Since the murder of the United Healthcare CEO, there have been any number of articles on the horror that is the US health care system. Even though, in my practice, I didn’t accept any payments from insurance companies, they still managed to make the lives of many of my patients miserable (or short, or both). The callous profiteering in that industry reformed my belief in the basic goodness of humanity, and was a major factor in my decision to retire.
I have stories. Way, way too many stories of abuses visited on vulnerable people by the health insurance industry. I read an article yesterday from ProPublica about one insured person’s plight, though, and it illustrated a small but particularly galling part of my experience.
https://www.propublica.org/article/unitedhealth-healthcare-insurance-denial-ulcerative-colitis
Did you see the part about the peer-to-peer phone call? That’s a favorite trick of insurance ghouls. They pay off some doctor — one who has never seen the patient in question and knows almost nothing about them and often wouldn’t be qualified to treat them anyway — to have a “peer to peer” phone call with their victim’s physician. Afterwards, they tell their victim and their family that “your doctor agreed with our doctor that your treatment isn’t medically necessary.” If confronted with their lies, “oh, it must have been a misunderstanding.”
The second time this happened to me in my own practice, I decided never to talk to insurance company people, lawyers, or (worst of all) insurance company lawyers on the phone. It helped that I generally hate telephone calls anyway. But the pattern had been emerging when I worked for the University and was pretty much required to take those calls. When I was in private practice and there was nobody but me who could have possibly “agreed” with the “peer” doctor, I finally recognized the game for what it was. In email or letters, there’s a paper trail. On the phone, they can make illegal threats, lie about conditions, try to bribe or extort, and engage in any manner of abhorrent, extra-legal behaviors without consequence. And they did.
One time I relented, but told the “peer” I was recording the conversation. He hung up without another word.
I should be clear that I was never uncooperative about communicating with the ghouls. I invited them to email; I offered them access to my secure messaging system; I would write letters and invite them to respond; I would exchange faxes — but I would not talk on the phone. None of that stopped the ghouls from claiming that I “wouldn’t answer their questions” or even claiming that I had agreed with them during a phone call that never took place. They are shameless.
I hope that none of you ever have to fight with an insurance company to get the life-saving care you need and paid for, but it seems inevitable that most of us will have to do so at some point. So here’s some advice:
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If you make it to Medicare age (or qualify for other reasons) don’t opt for a “Medicare Advantage” plan no matter what promises they make. Medicare Advantage plans make their profit by denying care. Period. Deny them the opportunity. Every time you get another Medicare Advantage come-on — and you will get many — remember that they’re fighting for your business because they know it will be so profitable to deny your care later on.
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Insist that everything be in writing. Yes, it’s a pain in the butt to write everything down. Yes, the insurance companies will suddenly develop a new-found concern for your confidentiality to try to refuse to let you use email. Printing and mailing letters is a pain and slows things down. But what really slows things down is allowing insurers to lie and cheat with impunity, then deny it all because you’re not allowed to record their perfidy. (I suppose if you live in a one-party consent state, it might be okay to do phone calls, but consult a lawyer first.)
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If they tell you a treatment isn’t medically necessary, insist that they tell you the name and license number of the physician who made that determination. I’m not a lawyer, but I believe in most states you have to be a physician licensed to practice in the patient’s state to make such determinations.
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Sometimes, they’d give me a name and license number. I’d then contact that physician and asked how they justified denying life-saving care but I’m glad they were willing to assume full legal liability for their decision. (In most states physicians are required to have a contact address published on the medical board site.) Often, the physician would reply that they’d never heard of the case. When I’d send them the written correspondence where their employer had asserted that they had made the determination, it usually resulted in the insurer rapidly backing down — presumably after the physician confronted the company with demands that they not make such false representations.
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Occasionally, the doctor would admit to making the determination, but then be horrified when confronted with the actual facts of the case — about which they had been kept in the dark.
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One time, I was told the determination of lack of medical necessity had been made by a pharmacy technician. That would be like having a pool typist in a law firm represent you in court. I reported that one to the Medical Board of California (“we don’t concern ourselves with those kinds of things”) and the Board of Pharmacy (“we don’t see anything wrong with that.“) I saved copies of those letters from the boards because they were so outlandish.
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Often, just demanding the name would cause the insurance company to back down rather than just admit they’d made the whole thing up.
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I’m sure that I’m not alone in having the murder of an insurance company CEO dredge up all kinds of horrific memories. There must be a lot of that around the country right now.
—2p