Quora: How Does Insurance Impact the Way Doctors Treat Patients? Way Too Much

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Answer from Gary Larson, Medical Director - Procure Proton Therapy Center:

How much impact does a patient's insurance have on how doctors treat that patient? In the U.S., way too much!

I spend about 15–20% of my time dealing with insurance companies—advocating for patients whose carriers deny coverage for the treatment they need. I've long since given up expecting logical arguments, or honesty, from them.

Each insurance company has a list of "covered procedures" and if the patient needs something that's not on the list, it is denied. If they need a study, procedure, or medication refill more often than the standard interval, it's denied.

After the first denial, we set up a "peer-to-peer" call. I talk to a doctor (who makes calls for an insurance company because for some reason, they can't practice medicine). They quote the coverage policy and emphasize that they can't make the decision - but quote their book which says I can go on to the appeal process.

On the appeal, we send medical records and relevant published clinical trials supporting the patient's need for the procedure. This may take a month (an average amount of time that each insurance company specifies in it's manual). Maybe 20% of the time, this results in approval, but 80% require another appeal.

This time, they let you talk to an outside reviewer—usually a doctor who is actually practicing medicine. I have success with probably 50% of those.

After the final denial, the patient has to go to the State Insurance Commission or hire a lawyer.

Since I take care of cancer patients, most of them can't wait for treatment as long as this process takes, so many of them just have something cheaper done. We refer to this as "Denial by Delay".

My personal oncologist and I recently went through this process for some studies I needed following treatment for my cancer. The insurance company's book said that pre-authorization was not required, so I had them performed, but then they refused to pay for them. More recently, I actually got a pre-authorization—just to be on the safe side—and they still denied it after it was done. Overall, I spent almost a year going through the appeals process—with the help of my doctor. Finally, I enlisted the help of the State Insurance Commission and they got results in thirty days. I didn't think to call them initially—after all, the tests were medically necessary—like I said, I've given up expecting logic or honesty from insurance companies.

From now on, I'll suggest the State Insurance Commission to my patients earlier in the process.

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Quora: How Does Insurance Impact the Way Doctors Treat Patients? Way Too Much | Opinion