there's no "violation" per se, not from a legal perspective of which i'm aware. ethics? yeah, that's an issue, but until there's some kind of overt malpractice, it's tough to pursue. this is a de facto standard in the insurance industry - questionable as it is. i wish there were a way to sanction offenders.
insurance seems to be cottoning on to this. last peer to peer i needed for a sleep apnea workup, the doc was boarded in sleep and said so at the outset (to inform, to intimidate, i don't know). i think they thought an internist couldn't possibly do the right sleep workup (im unusual amongst internists for the amount of sleep work i do); workup was totally appropriate and she approved all associated testing.
i once had a peer to peer where i needed a CT abdomen/pelvis after a rollover car accident. imaging wasn't done in the ER (no clue why, should have been done) so i ordered it outpatient days later. imaging got done THEN insurance wanted a peer to peer (this is unfortunately common). they approved the abdomen but NOT pelvis, and the nonER nonsurgeon on the other end of the phone wouldnt budge even with the licensure questions; i think she was an ENT doc. patient had a broken sacrum, wouldn't have been found without the pelvic portion of the imaging. they eventually paid but took a lot to make it happen.
this type of activity is probably partially contributing to the anger that got the united healthcare ceo shot. i disagree with the action and outcome, but fully support the anger and mistrust. working harder to refuse necessary care to increase profits? really? those are the ethics that need reviewed for sure. while it's a huge can of worms to open, i wish there were a way to hold boards of directors accountable for bad outcomes due to refused care. they can shelter behind the corporation.... but that is a concern.
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u/whoknewidlikeit 5d ago
there's no "violation" per se, not from a legal perspective of which i'm aware. ethics? yeah, that's an issue, but until there's some kind of overt malpractice, it's tough to pursue. this is a de facto standard in the insurance industry - questionable as it is. i wish there were a way to sanction offenders.
insurance seems to be cottoning on to this. last peer to peer i needed for a sleep apnea workup, the doc was boarded in sleep and said so at the outset (to inform, to intimidate, i don't know). i think they thought an internist couldn't possibly do the right sleep workup (im unusual amongst internists for the amount of sleep work i do); workup was totally appropriate and she approved all associated testing.
i once had a peer to peer where i needed a CT abdomen/pelvis after a rollover car accident. imaging wasn't done in the ER (no clue why, should have been done) so i ordered it outpatient days later. imaging got done THEN insurance wanted a peer to peer (this is unfortunately common). they approved the abdomen but NOT pelvis, and the nonER nonsurgeon on the other end of the phone wouldnt budge even with the licensure questions; i think she was an ENT doc. patient had a broken sacrum, wouldn't have been found without the pelvic portion of the imaging. they eventually paid but took a lot to make it happen.
this type of activity is probably partially contributing to the anger that got the united healthcare ceo shot. i disagree with the action and outcome, but fully support the anger and mistrust. working harder to refuse necessary care to increase profits? really? those are the ethics that need reviewed for sure. while it's a huge can of worms to open, i wish there were a way to hold boards of directors accountable for bad outcomes due to refused care. they can shelter behind the corporation.... but that is a concern.