Why Do They Call it Peer-to-Peer Review?

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Just got off the phone with a sell out.  You see, I ordered at CT of the abdomen on a patient and someone else rejected that order. I will not go into detail in this blog other than to say that the “doctor” I spoke to got into a fight with me.  Sure I was terse with her as well but she told me that I needed a abdominal and pelvic ultrasound first. So, the conversation went as follows:

Me: “What if the ultrasound doesn’t show anything?

Insurance doctor: “Then you can order the CT”.

Me: “What if the ultrasound shows an abnormality?”

Insurance doctor: “Then you can order a CT to confirm it”?

Does anyone see the insanity of this?  I sure hope so.  Let’s just say the conversation ended with raised voices and me hanging up.  Prior to leaving the conversation there were some heated words. No curses but I may have mentioned “selling your soul”.  Anyway, she used the phrase “Doctor, you are being abusive”.  Abusive?  Because I am fighting for my patient?  Because the system is ludicrous? Because the patient was relying on me to get this done?  Because I, and not the insurance company, is liable if the CT gets delayed and not done?  Because this supposed doctor does whatever the insurance company tells her to do?

This is a warning to you doctors out there.  My guess is that the “Doctor, you are being abusive” line was taught to her and is a common phrase used to defend themselves .  It is verbal judo to turn the table on you and show that they are now the victims.  Do you see how pathetically brilliant this is?

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  22 comments for “Why Do They Call it Peer-to-Peer Review?

  1. October 6, 2016 at 11:09 am

    What do people think about having an area on this site where subscribers could post the names of the medical directors they spoke with associated with the specifics of their encounter? This could function as a sort of “Yelp” for medical directors. If medical directors knew that their decisions would end up as publicly searchable information, could this help the public by helping keep the medical directors in line? Think about it. Attorneys for families whose care is inappropriately delayed, state medical boards, and consumer groups might all benefit. Increasing public awareness could force changes in laws that would make medical directors legally liable for the decisions THEY make overriding or delaying care we know is necessary to meet community standard and for the ethical and competent practice of medicine.

    I think it is worth considering.

    • Doug Farrago
      October 6, 2016 at 3:01 pm

      Sounds great but…..they would definitely sue me.

  2. John Parkin M.D.
    October 6, 2016 at 9:36 am

    I have always felt that docs who chose non-patient care jobs do it because they are neither willing nor capable of the actual practice of medicine. Many have sold out to the insurance companies and merely echo the policies of their bosses. Calling somebody a sellout under these circumstances is not abusive but merely expressing the truth.

    • Gerry
      October 10, 2016 at 12:21 pm

      In a fair number of cases, that was a waste of a seat in medical school, and a residency. And a pity. And an expensive public mistake.

  3. William Douglas Given MD
    October 5, 2016 at 7:39 pm

    I ask what their name is so I can tell the family who to sue when my patient dies. That really grabs them by the short hairs.

  4. Yvonne
    October 5, 2016 at 5:50 pm

    When I get that type of insurance response, I ask for the doctor’s full name (spell it out) and home address. They ask why? and I say so my patient knows where to send the subpoena when their diagnosis is delayed. Usually works.

  5. Bridget Reidy
    October 4, 2016 at 4:05 pm

    The abusive line is planned. Everyone ‘knows’ doctors are abusive so the successful administrators (and some nurses) know we can be manipulated that way as we will be overly accommodating rather than fit the stereotype. Similarly, we adopted a tool that made us less efficient because we as individuals didn’t want to fit the dinosaur stereotype. They know how to manipulate us. How many of us harboured thoughts against bureaucracy and pro authentic medicine but never voiced them back when all this started. I know when I did I was looked at as hopelessly blind to the need for change that had to involve less power for MD’s, and I think the existence of blogs like this is chipping away at some of their power, so expect to hear more about how disruptive and abusive we are.

    When I was going through a lot of phone calls prior to my bankruptcy (sort of) I noticed one company different employees always said “You sound upset”, before I got upset, then I figured out that was their plan. First they interrupted repeatedly and accused me of not listening, and interrupting. By the third call I had cultivated the voice of calm and never interrupted, not even to say “yes I know, you just said that three minutes ago, you see I was listening”, but the accusations didn’t change. Presumably there’s something I might have said if I was upset that would have been in their interest, not mine, like maybe “I’ll pay you back as soon as I can”.

    • Allison
      October 5, 2016 at 10:49 am

      When I get the “you sound upset” response, I tell the person on the phone “you don’t read people’s emotions very well, do you? That’s actually a pretty severe psychological disorder, perhaps you should have that checked out.” That stops them cold.

  6. HJR
    October 4, 2016 at 3:30 pm

    For a period of time now, Medical Assistance will deny every admission and then say, “You should have been able to deal with this within 24 hours so you should have instead billed it as a 24 hour observation stay.” One time I said, “Well, my administrator said MA patients can’t be placed on obs.” Then she said, “Oh, you can put MA pt’s on Obs, we just don’t pay for it.”

    Oh, I see the logic there. ????

  7. HJR
    October 4, 2016 at 3:17 pm

    Always have the patient or parent/child of the patient on the line at the same time through a conference call of some type. Make sure the rent-a-doc knows this is occurring. I’ve yet to have one disagree with what I recommended.

  8. Sudha Prasad
    October 4, 2016 at 1:26 pm

    Oh Doug!! I have heard this so many times, I am surprised that you are surprised.
    Do you think bringing the information to the people will make a difference?
    What do you think?

  9. politovski
    October 4, 2016 at 1:07 pm

    doug, love the post. i always ask the dr. no’s for their full name, license number, office address, malpractice insurance carrier and policy number. when queried why, i say that i am documenting all of this so that in the event of a lawsuit, they will also be named for practicing poor medicine. that usually punches it through.

  10. Ben Van Raalte
    October 4, 2016 at 11:37 am

    No different than the taught response to tell the patient the denial on payment is “the way your doctor wrote up the claim”. In other words, if your doctor had coded your bill as malignancy when it was not a malignancy we are required to pay for it, but since it is not malignancy, and your doctor, is honest, your claim will not be covered. We dont want to say we dont cover this, it is taught to say it is the way your doctor wrote up the claim, transferring blame.

    I had the same conversation about selling your soul 25 years ago when a HMO denied coverage for a birth defect. I told her how could you have a job where you denied treatment to disfigured children, it was no different than being a member of the Nazi party and going along with killing Jews at the time, saying Im just doing my job. I told her I would rather starve than deny treatment to disfigured children

  11. GClark
    October 4, 2016 at 9:54 am

    Only recently are my “peer-to-peer” reviews getting denied. The reviewer simply quotes the insurance company policy with no actual review of what the patient needs. I now end my review by telling the reviewer “I hope that neither you, nor anyone in your family, needs the requested procedure and comes up against someone like you who denies them. But, only then will you understand the frustration my patient and I feel”. Interestingly, my past 2 denials have been overturned by the patient appealing it themselves.

  12. LeeS
    October 4, 2016 at 9:09 am

    Sounds like you had a nurse on the line rather than a physician. The phrase, “doctor, you are being abusive” gave her away!

    • Thomas Guastavino
      October 4, 2016 at 9:30 am

      These days I would consider the label “abusive” a badge of honor.

  13. Steve O'
    October 4, 2016 at 8:16 am

    What makes for even more yucks is that the peer doctor/mouthpiece is probably hired on contract basis, maybe even a locum. They’re making calls with their butt to the breeze as well. If the insurance company gets sued, it’ll dump and run, saying “Hmm, we never told Dr. Maryjoe which CT’s to refuse. If something went wrong, it’s not our fault.” The Insurance Doctor’s just as big a patsy as the treating doctor. The company puts up the firewalls, and watches the money roll in.

    We’re seeing now that there’s almost no money left to squeeze out of operations; now the only way to up the cash flow is by upping the premiums. The rubes have to shift to Medicaid, and then Medicaid will be run by the MCO’s, and then – what? The money train is near the last station, I fear.

  14. William E Green III MD
    October 4, 2016 at 7:01 am

    Welcome to the “new world order” in medicine. Agree with Dr. Gutavino, just tell the patient that “I recommend you get the CT scan, but YOUR insurance denied it and they want to get the Ultrasound first, then IF it shows something abnormal, then they want a CT scan”.
    This is why I am no longer accepting insurance! Worked too hard getting triple board certified, etc. to “fight” with someone over appropriate care.

    • Thomas Guastavino
      October 4, 2016 at 8:09 am

      Actually it was kind if fun having the insurance “physician” call me back with their tail between their legs.

  15. Thomas Guastavino
    October 4, 2016 at 6:09 am

    Its not worth fighting these battles because these people do not fear the wrath of physicians, but they do fear the wrath of patients. So what I did was to simply say OK, explain to the patient what was going on, then got the patient to call and yell at the insurance company. Worked every time.

    • Seneca
      October 4, 2016 at 7:37 am

      Even better to get the HR department of the employer who pays the insurance along with a 10% annual premium increase.

    • Gerry
      October 10, 2016 at 12:34 pm

      Speaking as a patient, now: Try that with Tricare/ExpressScripts. I got a fairly disparaging note from a “Medical Director” at ExpressScripts denying my doc’s script for a specific medication, one I’d been established on for some time (I’ll note that a similar denial led to a allergic reaction, when I was restarted, to exenitide). So, as the patient, and one who speaks the language, I undertook to find said medical director and continue the discussion. Express Scripts doesn’t have a record of “him” in their corporate phonebook, so I could be connected. I found no evidence a physician or even a PhD by that name was in some form of clinical practice in the past, or, for that matter, existed within the framework of what we call “medicine”. My e-mail was returned as undeliverable when addressed to his most likely name at the company, and a similar e-mail to their customer service department told me, without further appeal, they had no record of him. My PCP and I finally concocted a story likely to get us the drug WE felt was appropriate, but only after a fairly miserable trial on another “similar” drug that failed to have the desired effect, but had some bothersome side effects.

      During this, I did manage to engage a pharmacist on the line who was unable to answer specific questions about half-life, metabolism, elimination or similarities therein to the desired drug. She did know that the company’s formulary said their drug was the appropriate one to substitute for the one I’d been prescribed.

      I’d have loved to have had a chance to talk to the guy who’d engineered the original denial to determine if he’d ever seen clinical practice.

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