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Doctors With Histories of Big Malpractice Settlements Now Work for Insurers
(www.propublica.org)
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this post was submitted on 17 Dec 2023
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I don't like insurance companies. But the skills required for surgeon vs medical director are vastly different. Lacking the skill to perform a surgery doesn't preclude the knowledge of medical necessity. I don't have any problem with someone switching careers when one clearly isn't working out, especially when the one not working out is 'surgeon'.
Except these physicians are often completing something called a "peer-to-peer" on behalf of the insurance companies, not just making broad treatment decisions. This is a process by which an ordering physician is required to call a physician employed by the insurance company to justify a testing or treatment course to their "peer". Unfortunately these "peers" are often composed of physicians who did not complete residency and/or who do not currently practice, let alone in the specialty of the physician who is required to call for the peer-to-peer.
This leads to rather absurd results in which a board certified, practicing sub specialist (cardiologist, neurosurgeon, oncologist, etc) with 5+ years of specialized training after medical school has to convince a physician who may never have even practiced that they know what they're doing. I personally think if you're not a neurosurgeon, neuroradiologist, or neurologist then you aren't really qualified to cancel a neurosurgeons MRI, but hey, I don't get a bonus for denying claims.
From what I can tell, those peer to peers are primarily used to make the physician decide he doesn't want to waste the time doing a peer to peer. You'll eventually get to the point that the insurance company WILL be liable for adverse outcomes for denying the intervention, and they want to toe as close to that line as possible.
No the insurance company is basically never held liable (at least to the best of my knowledge). They claim they aren't dictating care, just determining whether or not they would pay, and that the patient's treating doctor should be the only one liable even if the insurance company denied coverage for recommend treatments or tests that would have prevented the adverse outcome. People have tried to sue them for delays in care they've caused but generally unsuccessfully as far as I know. Unfortunately insurance often denies payment for very needed care even after many appeals and prior auths and tons of other bull. So yes they are trying to waste time and hope the doctor doesn't try to go through appeals and peer to peers and things (that eat up many hours of time and end up costing the healthcare system as a whole even more money), but there's no guarantee they will come around and actually pay up in the end even if that's all done. And they aren't held responsible even if they effectively prevented needed care by refusing payment. They're a cancer on our healthcare system.