Peer-to-Peer Physician Reviewer Bullsh%t

I am almost embarrassed to write this blog entry because it is so obvious.  Here is what just recently happened:

California’s insurance commissioner has launched an investigation into Aetna after learning a former medical director for the insurer admitted under oath he never looked at patients’ records when deciding whether to approve or deny care.

During the deposition, the doctor said he was following Aetna’s training, in which nurses reviewed records and made recommendations to him.

All of us doctors knew this already.  It is obvious these reviewers are scam artists when you talk to them.  They are lowlife sellouts who just deny your requests.  They ALSO have been taught to pretend to be victims if you get mad at them. That is their new strategy.  They start reading set responses like:

  1. “Dr ___, your tone is abusive and this call is being recorded.”
  2. “Dr ___, your anger is inappropriate and will be reported.”

All these are scare tactics.  I don’t know the answer.  Maybe this case will blow up but I recommend you try this when talking to a physician reviewer (this info was told to me and it works):

“Hi, before we start can I get your name and exact spelling, please?  Thank you.  I am putting it in the chart so if this procedure/test/referral is denied then your name will also be there for the attornies to question.”

So here are my questions:

  1. What are your most ridiculous rejections?
  2. What line do you use to get things approved?
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  14 comments for “Peer-to-Peer Physician Reviewer Bullsh%t

  1. Mamadoc
    February 14, 2018 at 9:55 pm

    Just a reminder… these a*& h^%es are NOT our peers.

    1+
  2. Chris
    February 14, 2018 at 12:55 pm

    I am a family physician and also do wound care and hyperbaric medicine. I had a teenager patient with clubfoot deformity, spina bifida and a foot ulcer that went all the way to the bone. I wanted to use negative pressure wound therapy on the wound so got into an argument with the reviewer. He volunteered that he was a surgeon and he had used wound vacs before but he obviously didn’t know what he was talking about. He told me I could not apply a wound vac to the patient because the wound had too much slough and he couldn’t or wouldn’t accept the fact that I debrided the slough away prior to application of the wound vac. After arguing with him for about a half an hour I told him that if he didn’t approve my recommended therapy I would give the patients parents his name so that they would hold him responsible when she needed an amputation. Then he asked me what would satisfy me and I told him “give me a wound vac for this patient!”. Then he said “for how long?” and I said “until her wound is healed or until I think it won’t do her any more good”. He finally relented and the patient healed up quickly…she still has her leg.

    Another patient of mine had a Wagner 3 diabetic foot ulcer that had failed a 9 month course of treatment by a podiatrist when she presented to me. This is a clear-cut indication for hyperbaric oxygen therapy I immediately wanted to treat her with them but the insurance denied. I got on the phone and spat out this history in about 15 seconds and the reviewer said “approved”. I am not sure why I had to schedule a phone call for that when our staff had provided the exact same information to the insurer and all this history was in my office note but, whatever.

    2+
  3. ckoop
    February 12, 2018 at 4:43 pm

    I agree with your concept of asking for the reviewer’s name, etc. and also making certain that you have the correct spelling and the state in which they are licensed or practice. If the reviewer turns down a reasonable request I then tell them that if they persist in the refusal I will report them to their licensing bureau. This usually succeeds in getting approval. In fact in my state one of the major payers told its reviewers just to approve my requests.

    2+
  4. JRDO
    February 12, 2018 at 3:29 pm

    Me: Need a CT of abd/pelvis for lower abd pain.
    Physician Reviewer: Did you do an US?
    Me: No. If I do the US and it’s normal can I then get the CT scan?
    PR: Yes.
    Me: If I do the US and it’s abnormal can I then get the CT scan?
    PR: Yes.
    Me: Why do I have to do the US if the CT will be approved regardless of the result of the US?
    PR: Protocol
    Me: Grrrrrrrrr

    4+
    • ckoop
      February 12, 2018 at 4:45 pm

      Good example of how to waste money for unnecessary procedures. Also shows why getting approvals is absurd.

      1+
    • February 12, 2018 at 5:02 pm

      I did this one before. The ‘radiologist’ saw it my way eventually and I didn’t do US first. Nowadays most of the imaging centers here in Tampa do the legwork to get paid by the insurance company. Also most of our patient pay cash so we don’t have to deal with the insurance.

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    • Doug Farrago
      February 12, 2018 at 5:49 pm

      I had the same incident!!!!!

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  5. Dr Bonz
    February 12, 2018 at 2:36 pm

    There is now an insurer in my area that will only authorize me to do a total knee replacement as AN OUTPATIENT PROCEDURE. I have called and fight with them all the time but they are unyielding. I then have to tell my patient that the only way they can get their knee replaced is if they change their insurance.

    Another company (and this is getting more popular and will probably become common) is the denial of a knee replacement in anyone with a BMI over 40 (which is a majority of my patients that need a replacement). They tell us that the patient has to diet and lose weight before they will be approved. Of course they can’t excercise in order to facilitate this since they have bad knees and most can’t lose weight anyway, as this is what got them in trouble in the first place.

    3+
  6. Stephen Rockower, MD
    February 12, 2018 at 2:18 pm

    I’m an Orthopaedic surgeon. A patient came in with a ruptured quadriceps tendon which I easily identified. Phone call for authorization:
    Me: The patient has a quadriceps rupture which needs surgery
    Reviewer: How do you know it’s ruptured? Do you have an MRI?
    Me: I EXAMINED THE PATIENT!!! He has a divot above his patella and can’t actively extend his knee
    Reviewer: But how do you KNOW it’s ruptured?
    Me: ARRRGGGHHH

    6+

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    • Perry
      February 12, 2018 at 2:20 pm

      You mean a doctor can actually make a diagnosis without a test? Inconceivable!!!

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  7. Perry
    February 12, 2018 at 2:01 pm

    The stories are probably infinite. The sad part is, for all the crowing about the newly insured, I don’t see any real benefit to insurance. Meds are rejected, tests are denied, ER visits denied, it goes on and on. Meanwhile people are paying thousands of dollars in premiums for, what? One of my office staff said today her husband’s scripts for Humulin 70/30 has been denied because the insurance company wants him one 75/25. I advised her to call her insurance company and accuse them of practicing medicine without a license because of medication denials.

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  8. DrWally
    February 12, 2018 at 1:16 pm

    30 year old patient with 6 mos knee swelling, pain, and instability secondary to an injury (I would not have waited that long). No improvement with conservative care. 20 minutes on hold, first question upon peer to peer was “What is the Tesla number of the MRI machine?”. I replied that I had no idea. He then stated he would review the case when I called back with the Tesla number. I asked him what number was acceptable and he said he could not tell me that. I then asked him to review the chart with me and let me know his decision would be if the Tesla number was found to be acceptable. He refused.

    I hung up and found the Tesla number from our hospital and called back (another 20 minutes on hold) and got another reviewer. He said the number was fine, but he needed to review the chart
    and get back to us. 3 days later..denied. No reason.

    This crap goes on every day of my life.

    My 2 biggest reasons for burnout… EHR unworkability and 3rd party intervention in my patient care.

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  9. Deb
    February 12, 2018 at 12:58 pm

    Best one actually was my husband’s who does wound medicine. Peer to peer for elderly diabetic foot ulcer suspicious for osteo–standard of care is MRI. Reviewer was a pediatrician (who wasn’t sure which states they were still licensed in) who refused because plain xray had not been done. Asserted that there was difference in treatment of osteo in a kid vs adult….. He called back, spoke to different reviewer and got approval. But wasted 90 minutes of his life…

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  10. Hawgguy
    February 12, 2018 at 12:29 pm

    I have used similar tactics – but I wait until after the rejection. No sense in starting off on the wrong foot.

    Our testicles are in a vice; On one side the cost conscious insuring agencies, on the other the malpractice vultures. Overseeing it all are the bean-counting minions with clipboards measuring productivity.

    5+

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