by Elizabeth Hofheinz, M.P.H., M.Ed., October 24, 2019
You spot a young man on the ground, holding his neck and writhing in pain…would you help?
You would,
but an insurance company wouldn’t, says one spine surgeon. “I am so sick of insurers
finding any excuse to deny coverage,” he states. “They really love to say that a
procedure is ‘experimental’ and are not at all clear about when exactly something
reaches the point of being nonexperimental. The insurers hide behind the
argument of ‘protecting patients’ from ‘experimental treatments.’” 
“For example, if a surgeon wants to perform a fusion for discogenic back pain there is no way to do that under the AIM criteria that BCBS and other insurers are standing behind. They have used ‘experts’ to compile extremely conservative guidelines that have no ability to make case-by-case exceptions. This is not the way medicine is intended. Their purpose is to decrease the number of procedures done and give themselves the ‘cover’ that they are not making the determination, but a group of expert doctors are. This is a farce and causes harm to patients that have paid a great deal of money for insurance to take care of themselves only to find out that they really don’t have insurance.”
“I understand that there are too many fusions going on these days. I tend to be conservative and always attempt conservative management with rest, medications, physical therapy and sometimes injections as a first line of treatment. But there are many situations where patients still end up needing fusion in order to be able to live a reasonable life.”
“I had a 33-year old patient with an injured disc who could not walk, sleep, or work. The guy was miserable, so I did an injection, which worked. He was very fortunate because the insurer would never have covered surgery based on his specific criteria.”
So what the hell is a surgeon to do?
“If the patient is employed by a large company—where there are a lot of lives being covered—there is a chance that the HR department will help out. Sometimes, a good HR person will get on the phone with the insurer and say, ‘We want this surgery done.’ I’ve seen it work.”
“For years surgeons have been accused of wrongdoing or fraud, but what about the unethical position that insurers put us in? There we are, watching someone’s life fall apart, and if we only check a little box saying that ‘yes’ Mr. X or Mrs. Y has urinary retention in order to get the surgery approved, then what do we do?”
Envisioning what happens behind the scenes at insurers, this surgeon notes, “Level one in the approval process is frequently a high school graduate. If this person sees that all of the ‘boxes are checked’ then the procedure likely gets approved. If not, then it is either denied or a peer review occurs costing the insurance company money for their review physician and the surgeon time out of their day—which is uncompensated—to discuss the case with the peer review physician.”
“Frequently the peer review physician can only regurgitate that company’s guidelines and has no power to make an exception. Thus, becoming a waste of time and money for both parties.”
“The other issue is that the peer review physician may not be able to understand the problem because they are a different specialty than the surgeon. In that case, it truly isn’t a ‘peer’ review.”
“Typically, these denials and peer reviews occur in less than 24 hours of the proposed procedure even when the insurance company has had the request for 2 or 3 weeks. Most important is the denial incredibly inconveniences the patients who have taken off time from work and made other arrangements. Sometimes family has flown in. The patients now have to have extended time of pain and disability unnecessarily. Although less important, it leaves a hole in the hospital and surgeons’ schedule for the following day and the support staff and vendors may have spent significant time and revenue flying in implants or personnel for the procedure. The total emotional and economic costs are huge when you consider all parts of process.”
“One issue is that we surgeons don’t know what all the boxes are. It is a ‘shell’ game that is made purposefully that way to allow the insurance companies to have further control.”
And if he could corral the insurance companies in one room for an hour, he would say…
“Ladies and Gentlemen, our first responsibility is to our patients and provide care in a timely fashion that is appropriate and will help restore our patients back to a functional lifestyle. Although I support the use of guidelines, they should be ‘just that’, guidelines. Not ‘black and white’ inflexible criteria to stand behind to deny a case. In life and medicine there are always reasonable exceptions to be made. What we ask, is that we be allowed to practice medicine in a safe and reasonable way that is in alignment with the standard of care and that peer review physicians have the power to make exceptions. Further, we would ask that peer review physicians be truly our peers —physicians/surgeons who are in active practice actually performing on a regular basis the procedures we are requesting for the same indications.”