The Doctor is Grumpy

Not covered under your plan


Doctor Grumpy:

I’m not taking sides in the health care debate, but I do want to clarify something.

I see people on the news screaming that they don’t want “bureaucrats” between them and their doctor, and are afraid that’s what government health care will bring.

WTF? THAT’S THE WAY IT IS NOW, PEOPLE!!! I hear my nurse Annie on the phone all day trying to get approval from non-government insurance companies for tests, medications, physical therapy, ANYTHING that I order.

Look at your insurance card. Doesn’t it say things like “in-network” and “formulary”? Who the hell do you think came up with those? Not us docs. Dat be dem dere byoo-row-kratz!

Look back at some of my posts (like this, or this). I routinely have medications (both brand name and cheap generics) and tests refused by insurance companies. For an excellent commentary on this from the pharmacy side, this was written by FranticPharmacist.

So if you don’t want bureaucrats between you and your doctor- TOO BAD. They’ve been there for years. THE ONLY PEOPLE WHO DON’T HAVE THIS PROBLEM ARE PAYING CASH FOR EVERYTHING!

In fact, for those of you who don’t want the government running this, THEY ARE ACTUALLY ONE OF THE BETTER ONES TO WORK WITH! Just ask Annie. Medicare doesn’t question the majority of my tests, or meds. Yes, they don’t cover everything, nor should they, but they don’t fight with me over stuff like MRI’s on stroke patients. Uncle Sam (unlike Aetna, Cigna, Humana, and many others) tends to leave these things to the doctor’s discretion. Annie prefers Medicare patients for this very reason – they make her life easier.

So what happens to you the way it works NOW, with your non-government insurance?

You come to me for some neurological issue, which requires further work-up. So I order, say, an MRI and MRA of your head.

Annie gets the order, and calls Bozo Insurance, Inc. (BII) to schedule it. BII refuses, saying they want more information. So they fax us a 5 page “pre-auth” form, which Annie spends 20 minutes filling out and faxes back. Then they say the form wasn’t enough, and they also want copies of your office notes, so we send those, too (yup, when you joined BII you agreed that they can read your medical records).

So a few days go by. BII will claim they never got our fax. Or that we filled the form out wrong. Or that they don’t cover Capricorns when the moon is in Pisces. And we don’t know this until Annie calls back after a few days, because they’re hoping we forgot about it.

Eventually they’ll deny the whole thing, on the grounds that you don’t meet criteria for an MRI and MRA. This decision is usually made by a non-medically trained person with a minimum of a GED. They do this because they want to see just how badly I want the test.

So they tell me I can appeal this via “peer-to-peer” review. Which means I need to personally call their “physician reviewer” to argue with them as to why I want the study.

So, during my insanely busy day at the office I have to call them. I’m promptly put on hold for 10 minutes, before finally reaching the reviewer. This person is a doctor- but NOT necessarily in my specialty. In fact, it’s usually something like a retired dermatologist, who hasn’t done neurology since medical school in 1938. Or an OB/GYN who hated his job, and is doing this now instead. Or some doctor who immigrated from Lower Swazbodiaczk and can’t get a U.S. medical license (but your insurance company hired him to decide what medical care you need). But it’s almost NEVER someone actually in my field, who might understand why I want the study.

So after telling your life history to Dr. Denial, one of 2 things will happen. They’ll deny both studies, and want you to try medication or physical therapy or psychotherapy or holistic reflexology or whatever, and if you fail that THEN I can try to resubmit a request for the test. OR they will flip a coin and say they will cover the MRI, but not the MRA. Or vice-versa. They’ll say that if the first test is fine, THEN I can start over trying to get the other covered. Maybe.

And many of these companies actually pay these “reviewers” bonuses based on HOW MUCH MONEY THEY SAVED THE COMPANY BY DENYING TESTS.


If you want to read the funny part you gotta follow the link.


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13 Responses to The Doctor is Grumpy

  1. Till I went to the link, I thought the doctor here was Ron Paul.

    ANyway great point.

  2. votermom says:

    The funny part is well worth reading. LOL.

    Healthcare used to be my number one issue. I still feel as strongly about it, since it is even more broken with Obamacare, and yet Obama has managed to make the economy and corruption an even bigger and more urgent problem. Congratulations, President Obama.

    • DandyTiger says:

      I didn’t think it could get worse. ThenObama proceeded to do what he was paid to do, let the insurance industry write a healthcare bill. it’s Christmas everyday for the insurance industry under Obamacare.

      Hey Obots finally waking up, does us all a favor, never get involved in politics, ever. You clearly don’t have the metal capacity to handle it.

  3. Dario says:

    And Medicare is less bureaucratic and more efficient than the private insurance companies.

    • DandyTiger says:

      Exactly. And when it’s having trouble, it’s like a canary in the coal mine. It means the rest of the industry is way worse.

  4. ruralcounsel says:

    Here’s the difference…if I don’t like the insurance coverage I have, there are ways to change which set of private bureaucrats I have to deal with. So they at least have some incentive to want my business.

    If the Gummint takes it over, game over. What little commercial leverage I might have is gone. Dead. Over. In fact, the leverage gets reversed. If in frustration I swear at a gummint bureaucrat over the phone or screwing up the MRI request, instead of just getting hung up on, I’m likely to be put on some watchlist, audited by the IRS, or hit by a no-knock warrantless midnight raid.

    • myiq2xu says:

      You obviously never pissed off the phone company before.

      • ruralcounsel says:

        Another highly government regulated “private” industry. utilities are more like government…because of high sunk infrastructure costs in a physically limited area.

        Think how’d it would be if different power or harline telephone companies got to put up competing poles and wires…used to be that way and it was insane. Nowadays, not so much for telecommunications because cell phones don’t require the same level of infrastructure to each house. Lot’s of competition out there for the cell phone business.

    • votermom says:

      Most people don’t actually have that much choice on which insurance company to pick. The employer has the choice, which is limited by state. A big employer will typically pick one PPO, one HMO, and one catastrophic-only.

      Here’s another difference. The Govt does not have a legal profit motive to act as conflict of interest. The GAO’s job is to keep medicare honest.
      The private insurance MUST try, like any type of insurance, to limit claims. They are in it for the shareholders – that’s their responsibility.

      • ruralcounsel says:

        Anyone who listens to the deficit, debt and tax talks these days and thinks government doesn’t have a profit motive isn’t paying attention.

        Haven’t you been listening? You aren’t paying your “fair share”.

        • votermom says:

          They don’t have a legal profit motive. They profiteer through cronyism and corruption.
          I still believe that we can have a fairly clean and limited professional “bureaucracy” if we clean out the top.

      • ruralcounsel says:

        And people have some choice now. You can change employers. You can be self-employed. If the system were set up sanely, you’d have a cafeteria option to take the insurance offered by your employer or cash to get your own (or go uninsured and stash the money in a HSA). If you don’t like the limits placed on you by state gov’t, move. But turning it over to the Feds just makes it worse.

        Fed Gov’t run means NO CHOICE. Ever.

        And criminal liability for giving false or misleading evidence to a federal official…so if it ever gets down to a he said/she said, you could be charged with illegally trying to extract government services or threatening a federal employee. You’d better hope that phone recording is working and you kept your temper.

        • ralphb says:

          Why don’t you get back to selling fucking insurance. Your argument is pure shit which isn’t worth the time it takes to read it, let alone rebut it.

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