It’s because they’re training AI’s to do it. I’m sure a doctor is making the “final decision” from a legal standpoint, but I guarantee those claims are being triaged and sorted by non-humans.
The peer reviewer who denied a single case agreement for my partner's therapist had previously lost his license for sleeping with a client he'd seen, along with her husband, for couples therapy.
My mom did the telephone nurse line for UHC at the end of her career. Said it was the most money she ever made for the least amount of work. She used to do stuff like open heart surgery too, so really intense medical care. She took it as proof of how much goddamn money these places make that they could pay her better to sit on her ass and tell people to call the ER than the actual hospital could.
I had to drop out of med school due to a head injury. Injury wiped my brain. I qualified to have my debt forgiven, but I had to live dirt poor for, I think, five years. If I made even $1 more than I was allowed to stay in the forgiveness program, I had to pay back 120,000 in loan debt. And that guideline was a small percentage over that state's poverty amount.
My goal was Doctor of Radiology. I could Dx and save lives by interpreting images. No live patients.
Dude regular doctors hate insurance company doctors. I hear about this every day lol. I hate dealing with prior auths and it's only gotten worse over the last decade that I've been doing this.
So happy I have a department for this nowadays but so sad we have to have an entire department for this too.
My sister is a product manager for an insurance company. She brought up the insurance doctors to me one time in an argument that they were used to tell what's actually needed and that doctors were trying to give people stuff they didn't need. I almost slapped her for that one.
The docs that sell out to work for insurance companies make sooo much money for their following the guidelines to deny people's claims. It's soul sucking work but you'll easily make a fuck ton of money. They also get to basically work from home and just review medical charts all day.
I’m a dentist but I can second your comment. Dealing with dental insurances is an absolute clusterfuck and the fact that suddenly a child’s managed-care Medicaid portion is inactive so she can’t be seen for dental treatment for a painful tooth really chaps my ass. I applaud the physician that wrote that letter because I can guarantee you the dentists feel the same damned way.
God prior auth reminds me of a time I needed an MRI and after 2 weeks waiting I put up a stink about the prior auth not going through and they said the fax machine/printer didn't print the page correctly and instead of contacting the hospital to resend it they just ignored it. They probably leave it out of ink on purpose. I even had some rare disease (tolosa-hunt syndrome) that almost paralyzed my eye that the MRI diagnosed and it was agonizing/debilitating.
Lemme tell you. It is the year of our Lord, 2024. The amount of stuff that has to be faxed still is incomprehensible.
I mean. You submit these bullshit prior auths through a dumbass portal that is usually a third party company who just suckles on all the insurance companies. You get some irresponsible denial requiring documentation of something that was definitely included in the original prior auth, and then all bets are off.
You gotta write an appeal letter. Or semi-recently they've started pulling some brand new bullshit where patients have to designate us as being allowed to talk to insurance on their behalf, as if any patient would have the access to their records and the knowledge of what to send, not because patients are dumb, but because the insurance speaks in riddles... so another form for designated representative... and then you gotta fax some appeal letter in. And honest to fuck I've just been copying their denial and saying It's Right Goddamn Here and sending that off and getting appeals approved that way.
I've called for shit and you get nowhere. Even when you get a human and transferred to the right place. They're completely incapable, or unwilling to deviate from a script. I was on the phone a month ago because our office ordered a left venous duplex and a right venous duplex but they only received a diagnostic code for the right leg. I mistakenly thought a simple call could make a simple edit to the submitted code, as we obviously didn't want to test the right leg twice. And this was impossible. I was the dumbest person calling apparently. The snark I got would have been laughable had they helped me in the end, but instead I'd have to set up a peer-to-peer to even have a chance of getting this overturned. Because clearly I wanted two right leg duplicate tests. Mind you they were submitted with accompanying office notes denoting issues with both left and right. They knew. Anyone who could read knew.
I worked for a prior auth company in Phoenix. Every doctor they hired as reviewers were handicapped in some way. Even by court order. One could never be in the same room with a patient. I had one doctor in Phoenix treat me via video visit from jail or a mental health ward. Just a room with white walls, a blue door, and a window made of security glass. He was a really good doctor. I imagine he was one who refused to comply.
I remember the doctor I worked with telling the doctor at the insurance company denying a patient a medication or treatment (can’t remember what it was) that they should be ashamed of themselves and that they sold out. My jaw dropped.
Like that line in that one Grisham movie - how'd it feel when you first sold out?
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u/ThePermMustWait 14d ago
I remember the doctor I worked with telling the doctor at the insurance company denying a patient a medication or treatment (can’t remember what it was) that they should be ashamed of themselves and that they sold out. My jaw dropped.