Insurers Aren’t Always the Bad Guy – Even if They Often Are

Some of you may have read my article from last week kindly published as a special bulletin. For those who did not, let me recap. There was a huge recent social media uproar when a plastic surgeon posted a video describing how she was called out of the operating room in the middle of a surgery to talk to an insurance company medical director to get approval to admit her patient as an inpatient after surgery.

The outrage certainly seems appropriate – unless you dig into the details.

As best as I could determine, the patient’s breast reconstruction surgery was prior-authorized as outpatient surgery, and when the surgeon informed the staff that morning that the patient would be staying overnight, instead of simply reserving a bed for the patient for routine overnight recovery, they called the insurer for inpatient authorization. The insurer offered a peer-to-peer discussion, so the staff pulled the doctor out of the OR.

This was a total failure of the utilization review process at that facility. Monitor Mondays listeners all know that planned overnight recovery is not a valid reason to request inpatient admission. Requesting that the surgeon break scrub to talk to an insurance company doctor is also not appropriate; calling the physician advisor to sort this out would have been the right action. The insurer was right here. Yes, that’s right: they can be right, and we can be wrong.

Another case that recently hit social media also fits into the same category of inappropriate anger directed at a payer. In this case, someone on LinkedIn posted about a patient with bile tract cancer whose insurance company was denying approval for a liver transplant, leading the patient to start a GoFundMe to try to raise money. This patient’s plea included a picture of him with this wife and small children. As expected, outrage at the payer ensued.

The post even included the denial letter from the insurer. And from that letter, we can see that he has a diagnosis of primary sclerosing cholangiocarcinoma, and the payer denied coverage for the transplant, noting that it is not medically necessary.

Rather than jump on the bandwagon, I used available information and did some research. One of the definitive resources for determining proper treatment for cancer is the National Comprehensive Cancer Network (NCCN), which publishes evidence-based guidelines for treatment of almost every cancer at every stage. And NCCN clearly states that liver transplant is not indicated for such a patient, outside a research protocol. Inappropriate outrage once again.

As it turns out, it appears that the payer did eventually approve the transplant. Did they get additional clinical information, or simply bow to the social media pressure? We don’t know.

I know these decisions can be extremely emotional, but organ transplantation faces the issue of limited supply; it is not like an insurer denying coverage for a knee replacement. Who is advocating for the other patients on the waiting list who now may be bumped down to make room for this patient, possibly endangering their lives?

Dr. David Duncan, a physician advisor at Inova Health, summarized this well in his LinkedIn response. He said “one of the requirements of being an adult is gaining perspective and admitting when you’re wrong and don’t have enough information.” What good advice.

Alas, my defense of insurers could only go so far, as I recently personally became a victim of their games. In January I had my screening colonoscopy, per the U.S. Preventive Services Task Force recommendation for patients my age. The procedure was performed at an in-network ambulatory surgery center by an in-network physician. According to federal law, such a screening test should be performed without any financial obligation to the patient.

I was then surprised when the statement arrived from the gastroenterologist, indicating that I owed about $700 as my coinsurance. I noted on the claim that they coded the procedure properly, using the HCPCS code for screening colonoscopy and the CPT® code for anesthesia for a screening colonoscopy. Yet when Blue Cross of Illinois processed the claim, their system indicated I owed money.

I contacted Blue Cross and was told “the provider submitted this as a diagnostic test, not a screening test. You will have to get them to correct it.” I replied that I could see they used the correct screening codes, to no avail.

Rather than get into a never-ending series of calls back and forth, I decided to file a complaint with the state insurance commission for violation of federal law. Of course, that was rejected, but it did get Blue Cross to review the claim – and lo and behold, they noted that “the claim was processed incorrectly,” and they paid the provider the amount due.

I do not see any way that this claim could have been processed incorrectly unless the Blue Cross system was programmed to do exactly what it seemed to have done: change the code from a screening code to a diagnostic code to avoid 100-percent coverage.

Do I have proof of this? Of course not, but with such a simple claim with no extenuating factors, it seems difficult to come up with any other explanation.

This reminds me of the topic of another of my recent articles, UHC’s automatic downgrade of emergency department visit codes, also in violation of federal guidelines, using their proprietary tool. I know enough about the regulations to have called out Blue Cross on this, but I doubt every consumer will question their bill and be willing to make the effort to fight.

Programming note: Listen to Ronald Hirsch MD every Monday when he makes his Monday Round on Monitor Mondays with Chuck Buck, and sponsored by R1-RCM at 10 Eastern.