Public Shaming of Soul-less Pain Peer-to-Peer Reviewers...

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drusso

drusso

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Time for "direct action" against the sham MD "peer to peer" review process. For all upcoming peer-to-peer reviews, ask the peer reviewer for:

1) Their full name
2) Medical license # and state
3) The specialty of origin and Pain Medicine BC status

Then, post the information here:
 
There’s a fine line between public shaming and doxxing. Doxxing has legal implications.

www.brickdonlaw.com

What is "Doxxing" & Is It Illegal?

"Doxxing" has become a hot-button issue online, particularly as it's led to the harassment, stalking, and other disruption of peoples' lives. Find out more about what this practice is and whether it's legal or not on our blog.
www.brickdonlaw.com
 
drusso said:
Time for "direct action" against the sham MD "peer to peer" review process. For all upcoming peer-to-peer reviews, ask the peer reviewer for:

1) Their full name
2) Medical license # and state
3) The specialty of origin and Pain Medicine BC status

Then, post the information here:
Click to expand...
Along similar lines, I was thinking about a non-profit, physician led organization that places TV, billboard, and other ads that shame health insurers for various things.

We can go after the sell-out docs, but they'll be instantly replaced if needed.

Insurance companies are placing ads that mislead patients into thinking they will be "covered". We need some counter advertising that sheds a harsh spotlight on what happens if a patient actually needs medical care.
 
Agast said:
There’s a fine line between public shaming and doxxing. Doxxing has legal implications.

www.brickdonlaw.com

What is "Doxxing" & Is It Illegal?

"Doxxing" has become a hot-button issue online, particularly as it's led to the harassment, stalking, and other disruption of peoples' lives. Find out more about what this practice is and whether it's legal or not on our blog.
www.brickdonlaw.com
Click to expand...

All public available information.
 
EviCore dude told me facetogenic pain can not radiate into the hamstrings and buttocks in a pt with moderate stenosis and severe facet arthropathy.

"She's got stenosis."
"...but not radiculitis...She has severe spondylosis and facetogenic pain."
"Spondylosis is ubiquitous in society."
"...so is stenosis man..."
 
SommeRiver said:
EviCore dude told me facetogenic pain can not radiate into the hamstrings and buttocks in a pt with moderate stenosis and severe facet arthropathy.

"She's got stenosis."
"...but not radiculitis...She has severe spondylosis and facetogenic pain."
"Spondylosis is ubiquitous in society."
"...so is stenosis man..."
Click to expand...
Had a Work Comp reviewer tell me “it’s debatable” whether facetogenic pain exists. I should have gotten his name.
 
drusso said:
Time for "direct action" against the sham MD "peer to peer" review process. For all upcoming peer-to-peer reviews, ask the peer reviewer for:

1) Their full name
2) Medical license # and state
3) The specialty of origin and Pain Medicine BC status

Then, post the information here:
Click to expand...

Sure we should do that?

SDN Members do peer-to-peer review.
 
they are being paid by their employer, the insurance company.

you expect them to be fair and unbiased?


thats also why experts who promote a therapy - whether it is SCS, DRG, opioids, etc. - and are getting paid by the company are biased, and this needs to be considered in reviewing their data.
 
Ducttape said:
they are being paid by their employer, the insurance company.

you expect them to be fair and unbiased?


thats also why experts who promote a therapy - whether it is SCS, DRG, opioids, etc. - and are getting paid by the company are biased, and this needs to be considered in reviewing their data.
Click to expand...

Because every 1st year medical says to themselves, "When I grow up, I want to work the insurance company..."
 
I do peer to peer.
My job: read the records and see if what’s documented matches the requirement for the request. Then call and see if they forgot to document something. These insurance companies write the verbiage for when they will cover something. Want opioids? There are requirements for that. Want to continue opioids? Want to do an epidural? All have specific requirements that are given to the reviewer for that specific insurance. If the insurance company decides that Soma is not recommended for anything at all and you rx it it will be denied by a peer to peer and no matter how mad you get, it’s not going to change anything. I have approved things that were sent back to me for denial with the specific verbiage of the policy. When a person buys a policy it’s for that coverage. Insurance companies are narrowing what they will pay for citing “evidence” when its in their favor and saves money short term. I agree that this is a problem but your solution is silly and a waste of time.
 
SpineBound said:
I do peer to peer.
My job: read the records and see if what’s documented matches the requirement for the request. Then call and see if they forgot to document something. These insurance companies write the verbiage for when they will cover something. Want opioids? There are requirements for that. Want to continue opioids? Want to do an epidural? All have specific requirements that are given to the reviewer for that specific insurance. If the insurance company decides that Soma is not recommended for anything at all and you rx it it will be denied by a peer to peer and no matter how mad you get, it’s not going to change anything. I have approved things that were sent back to me for denial with the specific verbiage of the policy. When a person buys a policy it’s for that coverage. Insurance companies are narrowing what they will pay for citing “evidence” when its in their favor and saves money short term. I agree that this is a problem but your solution is silly and a waste of time.
Click to expand...

Morally, how comfortable are you interfering in other relationships? Do you ever feel like "ants at a picnic?" I couldn't live with myself if I knew that I was purposely interjecting myself in between a doctor-patient relationship.
 
drusso said:
Morally, how comfortable are you interfering in other relationships? Do you ever feel like "ants at a picnic?" I couldn't live with myself if I knew that I was purposely interjecting myself in between a doctor-patient relationship.
Click to expand...

I respect your wisdom but feel the opposite. I’m just the messenger and don’t think twice about it
 
SpineBound said:
I respect your wisdom but feel the opposite. I’m just the messenger and don’t think twice about it
Click to expand...
Any tips for dealing with the process? I try to be proactive but I do still get denials for “not documenting” information that was in my assessment and plan very plainly - clearly a reflex denial by someone who didn’t actually read the note.
 
SpineBound said:
I do peer to peer.
My job: read the records and see if what’s documented matches the requirement for the request. Then call and see if they forgot to document something. These insurance companies write the verbiage for when they will cover something. Want opioids? There are requirements for that. Want to continue opioids? Want to do an epidural? All have specific requirements that are given to the reviewer for that specific insurance. If the insurance company decides that Soma is not recommended for anything at all and you rx it it will be denied by a peer to peer and no matter how mad you get, it’s not going to change anything. I have approved things that were sent back to me for denial with the specific verbiage of the policy. When a person buys a policy it’s for that coverage. Insurance companies are narrowing what they will pay for citing “evidence” when its in their favor and saves money short term. I agree that this is a problem but your solution is silly and a waste of time.
Click to expand...

so why do they need you if all you do is read a policy and check off boxes? an LPNj could do that. you are a figurehead, so they can put an MD next to their denial and give it some legitimacy. if you medically "agree" with all of the insurance policies in place, then there is no conflict of interest and you are providing reasonable medical care.

HOWEVER: we all know that some of these policies are complete BS, and written so as to deny care and save the insurance company money. you are literally stuffing money in the pockets of the evicore, cigna, and aetna CEOs for a pittance of cash. it is shameful

"im just the messenger" is a weak moral stand. if something is wrong, it is wrong.

i think a lot of docs just do these peer-to-peers because they dont know better. they see it as a way to make cash on the side without realizing that they are doing the opposite of what they should be doing as a physician. they are not providing care, but rather denying it.
you are not some medicare fraud investigator or righting any wrongs of society by working as a peer to peer.

hippocrates would not be happy
 
Why don’t you do a little work as a physician reviewer and try toapprove things and look at the machine from the inside?
SSdoc33 said:
so why do they need you if all you do is read a policy and check off boxes? an LPNj could do that. you are a figurehead, so they can put an MD next to their denial and give it some legitimacy. if you medically "agree" with all of the insurance policies in place, then there is no conflict of interest and you are providing reasonable medical care.

HOWEVER: we all know that some of these policies are complete BS, and written so as to deny care and save the insurance company money. you are literally stuffing money in the pockets of the evicore, cigna, and aetna CEOs for a pittance of cash. it is shameful

"im just the messenger" is a weak moral stand. if something is wrong, it is wrong.

i think a lot of docs just do these peer-to-peers because they dont know better. they see it as a way to make cash on the side without realizing that they are doing the opposite of what they should be doing as a physician. they are not providing care, but rather denying it.
you are not some medicare fraud investigator or righting any wrongs of society by working as a peer to peer.

hippocrates would not be happy
Click to expand...

Since you consider insurance policies and denial of care (rubber stamped by an MD) immoral you should definitely act on it. I look forward to YOU saving America’s healthcare. How will you do it without printing money or denying care?
 
SpineBound said:
Why don’t you do a little work as a physician reviewer and try toapprove things and look at the machine from the inside?


Since you consider insurance policies and denial of care (rubber stamped by an MD) immoral you should definitely act on it. I look forward to YOU saving America’s healthcare. How will you do it without printing money or denying care?
Click to expand...

im not sure if your questions are rhetorical or not.

i understand the need to "ration" care. i actually agree with that concept. but that is not what you are doing. you are going through an algorithm written by someone else. if we learn anything in our business, it is that patients dont follow algorithms. e.g.: why does the 80 y/o with severe stenosis need PT? you are rationing care for the sole reason of making money for insurance companies. you are not rationing care for the benefit of public health.

it is true that i dont know how the sausage is made. i havent been a "peer reviewer". i couldnt bring myself to take money from those charlatans. i woudnt sell out.

how would I save america's healthcare? sort of off topic, but i would offer a crappy, cheap plan for everyone, then if you have the means, you can buy the cadillac plan with name brand drugs, no wait for MRIs, elective surgeries when you want them. if you dont pay for the cadillac plan, then you get care similar to europe or canada.

but just to be clear, what you are doing as a peer-reviewer is not, in any way, SAVING america's healthcare.
 
SSdoc33 said:
so why do they need you if all you do is read a policy and check off boxes? an LPNj could do that. you are a figurehead, so they can put an MD next to their denial and give it some legitimacy. if you medically "agree" with all of the insurance policies in place, then there is no conflict of interest and you are providing reasonable medical care.

HOWEVER: we all know that some of these policies are complete BS, and written so as to deny care and save the insurance company money. you are literally stuffing money in the pockets of the evicore, cigna, and aetna CEOs for a pittance of cash. it is shameful

"im just the messenger" is a weak moral stand. if something is wrong, it is wrong.

i think a lot of docs just do these peer-to-peers because they dont know better. they see it as a way to make cash on the side without realizing that they are doing the opposite of what they should be doing as a physician. they are not providing care, but rather denying it.
you are not some medicare fraud investigator or righting any wrongs of society by working as a peer to peer.

hippocrates would not be happy
Click to expand...

I can't believe I agree you whole-heartedly...
 
I look at it differently. I try to get things approved for the requesting doc as a peer reviewer. But guess what. Almost no one takes the call or calls me back.

Here is some advice: take the call, listen to what the reviewer tells you and comply with the required documentation.

The vast majority of requests I review are deficient in documentation and/or for items clearly not allowed under wc coverage, i.e. topicals, stem cells etc
 
Most MD/DO's who get enticed into doing peer-to-peer reviews don't realize that their employer doesn't have their best interests at heart. The insurance company has a fiduciary duty to the stockholders. The MD reviewers are just a means to an end. It's a sordid little industry. A good friend of mine worked for Evicore and described how she would be bonused based upon production targets. Let's be clear: Production targets were denial of care. It's a very toxic industry and Evicore has no "skin in the game" in terms of promoting and advocating for real changes in care delivery that matter to doctors.
 
Ignore peer to peer -as mentioned they just read a list of fake insurance guidelines back to you.

1. Have patient contact their HR dept and see if risk of losing that employer's covered lives will change the insurance company's bad behavior.
2. Send them to the ER
3. Bring them back for a follow up. Read the fake guidelines to them and have them parrot the responses required and resubmit.
4. Make the uncompensated call to Dr. Hack and tell the patient tx was still denied and to get different insurance next year.
 
Last edited:
SSdoc33 said:
im not sure if your questions are rhetorical or not.

i understand the need to "ration" care. i actually agree with that concept. but that is not what you are doing. you are going through an algorithm written by someone else. if we learn anything in our business, it is that patients dont follow algorithms. e.g.: why does the 80 y/o with severe stenosis need PT? you are rationing care for the sole reason of making money for insurance companies. you are not rationing care for the benefit of public health.

it is true that i dont know how the sausage is made. i havent been a "peer reviewer". i couldnt bring myself to take money from those charlatans. i woudnt sell out.

how would I save america's healthcare? sort of off topic, but i would offer a crappy, cheap plan for everyone, then if you have the means, you can buy the cadillac plan with name brand drugs, no wait for MRIs, elective surgeries when you want them. if you dont pay for the cadillac plan, then you get care similar to europe or canada.

but just to be clear, what you are doing as a peer-reviewer is not, in any way, SAVING america's healthcare.
Click to expand...

i think spinebound is doing peer to peers for workcomp? i dunno, I could be wrong about that, but that's a vastly different beast than P2P for private insurers
 
Gauss said:
i think spinebound is doing peer to peers for workcomp? i dunno, I could be wrong about that, but that's a vastly different beast than P2P for private insurers
Click to expand...

Read the reviews on Indeed for Evicore and other peer-to-peer review organizations. I would never pimp out my medical degree for these businessmen.

Working as a Physician at eviCore healthcare: Employee Reviews | Indeed.com

Reviews from eviCore healthcare employees about working as a Physician at eviCore healthcare. Learn about eviCore healthcare culture, salaries, benefits, work-life balance, management, job security, and more.
www.indeed.com www.indeed.com

Pain societies and physician groups need to take strong action to limit MD/DO participation in these unethical schemes. I can't see how anyone can defend their participation in these relationships.

No Integrity or Compassion

Physician Line Specialist (Current Employee) – Melbourne, FL – October 4, 2017
I have worked at eviCore for six and a half years. Originally when we were Medsolutions I was able to get a promotion based on my knowledge and work-skills. Now I haven't been able to get anything I've applied for. And it's either because I have not been awarded an interview or they choose some one less qualified. This place is a mess with management, every time a member has an issue and you reach out to a supervisor, the supervisor looks the other way and basically passes the buck to some one else. In addition the ATTENDANCE policy is not family friendly... If you miss more than two days in a three months period (whether you have substantial proof of and illness or something out of your control) your superior will put you on corrective action. Med Solutions was amazing once a time ago they knew what integrity and compassion and honesty was. But now, all you have is a bunch of power hungry individuals with no compassion or integrity.

Cons
attendance policy, no balance for family life, stressful

Wanna work for the devil?

Physician Line Specialist (Former Employee) – Colorado Springs, CO – September 22, 2017
Sign your soul away today by helping these horrible human beings help the medical insurance companies they are contracted to work for save money by messing over patients. They'll use you up and throw you away and then when you try to get unemployment benefits to get back on your feet they'll fight you on it and win because they have a whole legal department set up to defend themselves against such things. Why? Massive turnover. Seriously the worst company I've ever worked for.
Pros
Working from home was nice.
Cons
Almost everything else.
 
drusso said:
Morally, how comfortable are you interfering in other relationships? Do you ever feel like "ants at a picnic?" I couldn't live with myself if I knew that I was purposely interjecting myself in between a doctor-patient relationship.
Click to expand...

It's a doctor-patient relationship that's paid for by insurance.

Whenever my patients complain about their prior auths not getting done as fast as they want, I remind them they can get anything right away if they are willing to pay cash.
 
Agast said:
It's a doctor-patient relationship that's paid for by insurance.

Whenever my patients complain about their prior auths not getting done as fast as they want, I remind them they can get anything right away if they are willing to pay cash.
Click to expand...

Yes, Cash is King...I can personally attest to that:

www.oregonlive.com

Insurers are setting patients up for failure (Guest opinion)

As a cancer survivor and physician specializing in pain management, I understand the importance of prescribing the right medication at the right time.
www.oregonlive.com www.oregonlive.com

"After lengthy appeals and subsequent denials, I was able to obtain a personalized treatment plan. This therapy was precisely targeted, offered the fewest side effects and gave me the best odds for a cure. I knew how to navigate the system and fight insurance companies and paper shufflers who insert themselves between doctors and patients. But even for someone with my expertise, it wasn't easy."
 
Last edited:
hyperalgesia said:
Docs who do these peer to peer are indirectly employed by the patients who buy the insurance.
Click to expand...

Are you comfortable with the level of accountability that insurance doctors have who deny care? Is it the same kind of skin in the game you do? Or, is it more flying the remote control drones?
 
skin in the game...
like the patient who calls my scheduler and reams her out because greater occipital nerve blocks are not a covered benefit under her insurance plan and now what is she supposed to do???

glad we fielded that call for the insurance company.
 
drusso said:
Are you comfortable with the level of accountability that insurance doctors have who deny care? Is it the same kind of skin in the game you do? Or, is it more flying the remote control drones?
Click to expand...
They are not acting as doctors in this role.

There is exactly ONE reason insurance companies hire docs instead of non-docs. That reason is to draw your fire.
 
Yes I do peer to peer for Ca work comp using MTUS ACOEM and ODG guidelines. There’s no shame in doing them. I deny bilateral 3 level TFESIs along with 3 level bilateral epidurograms AND myelograms with sedation at ASCs all the time. I doubt you’ve got any beef with me.
 
I had a peer to peer request today. Funny I put in the order for an US guided block like 4 to 5 weeks ago. Procedures this afternoon and my 3 PM pt is late so I hustle back to my desk and call...I get the front desk of some other doctor's office. That is after the 30 sec message telling me to call 911 for an emergency and head to the nearest ER. Finally get a human and the name is wrong on the pt so we had to fix that. It is now 10 min I'm on the phone and my 3PM is already on the table waiting now. The P2P MD isn't available by the way, but she will call me back ASAP. I still haven't heard from her (3 hrs and 50 min later as I type this) bc I'm on her time not mine. I'm taking a dump right now so if she calls now I'll have to turn off the fan bc my voice will be echoing and she's going to hear the fan and it will be awkward. In that case I'll have blown up this bathroom and my family may get upset.

Sort of like in August of 2018 when I ordered a LSB on a pt with clear CRPS and was denied and a P2P was requested. They finally called me on Dec 21 (Friday) and said the P2P had to be completed by the end of that day. I'm going on Christmas vacation that afternoon so I call them and leave a message. They returned that call on Dec 27 while me and my family were staying at my mother's house and I was in the act of shaving. The guy on the phone said, "Well, seems like everything we need is documented and in order...Don't see why this was denied. We can approve it."
 
...or the time a radiologist denied my epidural bc the pt had spinal stenosis and not foraminal stenosis to explain the leg pain. She said I hadn't met their criteria and to visit the website that contained the criteria. Well, the website containing the criteria listed exactly what was in my last progress note in exactly the same format. Still was denied bc it wasn't foraminal stenosis...Next came the recommendation from the radiologist to "consider piriformis syndrome."

A radiologist told me to consider piriformis syndrome...Masters of physical exam are radiologists.
 
DOctorJay said:
skin in the game...
like the patient who calls my scheduler and reams her out because greater occipital nerve blocks are not a covered benefit under her insurance plan and now what is she supposed to do???

glad we fielded that call for the insurance company.
Click to expand...
You mean an upper cervical and occipital trigger point injection? 😉
 
SommeRiver said:
I had a peer to peer request today. Funny I put in the order for an US guided block like 4 to 5 weeks ago. Procedures this afternoon and my 3 PM pt is late so I hustle back to my desk and call...I get the front desk of some other doctor's office. That is after the 30 sec message telling me to call 911 for an emergency and head to the nearest ER. Finally get a human and the name is wrong on the pt so we had to fix that. It is now 10 min I'm on the phone and my 3PM is already on the table waiting now. The P2P MD isn't available by the way, but she will call me back ASAP. I still haven't heard from her (3 hrs and 50 min later as I type this) bc I'm on her time not mine. I'm taking a dump right now so if she calls now I'll have to turn off the fan bc my voice will be echoing and she's going to hear the fan and it will be awkward. In that case I'll have blown up this bathroom and my family may get upset.

Sort of like in August of 2018 when I ordered a LSB on a pt with clear CRPS and was denied and a P2P was requested. They finally called me on Dec 21 (Friday) and said the P2P had to be completed by the end of that day. I'm going on Christmas vacation that afternoon so I call them and leave a message. They returned that call on Dec 27 while me and my family were staying at my mother's house and I was in the act of shaving. The guy on the phone said, "Well, seems like everything we need is documented and in order...Don't see why this was denied. We can approve it."
Click to expand...

Are you comfortable letting these people dictate care to your patients?
 
drusso said:
Most MD/DO's who get enticed into doing peer-to-peer reviews don't realize that their employer doesn't have their best interests at heart. The insurance company has a fiduciary duty to the stockholders. The MD reviewers are just a means to an end. It's a sordid little industry. A good friend of mine worked for Evicore and described how she would be bonused based upon production targets. Let's be clear: Production targets were denial of care. It's a very toxic industry and Evicore has no "skin in the game" in terms of promoting and advocating for real changes in care delivery that matter to doctors.
Click to expand...
even a stopped clock is right twice a day
Click to expand...


fwiw, sometimes it is beneficial for the patient to call the insurance company and speak directly to them.
 
drusso said:
Are you comfortable letting these people dictate care to your patients?
Click to expand...

If you accept the insurance you accept all parts of it including its ever changing policies and peer review sub contractors. If enough doctors drop insurance plans you might see some change. That’s not gonna happen though Witt the new drs coming out of kaiser medical school and groomed to follow the system...
 
SpineBound said:
If you accept the insurance you accept all parts of it including its ever changing policies and peer review sub contractors. If enough doctors drop insurance plans you might see some change. That’s not gonna happen though Witt the new drs coming out of kaiser medical school and groomed to follow the system...
Click to expand...

A legitimate, albeit weak defense of your position. many if not most docs dont have that kind of clout in terms of which insurances they will accept. also, how do you keep abreast of all of the changes the insurance companies make, seemingly on a whim?
 
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