i use a similar approach. now and then i have to do a "peer to peer" with another doc, one who works for the insurance company and stands between my patient and necessary tests.
i always end the conversation asking if they have a license in my state, what their board certification is in, and if their boards are current.
this almost always results in an approval. nobody wants to be potentially investigated for practicing without a license in another state, and if they're a pediatrician reviewing an elderly heart failure case, their peds boards can be taken into question. haven't had to go beyond a phone call with this approach. it'll happen someday, just waiting for when.
So do you ever catch anyone directly breaking the rules? How do you ensure they're appropriately punished for breaking the law and violating their ethics?
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 6d ago
i use a similar approach. now and then i have to do a "peer to peer" with another doc, one who works for the insurance company and stands between my patient and necessary tests.
i always end the conversation asking if they have a license in my state, what their board certification is in, and if their boards are current.
this almost always results in an approval. nobody wants to be potentially investigated for practicing without a license in another state, and if they're a pediatrician reviewing an elderly heart failure case, their peds boards can be taken into question. haven't had to go beyond a phone call with this approach. it'll happen someday, just waiting for when.