Dear readers, based on your long experience with health insurance carriers, what is the likely answer to these questions?
Insurance carriers generally prod doctors to do more tests or fewer tests?
Would a carrier ever “discipline” a doctor for exercising his reasonable judgment to limit the number of tests before his patient is discharged?
Assuming you have been in practice for more than one day, your answers, based on probability, are predictable. Insurance carriers work diligently to limit the amount of money they have to pay. They demand doctors order fewer tests, perform fewer procedures, and prescribe fewer medications. How many of us have received a letter asking to justify the medical necessity for doing our jobs? Aren’t the daily acts of practicing medicine the making and implementation of decisions that are medically necessary? If they aren’t, wouldn’t that be the province of the Board of Medicine?
Read on and welcome to Rod Serling’s Twilight Zone.
A patient went to an Emergency Department in Tennessee for acute neck discomfort, a headache and bilateral arm tingling. A nurse practitioner ordered CT head and cervical spine, which revealed significant degenerative disc disease at two levels compressing the exiting nerve roots. In addition, the nurse practitioner ordered an EKG (normal) and labs (all normal) – including troponin, sed rate, and C-reactive protein. The nurse practitioner’s working diagnosis was cervical radiculopathy. Once dosed with an anti-inflammatory, the patient felt better and was instructed to follow up with her primary care doctor.
Three days later, the same patient returned to the same Emergency Department with the same symptoms. This time, she saw an emergency physician with years of experience. This time, the patient, in addition to the arm tingling, also complained of a sore throat. Work up for the sore throat was unremarkable and the working diagnosis was viral pharyngitis. The physician reviewed the previous work-up, made note of that work-up in the chart, and made a decision that no additional acute work-up was indicated.
The patient did follow-up with her primary care doctor who ordered a MR scan of cervical spine. That study revealed compression of assorted nerve roots and spinal cord flattening by large bone spurs. The primary care doctor sent the patient to a neurosurgeon who scheduled the patient for surgery.
The surgery, spinal cord and nerve root decompression, was performed three weeks after the ED visit. Immediately, the patient felt much better.
The following evening, the patient’s oxygen saturation dropped. Cardiology consult was called. The patient apparently had a myocardial infract. She was treated and discharged.
Back to the emergency physician. He received a letter from the patient’s insurance company. Its Quality Review Department was labeling him a bad boy. Why? For missing a looming cardiac problem.
For penance, they asked he attend a CME course on atypical presentation of chest pain in females. The letter did not state what would happen if he ignored the request. But it’s unlikely they would have let it go.
To be fair, the department did ask for the doctor’s side of the story. That story was simple. The patient presented with focal symptoms, none of which pointed to a cardiac problem. He reviewed the prior cardiac workup (labs, EKG, history and physical) and saw no need for additional cardiac work-up. The working diagnosis was cervical radiculopathy. Even with the benefit of hindsight, that was still the correct diagnosis. The patient was told to see her primary care doctor. The patient did as requested. The primary care doctor picked up the baton, made a proper referral, and the patient was scheduled for surgery.
Yes, the patient DID have a post-op cardiac event. Preparing a patient for potential surgery weeks down the road is known as medical clearance. Medical clearance for an unknown procedure down the road is outside of an emergency physician’s domain. It belongs to the patient’s primary care doctor, the surgeon, and the anesthesiologist. Or the other doctors who join that team.
The emergency physician was neither clairvoyant nor omniscient. The patient had no history of cardiac disease. The emergency physician had no idea the patient had an MR study. He had no idea the patient would be scheduled for surgery.
More typically, insurance carriers scold doctors for over-ordering tests, over-prescribing medications, and performing too many surgeries. Here, the carrier scolded the doctor for not doing a deeper dive, though I’m not sure what the Quality Review Department would have advised based on the facts at hand – a cardiac cath?
When I was a medical student in the operating room, one of my first tasks was mastering the art of cutting the suture just above a surgical knot. Every surgeon had a different preference. Some said my handiwork was too short. Others said too long. The only way to learn was to ask, “Do you want me to cut it too short or too long?”
Physician decisions are already reviewed by peer review committees in hospitals. They are also reviewed by the Board of Medicine.
Insurance carriers are now stepping into the lane. Looks like over-reach to me. What do you think? Do I have it wrong? Is it reasonable for an insurance carrier to demand a doctor take a specific CME course even though he did a reasonable acute work-up? Your thoughts, please. Comment below.
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The carrier sent the letter to the wrong physician. It should have gone to the primary care physician who could fight it out with the carrier. The poor E.R. doc should be left alone.
The easier way to avoid these problems is to regain control of healthcare altogether. It can be done, it is entirely possible and we can completely turn the tables around, particularly when dealing with the healthcare industry. I explained the strategy in a short article I wrote recently in linkedin. https://www.linkedin.com/pulse/how-regain-control-medicine-keep-what-left-our-mike-miguel-pappolla-?trk=portfolio_article-card_title
Suppose they had sent the patient for a cardiac cath. Very likely she would have gotten a drug-eluting stent and placed on an anti-platelet for a year and then told by neurosurgeon that surgery for nerve compression will be delayed until the drug is stopped.
Because, of course, that’s usually what happens when you seek a cardio cath, maybe “just in case” and “covering our bases (or CYA)”
So that would have been a terrible thing for the patient, and perhaps the stress of worrying about an impending test or impending stent placement might have triggered an even sooner MI
Dr. Lewis made a very cogent point here.
In an unrelated point, perhaps many of us would benefit from more education or updates and not see such suggestions as being penalized, although I appreciate the added burden of ever more education.
Insurance companies used to be in business to reimburse reasonable medical billing. It is a real stretch to begin deciding on matters of competency and needed CME. In most states that is the job of the state medical boarding perhaps provider networks. It would seem that MBAs in these companies are obsessed with controlling physicians and reshaping the practice of medicine.
ER doc should have checked his crystal ball before discharging the pt
The insurance company is practicing medicine. There is nothing apparently wrong with the ER doctors care.
I can see them going after the anesthesiologist for the fact that the patient had a cardiac event 24 hours after surgery. But in reality if the anesthesiologist has no problems with the patient’s blood pressure and observes no untoward EKG findings intra or post operatively, then why is the anesthesiologist in similar cases chased after as though he had done something wrong.?
If anything happens in the 30 days after surgery to the patient on a neurologic or cardiac basis they will chase the anesthesiologist as though they did something wrong. That is why there are risks to surgery and there are physiologic changes that can occur. Anesthesiologists are trained to minimize any physiologic changes that are detectable during surgery and perioperatively. However, if something happens afterward as in this case, how is that an anesthesiologist’s fault.
Again the ER physician did nothing wrong, and the insurance company is off base completely. Will they file that recommendation with the state medical board too?
As most insurance company reviews are done by non-MD’s, this rebuke and recommendation for additional CME/training is likely coming from a non-MD and then ‘endorsed’ by an MD who signs off on the idea. This is a total overreach on the part of the insurance carrier. What medicine already knows is that bodies under acute stress, including pain can have variable reactions and cardiac stress is certainly a known morbidity. But an ECG, troponin and CRP had already been performed. As MD’s we all know that an ECG can be perfectly normal with a patient suffering a cardiac event 24hr later. Women in particular have more vascular spasm that men due to loss of female hormone, specifically estradiol. With that ‘vasomotor instability’ of loss of estradiol that is associated with hot flashes and night sweats, there is also the same vasomotor instability that impacts the cardiac vessels that feed the heart, and the carotid vessels that feed the brain. Yes, women have atypical symptoms; but until we REALLY do the full work-up for women, which includes their hormone levels and make the commitment in medicine to recognize that loss of estradiol is a high risk medical issue due to increased vasomotor instability, then cases like we see above will continue to happen.
Victoria J. Mondloch, MD
RHM of Waukesha
National physician trainer
Waukesha, Wi
First off, I have come to believe that a requirement for most to be hired by an insurance company is a very low IQ, an inability to speak and/ or understand English or both. Just saying, based on my interactions with them – and dental is far easier to deal deal with than medical.
Second, the patient’s age is not listed. Is she still pre-menopausal (producing adequate estradiol, etc), peri-menopausal (sporatic estradiol) or post-menopausal (and all bets are off)?
Yes, women usually present with atypical cardiac symptoms. But an EKG was done and found to be WNL. According to the insurance company, if a woman presents with indigestion after eating a questionably safe meal, should catheterizations be done to rule out cardiac complications, or will they then give the ER physicians and everyone else grief for ordering too many tests when it turns out to be negative? This is beyond a double-edged sword.
My husband, who was 60, went to an ER c/o chest pain. His father died of a massive heart attack at 56. It turned out to be gastric, but in the meantime, our insurance company didn’t want to pay for the ER visit, saying he should have gone to Urgent Care – who would have sent him to an ER anyway.
We need to reign in insurance companies who have become too impressed with the power that they have been, unfortunately, allowed. They can, perhaps, be allowed to pass judgement when they all obtain MD/DO degrees (or DDS/DMD degrees for dental insurance) and get several years of actual clinical experience under their collective belts.