Physician Profiling

[Disciple]

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I don't believe that I over-utilize procedures.

However, I do put alot of effort into getting procedures pre-certified if I think a patient is getting screwed over.

About 2-3 months ago, treatment denials seemed to get a whole lot more difficult to appeal. As in, more extensive review of my records, longer denial letters, more extensive literature citations with references as current as 1 month ago, etc.

I could be imagining all this, but to those with experience and in the know, is physician profiling real?

Could my name be on the s***list of some UR director somewhere?


In the state I work it's well known that work-comp insurers will profile docs (return to work, utilization) when deciding to if you will be accepted to or kicked off of a MPN (medical provider network).

Is this pay for performance, or more accurately, punishment for poor performance?

 

[Tenesma]

is it physician profiling or just evidence based medicine??? which state do you practice in?

 

[jsaul]

is it physician profiling or just evidence based medicine??? which state do you practice in?

i'd be willing to bet a full day of fibromyalgic patients that he's practicing in california

 

[Disciple]

is it physician profiling or just evidence based medicine??? which state do you practice in?

The typical denials contain templated literature reviews. I provide my own references, appeal, and get them approved most of the time.

During phone conversations over treatment requests, I've been told by several UR pain docs that they no longer bother to request disc procedures in their own practices because they never get authorized. I'm wondering if I'm getting singled out for putting in the time and for having some success in obtaining pre-certification.

A couple of recent examples of changes I've noticed in UR:

I had recently requested a discogram. It was reviewed by a surgeon (it seems my requests no longer get routed to a pain doc). Instead of using the typical templated denial/lit review and a few sentences on why the treatement was denied, he dictated an extra 3-4 pages including his own literature review slamming not only the validity of discography, but IDET, all intradiscal procedures and the concept of "discogenic pain". I will appeal this, but will likely spend an extra hour looking up and refuting his reasoning/references.

Example #2: I request a stim trial for a patient S/P lumbar fusion with residual unilateral radic, failed ESIs/PT/opiates. Clear cut right? Denied 2 times. Third appeal goes to UR medical director who won't authorize trial because the patient has Diabetes and "the patient's symptoms may be due to Diabetic Peripheral Neuropathy". He will only authorize EMG/NCS and will not authorize the trial if the patient's has peripheral neuropathy found on EMG/NCS. Yeah, right, as if DPN typically presents as low back pain radiating down one leg. Never mind the fact that the patient's symptoms began with her injury and that the latest MRI shows scar tissue on the nerve roots corresponding to the patient's PE findings. He tells me that if peripheral neuropathy is found I should get the stim trial through her private insurance. So, I appeal again and the decision is pending.

My suspicion would likely not have been raised had I not had prior knowledge of some of the unscupulous things insurers in this state do routinely. At state medical society dinners I've had conversations with several pain docs who do UR. A couple told me they had been fired for authorizing procedures. Another said the UR company uses him to review requests only about once every 3 or 4 months because he does the same. However, when it comes to denials, I see the same 10 or so names on the denial letters over and over and over. During one discussion over an ESI, a UR pain doc told me that were it his patient he would do the ESI, but that he can't authorize my request "because his UR company won't let him".

I feel obligated to get treatments for patients that I feel are indicated, but am I getting myself black-balled in the long run?

 

[Aether2000]

I wonder if it is possible to file a class action lawsuit based on insurance company stupidity.

 

[Mister Mxyzptlk]

Perhaps what we should do is start a database of reviewers and their decisions. It would be very cool to see who the outliers are. We could even put the denial language up so you could tell if it was boilerplate.

In Texas W/C uses the ODG. I got a copy. In the introduction they all but come out and admit that the ODG is to be used as boilerplate that you can cut & paste into pre-cert determination letters. There a handful of companies that provide this kind of service to insurance carriers. I recall looking up one of them and finding that it was a business run by nurses and PhDs, with a few docs as "advisors".

My favorite story about UR is when I wanted to pre-cert a disco and the reviewer was really nasty. I had my staff call and find out who it was (they didn't even give their name).

It turns out it was a friend of mine. He was so busy he didn't even pay attention to the doctor's name on the pre-cert (IMHO, this should be redacted for each and every pre-cert to avoid bias based on personal friendship/animosity or prior interactions). So when I told him he had just reamed me out on the phone he apologized, saying he didn't see my name on the information he had. I had could hear him typing in the background. Then he told me he had just changed the pre-cert to "approved".

Too bad for you if you aren't friends with this fellow.

 

[Doctodd]

So why didnt you recognize his voice on the phone?

 

[Mister Mxyzptlk]

You never got a phone call from someone you know and didn't recognize the voice?