Holding Physicians Accountable for Unfair Denials

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By Jim DeWees, CP

I recently had a conversation with a state representative and a state senator in which I told them about a patient who needed a replacement for a transtibial prosthesis that was more than nine years old and was literally in three pieces. The foot and ankle were broken in half, and the socket was now too big for the patient. He was wearing five thick socks to fill up the socket. The patient's workplace-sponsored insurance company denied that the new limb was medically necessary.

I told them that I involved the employer in the matter, and within two hours of contacting the human resources director about the benefits, she had the precertification for the new leg. But once the leg was fabricated and delivered, the insurance company denied payment because it claimed that there was no precertification on file. I contacted the HR director, and she was confused because she had a copy of the precertification in her hands, as did I. So, I faxed her the denial for payment due to this non-existent precertification. Again, within a couple of hours, she had the payment approved.

In the meantime, I received a call from a representative of the insurance company who told me that it was my fault it was denied because there was no precertification on file and I had not followed its rules. I informed this person that I had a copy of the precertification in front of me, and so did the HR director, and that I was doing everything I possibly could to show this big employer how awful it is to work with this insurance company. I told the representative that I would try to convince other providers to do the same so that hopefully this company would never sign another contract with this insurance company. With that comment, the representative hung up on me.

Now I had even more fuel to share with the HR director. I already had the insurance representative's name, and thanks to caller ID, I had her phone number as well. It just so happens that this particular insurance representative is the HR director's contact person, and when I told her that the representative had hung up on me, she was even more upset. The HR director told me she was going to have a meeting about all these issues in addition to issues they already had.

As I continued my conversation with the legislators, I told them that I also had the name and address of the physician who made the denial on behalf of the insurance company in the first place. It was difficult to get, but I believe insurance companies are required to share the name of the doctor who denies any claim. I was shocked to learn that the doctor-an oncologist-works as a director in a large hospital in Milwaukee, Wisconsin.

I later learned that the hospital the doctor works for had no idea that he was also employed by the insurance company. The hospital said it was a conflict of interest. The hospital official I spoke with said that they would have to talk about this during the next directors' and administrators' meeting.

There was no reason for the doctor to deny this claim, and the insurance company made it more painful to have to appeal this decision and jump through more hoops just to get the pre-certification for the device.

I explained to the legislators that the doctor who made this decision had really damaged the life of this patient. He is a professional with a good job, but it is impossible for him to go to work since his job is not wheelchair or crutch friendly. It also took a lot of time out of my life to fight for this patient and help him get back to walking so that he could return to work. There is no accountability for this doctor.

The legislators and I discussed the need for legislation that would set some standard for these doctors and make it so that if any doctor was found to be making denials that are unfounded, questionable, or that harm or damage a patient, he would lose his license and ability to practice medicine in his state. And once some of these doctors lose their licenses, maybe other doctors will decide that they either need to make careful decisions on claims and approve the legitimate ones, or maybe they will decide that it is not worth working for an insurance company that has a rejections quota (which can't be proven at this point, but many former employees of insurance companies have testified about quotas and the rules and bonus plans associated with denials).

I encourage all prosthetists and other healthcare providers to keep a list of the denials that are clear examples of patients not getting what they need, and find out who denied the claims-even if they were later approved and paid-and then make sure you follow through and turn them in to the state medical boards to review.

If you have any thoughts or ideas about this issue, please let me know. I will keep everything confidential.

Jim DeWees, CP, works for the Prosthetic Center of Indiana, Bloomington. He can be reached