utilization review for insurance companies

[likeaboss]

how much can i potentially make doing pain management utilization review for insurance companies? i am board certified in pain med and anesthesiology. i’m only considering doing this because i have quickly lost my anesthesia skills and i worry about my job security. if everything does not go as planned i’d like to have my foot in the door somewhere that i can cover my expenses...

which companies are the best to work for?

---

Members don't see this ad.

 

[SSdoc33]

depends.

how much is your soul worth?

 

[likeaboss]

depends.

how much is your soul worth?

What's left of it? Not much.

 

[SommeRiver]

You want your peers to hate you?

 

[likeaboss]

You want your peers to hate you?

Is that how it is? All my peer to peers have been pretty pleasant. But I don't get a whole lot of denials...

But anyway, can someone just answer the question?

 

[hyperalgesia]

I did it years ago for a 3rd party that was contracted by various insurers. It paid like 120/hour and they decided how many pages you can do in an hour.

They expect a referenced denial based on a given source. And most importantly they use your name, which will be in bold at the bottom of their denial letter to the patient.

The final straw for me was when I approved PT and they came back at me with a different set of guidelines and told me to make my determination based on THESE guidelines.

I've been approached with offers between 110 and 130 per hour, which amounts to about 100 pages of chart review, sometimes call the requesting doc, and a signed letter with references.

Bottom line: they don't need you for your brain. The job is to be on the record as "the @#%hole doc who denied my care".

 

[likeaboss]

Interesting. My experience with appeals / denials has been this: I request an injection or stimulator trial or whatever, they deny it and say "please add an addendum documenting number of sessions of PT in the last 6 months, documenting failed conservative therapy" etc.

I add an addendum, we resubmit and get auth. I've never felt that they have been unfair.

Most of the time when this happens its because I failed to document something over the course of a busy clinic that I normally would document.

But I do frequently get denials for peripheral stim because the insurer just does not cover it. In that case, I don't blame the ****hole doc, it's the insurer that is restricting access.

 

[hyperalgesia]

Interesting. My experience with appeals / denials has been this: I request an injection or stimulator trial or whatever, they deny it and say "please add an addendum documenting number of sessions of PT in the last 6 months, documenting failed conservative therapy" etc.

I add an addendum, we resubmit and get auth. I've never felt that they have been unfair.

Most of the time when this happens its because I failed to document something over the course of a busy clinic that I normally would document.

But I do frequently get denials for peripheral stim because the insurer just does not cover it. In that case, I don't blame the ****hole doc, it's the insurer that is restricting access.

These are not the cases that make it to the utilization review doc. Insurers don't have to pay docs to implement good policy.

Don't take my word for it, give it a try. Maybe there are some good situations out there.

 

[drusso]

 

[likeaboss]

Insurers don't have to pay docs to implement good policy.

good point...

 

[painfree23]

Since everyone is crapping on these insurance jobs, any other options for OP looking for job security?

 

[likeaboss]

Since everyone is crapping on these insurance jobs, any other options for OP looking for job security?

screw it i’ll just drive uber if i need to

 

[drusso]

Since everyone is crapping on these insurance jobs, any other options for OP looking for job security?

Medical Review Officer (interpreting UDS's) is easy and pays. You can work in between patients. And, you actually feel like you're doing something good for society instead of sweeping floors on the Death Star.

 

[likeaboss]

Medical Review Officer (interpreting UDS's) is easy and pays. You can work in between patients. And, you actually feel like you're doing something good for society instead of sweeping floors on the Death Star.

thank you for that

 

[SommeRiver]

Sorry, but whether or not you blame the MD on the phone or not is irrelevant to the issue at hand - You're volunteering to be the spear tip FOR the insurance company who will pressure you to screw both me and my patient over, and the fact you've already defended the insurance companies once in this thread by saying it is your fault when stuff gets denied makes me think you're already lost.

Yeah, there have been times that I've forgotten to document one little thing and had procedures or meds get denied, but there are only a certain number of hours in the day and my having to go backwards in my work flow to add some little tiny piece of data so I can treat my patient is infuriating and utter BS.

We've all been there and know it is BS.

The single dumbest conversation I've ever had was with a "medical director" at EviCore who told me that facet pain can not hurt into the buttocks or hamstrings. Despite the fact that's an incorrect statement BY DEFINITION, he maintained that as their policy.

Is he criminally stupid? Probably not.
Does he KNOW he's wrong? Yes.
Is he merely acting as a tool for EviCore? Yes.
Is he being paid to be a horse's ass? Yes.
Do facets commonly refer into the buttocks and hamstrings? Yes.
Did I EVENTUALLY get my MBB and subsequent RFA? Yes.
Patient better? Yes.
You want to get on the phone and go out of your way to stop me from doing something reasonable for my pt bc I documented 5 instead of 6 weeks of PT when YOU KNOW that last week isn't going to change anything in my pt with 3 level severe facet arthropathy with effusions and cystic changes? I don't.

 

[SommeRiver]

screw it i’ll just drive uber if i need to

I'd choose Home Depot and write a blog.

 

[callmeanesthesia]

Sorry, but whether or not you blame the MD on the phone or not is irrelevant to the issue at hand - You're volunteering to be the spear tip FOR the insurance company who will pressure you to screw both me and my patient over, and the fact you've already defended the insurance companies once in this thread by saying it is your fault when stuff gets denied makes me think you're already lost.

Yeah, there have been times that I've forgotten to document one little thing and had procedures or meds get denied, but there are only a certain number of hours in the day and my having to go backwards in my work flow to add some little tiny piece of data so I can treat my patient is infuriating and utter BS.

We've all been there and know it is BS.

The single dumbest conversation I've ever had was with a "medical director" at EviCore who told me that facet pain can not hurt into the buttocks or hamstrings. Despite the fact that's an incorrect statement BY DEFINITION, he maintained that as their policy.

Is he criminally stupid? Probably not.
Does he KNOW he's wrong? Yes.
Is he merely acting as a tool for EviCore? Yes.
Is he being paid to be a horse's ass? Yes.
Do facets commonly refer into the buttocks and hamstrings? Yes.
Did I EVENTUALLY get my MBB and subsequent RFA? Yes.
Patient better? Yes.
You want to get on the phone and go out of your way to stop me from doing something reasonable for my pt bc I documented 5 instead of 6 weeks of PT when YOU KNOW that last week isn't going to change anything in my pt with 3 level severe facet arthropathy with effusions and cystic changes? I don't.

Some are clearly sellouts. I’ve heard Evicore is among the worst and thankfully have had minimal interaction with them. I’ve had to deal with work comp mostly, and although it is annoying trying to get ahold of a human since their peer to peers always go through a call center, I’ve generally found the reviewers want to be helpful. Even many of the BC/BS peer to peers I’ve done, generally it was because I needed to document something within their guidelines, and the reviewers were clearly verbally fishing for anything that would help me say “yes, the patient met that requirement.”
Most of these requirements were put in place because of overutilization. Places that put people on opioids to keep them coming back, then run them through a cycle of epidural/RF until they get sick of it or insurance stops paying, then put a stim in, regardless of whether any of it helped. I’ve mainly gotten attitude from reviewers before when they had to deal with a lot of places like that and were frustrated.

 

[likeaboss]

Sorry, but whether or not you blame the MD on the phone or not is irrelevant to the issue at hand - You're volunteering to be the spear tip FOR the insurance company who will pressure you to screw both me and my patient over, and the fact you've already defended the insurance companies once in this thread by saying it is your fault when stuff gets denied makes me think you're already lost.

Yeah, there have been times that I've forgotten to document one little thing and had procedures or meds get denied, but there are only a certain number of hours in the day and my having to go backwards in my work flow to add some little tiny piece of data so I can treat my patient is infuriating and utter BS.

We've all been there and know it is BS.

The single dumbest conversation I've ever had was with a "medical director" at EviCore who told me that facet pain can not hurt into the buttocks or hamstrings. Despite the fact that's an incorrect statement BY DEFINITION, he maintained that as their policy.

Is he criminally stupid? Probably not.
Does he KNOW he's wrong? Yes.
Is he merely acting as a tool for EviCore? Yes.
Is he being paid to be a horse's ass? Yes.
Do facets commonly refer into the buttocks and hamstrings? Yes.
Did I EVENTUALLY get my MBB and subsequent RFA? Yes.
Patient better? Yes.
You want to get on the phone and go out of your way to stop me from doing something reasonable for my pt bc I documented 5 instead of 6 weeks of PT when YOU KNOW that last week isn't going to change anything in my pt with 3 level severe facet arthropathy with effusions and cystic changes? I don't.

LOL. calm down.

 

[SommeRiver]

Some are clearly sellouts. I’ve heard Evicore is among the worst and thankfully have had minimal interaction with them. I’ve had to deal with work comp mostly, and although it is annoying trying to get ahold of a human since their peer to peers always go through a call center, I’ve generally found the reviewers want to be helpful. Even many of the BC/BS peer to peers I’ve done, generally it was because I needed to document something within their guidelines, and the reviewers were clearly verbally fishing for anything that would help me say “yes, the patient met that requirement.”
Most of these requirements were put in place because of overutilization. Places that put people on opioids to keep them coming back, then run them through a cycle of epidural/RF until they get sick of it or insurance stops paying, then put a stim in, regardless of whether any of it helped. I’ve mainly gotten attitude from reviewers before when they had to deal with a lot of places like that and were frustrated.

Really it is EviCore that sends me absurd stuff 90% of the time. I did have a radiologist once tell me they wouldn't cover an ESI bc the severe central stenosis won't cause a positive SLR, and given that I documented a positive SLR in a pt with mild foraminal stenosis they're not gonna cover it.

She actually told me to consider piriformis syndrome.

 

[likeaboss]

Really it is EviCore that sends me absurd stuff 90% of the time. I did have a radiologist once tell me they wouldn't cover an ESI bc the severe central stenosis won't cause a positive SLR, and given that I documented a positive SLR in a pt with mild foraminal stenosis they're not gonna cover it.

She actually told me to consider piriformis syndrome.

one of the spine surgeons i work with will not do peer to peer discussions with anyone who isn’t a “peer”, i.e. someone who is fellowship trained and board certified in spine surgery. that gets around the whole peer to peer with an NP or primary care doc who has no damn clue what they are talking about.

not sure if we can do this, but seems like a good move so u aren’t arguing with an NP whether someone needs an MRI or procedure

 

[SommeRiver]

Well...The likelihood you'll get a pain MD is actually pretty good as of right now. It's been awhile since I had a P2P that wasn't a true peer, but it also doesn't really matter if it is a peer if they're only able to go by whatever rules that insurer has set in place.

See my previous post about the guy who refused to agree that facetogenic pain can involve the buttocks and posterior thighs. Once my "peer" makes that claim the conversation can not move forward in my favor bc...he just said no. If they just say no, it doesn't matter what sounds I make with my mouth. They can just say no.

But I will say I'm getting a Pain MD on MOST of my P2P.

 

[SommeRiver]

By the way, I totally understand why insurance companies do what they do...There have been doctors completely abuse the system to the detriment of healthcare, patients, and MOST IMPORTANTLY the shareholders of the insurance company.

 

[likeaboss]

Well...The likelihood you'll get a pain MD is actually pretty good as of right now. It's been awhile since I had a P2P that wasn't a true peer, but it also doesn't really matter if it is a peer if they're only able to go by whatever rules that insurer has set in place.

See my previous post about the guy who refused to agree that facetogenic pain can involve the buttocks and posterior thighs. Once my "peer" makes that claim the conversation can not move forward in my favor bc...he just said no. If they just say no, it doesn't matter what sounds I make with my mouth. They can just say no.

But I will say I'm getting a Pain MD on MOST of my P2P.

ok but i know that lumbar facet pain can refer to the buttock and upper thigh. during a peer review i won’t argue that it doesn’t. there may just be a shortage of good reviewers out there who know what they are talking about... i’ve spoken with a few who i was 100% certain are not pain docs and maybe even not doctors. the one who thought an x-ray will show spinal stenosis among others.

needless to say i almost always win the argument and often humiliate and berate the person over the phone for wasting my time.

but when it’s a pain doc usually it’s more of a “please document daily physician directed exercises or PT and we are good”

 

[SommeRiver]

The majority of the time I get a peer the conversation takes 3 to 5 min and it is abundantly clear that MD has NOT read my note.

Problem is I don't have 5 min at 10 AM on Tuesday.