Insurance Companies Shenanigans

A lot of insurance companies now have physicians on their payroll. Their job is to review charts and then call their peers in clinical practice to tell them what treatments cannot be covered and what alternatives are available to them. This is for the sole purpose of denying coverage for certain medications and procedures.

Last year there was an uproar when one of the physicians employed by Aetna revealed that he basically acted on charts that he had not reviewed. He just went by the summaries of nurses employed by Aetna.

I have a young patient in her early thirties who has severe proteinuria due to secondary focal segmental glomerulosclerosis. The FSGS was a result of her severe morbid obesity. This patient has already developed osteoarthritis of her knees which limits her ability to walk or exercise. She is on three blood pressure medications and has obstructive sleep apnea. She is also prediabetic. She works at a desk job and has a young son who she takes care of. Having tried all forms of diet and exercise without much success, she tried to get approval for bariatric surgery.

We know that obesity is a chronic, relapsing and difficult to treat disease whichever way you look at it. We also know that research has shown that bariatric surgery produces good results with treating obesity and even reversing some complications from obesity such as diabetes and hypertension. I do agree that it is not for every obese patient and does carry some serious risks.

Well guess what, no surprises here. Insurance denied her bariatric surgery. I wrote two letters for her six months apart. I wrote about how she had tried various diets and how she was limited in her ability to exercise. The ketogenic diet was also not an option given her proteinuria and kidney issues. I talked about how her proteinuria was due to morbid obesity and she would likely have progressive kidney disease and thus may ultimately require dialysis. I wrote about her developing diabetes which she did not yet have but was almost certain to develop in her future.

But no. Nothing. Zilch.

I called the insurance company and was told that her case had been reviewed by my peers and the patient did not yet have diabetes and needed to do more to lose the weight.

I did not see her for a while but she remained in my thoughts. Our office got a call from her recently. She needed me to give renal clearance for knee arthroscopy/possible knee replacement. Her left hip was bothering her too and she may require surgery for that as well.

I saw her in my clinic. She was trying to be upbeat. She said she may have to go on disability and then bariatric surgery would likely be covered. This makes no sense to me at all but I cleared her.

I recently saw a blog post about doctors going over to the dark side when they join health administration. I think they are going to an even darker side when they join with insurance companies and deny patients rightful medications and treatments.

Please do not be that doctor.

Anupama Verma MD

Anupama Verma is a board-certified nephrologist practicing for close to seventeen years in Green Bay, Wisconsin. She graduated from the University of Nigeria and subsequently moved briefly to England. She then moved to the United States where she did her residency in internal medicine at the University of Pennsylvania/ Presbyterian health system. She did her fellowship in Nephrology at Lankenau Hospital in Philadelphia. She has lived and observed the practice of medicine on four continents and thus has unique insights into global healthcare. In addition, she teaches medical students and serves on the pharmaceutical and therapeutics committee at Bellin hospital. She believes strongly in preventive medicine and medical narratives to bring about change and healing. She is a patient and physician advocate and has contributed articles to KevinMD and Doximity among others. She is on Twitter and instagram @anuvmd. 

  3 comments for “Insurance Companies Shenanigans

  1. mamadoc
    August 15, 2019 at 10:28 pm

    Or some drone who couldn’t make it in practice. Insurance is the darkest of dark sides.

  2. Celia B Entwistle MD
    August 14, 2019 at 5:25 pm

    you are so right.
    Thank you for this article–and I am an ER doctor and I never clear anything. Which is why so many people come to the ER requesting CT’s and MRIs

  3. August 12, 2019 at 8:57 am

    Medicaid story- warning graphic content may not be suitable for all audiences.

    Even “clinical pharmacists” can go over to the dark side.

    I was treating an opioid dependent woman, who had detoxed and then suffered anaphylaxis to injectable naltrexone opioid antagonist.

    Second attempt to control her substance related cravings, Suboxone (buprenorphine mixed partial agonist/antagonist + naloxone antagonist) resulted in anaphylactoid reaction observed by me and one RN. Basically she developed mild airway edema, dependent edema with painful labial swelling.

    Round three- there is only one option left, other than will power ( which less face it doesn’t even work for sugar as we heard in the above blog post), buprenorphine alone. Yes, one could “abuse” it. No it doesn’t have the government approved deterrent added (you know, like how methanol was added to ethanol during prohibition).

    Bonus round, which option is the cheapest? You guessed it, it the only remaining option, buprenorphine, at 50 cents per day.

    Denied. Clinical pharmacist review states “The Medication is not indicated and is not consistent with best practice prescribing for the indicated disease. The patient is not pregnant. This medication will not be covered.”

    I am pretty sure I am being overridden by either a toddler or a sociopath.

    Fine benefit of the doubt, this is just a problem of primary gain seeking by executives. However they have been enabled by another sociopath, the PharmD or MD or NP on the clinical pharmacology team.

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