Shred, File or Call? My Top Six Stupid Insurance-Company Directives

Melissa Walton-Shirley


June 27, 2014

A few years ago, Dr Seth Bilizarian in his blog "Private Practice" spoke about the mounds of paperwork generated by insurance-company inquiries and directives. He was among the first to articulate that the issue is more than a mere annoyance. Since that time, it has become abundantly clear that dealing with endless recommendations, denials, precautions, warnings, and misinformation from these "corporations gone wild" has cost every medical office in this country scores of valuable labor-hours. But worse and much more important, the byproduct of greed in the sheep's clothing of "cost containment" is the endangerment of the lives of the patients these insurance companies serve. Denial of care is horribly detrimental and something we're unfortunately accustomed to dealing with, but the misdirection of care has blossomed in the recent scramble to cut the cost of pharmaceuticals and testing. Here are my top six choices for the stupidest (not to mention occasionally dangerous) insurance-company antics:

1. "Your patient has been prescribed Toprol XL, which is not on our formulary. Please select an appropriate medication from the list provided."

The definition of "appropriate" has morphed in the insurance world from "equivalent" to "less immediately expensive." They've obviously not received the memo that decreased compliance is a surrogate for increased death, stroke, and readmission, which are code words for cost. In a world where compliance rates are at best 50% on any given day, they should be "doing the math" that switching a patient to a twice- or three-times-daily drug dose can affect outcomes because of compliance issues. If their motives are as sinister as I believe they are, they aren't backed with intelligence. They are shooting themselves in their wallets by not doing the math. Furthermore, sotalol was on their list of "appropriate meds" to substitute for Toprol XL. That makes about as much sense as recommending that a 90-year-old ride a Harley Davidson into the office instead of driving her Buick. I can hardly bring myself to think of the potentially lethal consequences of substituting sotalol for a beta-blocker meant for heart-failure therapy or in patients with renal insufficiency. All cardiologists and most physicians in other specialties would understand the grave implications, but the potential for error exists in those less experienced in dealing with cardiopharmacology. It's hard to hear that those persons exist, but they do, because we are all human, even healthcare providers.

2. "Digoxin is a high-risk medication. Consider changing to lisinopril."

Don't communicate with me ever again about anything for any reason except to pay me for the good service I'm providing to this patient.

ARE YOU KIDDING ME? Since when did lisinopril become a rate-controlling agent for atrial fibrillation? If I had followed that stellar insurance-company advice, my patient would have landed in the ER with complaints of palpitation, chest pain, or shortness of air. She has afib that eats negative chronotropes for breakfast. It took a three-drug combination just to keep her resting rates below 100 bpm, where she's far more comfortable. She has not returned to the hospital for years. A recent trough level was 0.8 ng/mL. There is absolutely no reason to change her digitalis. It's abundantly clear the insurance company was recommending I change a medication for a patient without really understanding why she was on it or the implications of changing. I'm tempted to write them a letter that simply says, "Don't communicate with me ever again about anything for any reason except to pay me for the good service I'm providing to this patient."

3. "Your patient has been prescribed an ARB that is not formulary . . . yadda yadda yadda."

What the insurance company did not bother to find out or perhaps (and more sinister) didn't care to know was that after several months of trial and error, this patient's hypertension was superbly controlled on her recently added ARB. She felt great and had no discernible deleterious effects. I had danced around her creatinine issue successfully and had taken weeks to "sneak up" on her blood pressure with gradual titration. When I prescribed the equivalent dose of the "formulary" . . . er . . . less expensive ARB, she returned to the office with a blood pressure of 160/110 mm Hg. Another month later, we finally had her under control again. The expense to the insurance company included more office visits and blood work that certainly offset any savings for the year. (This should have been a "duh, forehead-slapping moment" for the insurance-company accounting department.)

4. "Your patient is on amiodarone. Our records indicate that your patient has not had a recent CXR . . . "

The tech at our office checked the patient's record. I documented our discussion regarding the need for routine pulmonary follow-up and the side effects of amio a long time ago. According to the last progress note, the patient had voiced that she had routine follow-up with her pulmonologist and a recent chest X ray and pulmonary-function tests (PFTs) (describing both as satisfactory). She is a compliant, reliable patient, and I have no reason to question her. However, we had not yet received a recent progress note from her pulmonologist visit. We then contacted the pulmonologist, who practices in another town. His office verified that a chest X ray and PFTs were performed in the last year.

My question to the insurance company is this: Why didn't you have a record of the last several chest X rays performed? If you didn't "pay" the provider for all those X rays, don't you owe the patient and/or the physician payment for those X rays? Will you be as diligent regarding the payment issue? Why didn't you call the patient directly, obtain the name of the pulmonologist, and contact their office, instead of tying up our office staff to untangle your inquiry? Can I bill you for that completely unnecessary 30-minute paper chase?

5. "Your patient has been prescribed an anxiolytic that can be dangerous in the elderly . . . "

Do you ever consider how much time you waste in a physician's office with this barrage of misinformation?

This type of communication from an insurance company is one of my greatest pet peeves. I always write back that "I'm a cardiologist and I do not prescribe anxiolytics. Please contact the prescriber." I have no idea why this type of communication would come to our office. To look up the patient record and confirm that I knew her medication regimen and then look over everything else again like all obsessive-compulsive cardiologists do only takes a few minutes, but when you multiply that by 10 times per day, it really takes a chunk of time. That time slot could be used for worthy patient care or even eating lunch, something many of us do about as often as we win the lottery. Furthermore, her internist or family doctor has weighed the risk and benefits of anxiolytics. Do you think your concern really trumps that decision-making process? Did you obtain the progress note and read it prior to pulling the trigger on the fax machine again? Do you ever consider how much time you waste in a physician's office with this barrage of misinformation?

6. I saved the best for last here.

This was my partner's case scenario just a few weeks ago. A young female smoker presented as an outpatient with chest pain of several weeks' duration. Her pain was a bit atypical but appropriately located for angina. My partner of 23 years, who has performed thousands of caths and tens of thousands of stress exams, recommended a stress cine evaluation. Her resting ECG was abnormal with asymmetrical T-wave inversion in the anterior leads (I'm not sure if he had a prior ECG for comparison). A stress cine would have gone a long way to exclude the presence of CAD. The insurance-company doctor insisted on a "plain treadmill." My partner argued the case and faxed the ECG to the insurance-company doctor, who reiterated that a plain treadmill should be performed first and if the patient kept having symptoms, to proceed with a cath. My partner was incensed, and I don't blame him. I don't know the outcome of his workup, but I know him; he probably had our tech take some cine clips on the sly without charging the patient, which is exactly what the insurance company knows we will do.

I've likely not told you readers anything you didn't already know or haven't experienced, but sometimes blogging, reading, and commenting are therapy. Sometimes expressing our thoughts begins a conversation in a room somewhere that serves as a small seed for change. I'd like to offer a few suggestions to our foes in the insurance world, which will likely fall upon deaf ears, but if conversations like these catch the attention of those who have the power to effect change, it's worth the time for a good rant.

Here are a few thoughts on the topic of how to rein in the insurance monsters:

1. LEGISLATE. Tea partiers won't like this one, but it would work. Pass a mandate that if a patient has been stable on a medication for over a month it would be illegal for an insurance company to affect their medication regimen in any way. Stable patients on good meds would no longer be considered fair game.

2. STOP contacting cardiologists about meds we didn't prescribe. If you have concerns, call the prescriber, or better yet, if it's your conscience you are trying to ease or if it's just a cover-your-butt move, contact the patient directly and document it in your own records.

3. STOP sending warnings about digitalis to cardiologists. We aren't morons. Many of us have been prescribing medications since before your company became a more cost-conscious conglomerate. Spend your time reinforcing the side effects to the patient. Don't write me a letter telling me what I already knew nearly 30 years ago when I graduated from medical school.

4. When a cardiologist asks for an imaging stress study on a smoker of any age, a postmenopausal female, a patient with a first-degree relative with established CAD, those with shortness of air, diabetes, hypertension, or with hypertrophic obstructive cardiomyopathy-type murmurs that need to be sorted, do not recommend a "plain" treadmill. I can produce any number of stress ECGs that were normal, where the entire anterior wall disappeared like a magic trick on a stress nuclear or lay down like I'd slapped it on a stress cine.

The buck needs to stop with us as subspecialists. We need to be trusted as capable of deciding if a symptom is cardiac related. Allow me to get the imaging study I need to reassure the patient, the referring physician, and myself that the patient is safe.

5. Fire the staff you've hired to kill all those trees with the paperwork you fax daily and use that money to buy our patients the medication they actually need and the testing they deserve. Or, since none of us really want anyone to lose their jobs at your company, use that staff to direct your calls and your inquiries to the patient directly. Do some one-on-one patient education, then allow them to bring up your concerns at their next office visit.

It's up to us to shred, file, or make a phone call about these issues. I hope, at the minimum, that you'll call or write your local congressperson and your state ACC representatives. After your local politician reads this rant, perhaps they will finally grasp the gravity of insurance-company interference in patient care and the impact on office staff resources. I'll bet they are insured by some private insurance company, so just maybe they will make a call that counts as well.


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