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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Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. Dr. Segal is a Fellow of the American College of Surgeons; the American College of Legal Medicine; and the American Association of Neurological Surgeons. He is also a member of the North American Spine Society. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.
Dr. Segal was a practicing neurosurgeon for approximately ten years, during which time he also played an active role as a participant on various state-sanctioned medical review panels designed to decrease the incidence of meritless medical malpractice cases.
Dr. Segal holds an M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.
In 2000, he co-founded and served as CEO of DarPharma, Inc, a biotechnology company in Chapel Hill, NC, focused on the discovery and development of first-of-class pharmaceuticals for neuropsychiatric disorders.
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