The business of denying health care to Americans

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
"Another type is more lucrative, providing an incentive for EviCore to cut costs, former employees said. Known as risk contracts, EviCore takes on the responsibility for paying claims. As an example, say an insurer spends $10 million a year on MRIs. If EviCore keeps costs below that figure, it pockets the difference. In some cases, it splits the savings with the insurance company.

“Where you really made your money was on a risk model,” a former EviCore executive said. “Their margins were exponentially higher.”"
 
This just confirms what we’ve already known about denials and prior auths etc that it is to limit payments and make more money for the insurance companies.. also it has a double benefit in that the more time physicians spend dealing with these sacks of s..t the less time they are seeing patients and providing care and thus limiting payments from multiple angles. I mean what sense does it make that if you get a denial for a technicality that you can’t resubmit for 3 months?
 
This happened to a patient of mine last week. BCBS Advantage plan. Request for SI injection through Carelon- P2P requested. I called them on Friday afternoon and they said they couldn't get a reviewer on the phone in time, so the case has to be withdrawn and resubmitted. For whatever reason, they couldn't do that and now the patient needs to wait 60 days to resubmit. The rep said this was a medicare rule they have to follow. She said different payers have different rules and it's totally arbitrary. I asked why they only allow a 2-week window for my procedures and she said that was payer-specific. The windows can vary.
 
powermd said:
This happened to a patient of mine last week. BCBS Advantage plan. Request for SI injection through Carelon- P2P requested. I called them on Friday afternoon and they said they couldn't get a reviewer on the phone in time, so the case has to be withdrawn and resubmitted. For whatever reason, they couldn't do that and now the patient needs to wait 60 days to resubmit. The rep said this was a medicare rule they have to follow. She said different payers have different rules and it's totally arbitrary. I asked why they only allow a 2-week window for my procedures and she said that was payer-specific. The windows can vary.
Click to expand...
Think we’d have a case for a class action lawsuit? Every one of us who takes Medicare “Advantage” plans deals with it, and it costs us financially and our patients medically.
 
powermd said:
This happened to a patient of mine last week. BCBS Advantage plan. Request for SI injection through Carelon- P2P requested. I called them on Friday afternoon and they said they couldn't get a reviewer on the phone in time, so the case has to be withdrawn and resubmitted. For whatever reason, they couldn't do that and now the patient needs to wait 60 days to resubmit. The rep said this was a medicare rule they have to follow. She said different payers have different rules and it's totally arbitrary. I asked why they only allow a 2-week window for my procedures and she said that was payer-specific. The windows can vary.
Click to expand...
an SIJ injection pays peanuts. not worth your time to deal with a P2P for this. or for anything for that matter.

always always always blame the insurance company when your patient cant get the care they need. tell them how much the CEO of humana or cigna makes. b/c it is indeed their fault, but their paperwork will make it seem like it is your fault when the patient reads it. we didnt create this system. and often times, we follow thier guidelines to a T, and they still deny. definitely do reasonable work and fight for your ptaitnets, but dont lose an ounce of sleep over this BS.

im not talking specifically to powerMD, just a general bitch session
 
I charge $15 for PAs and if P2Ps came up more often, I'd charge an extra $50 for these. As it happens, I like this patient a lot. Her blueberry muffins are amazing. I told the rep that Carelon may not realize it, but this sabotage of the patient's Medicare coverage works out for both of us. They get to keep whatever ill-gotten gains come from Medicare, and I am now out from under my contract with them on this injection- and can thus charge a fair cash rate. Everyone wins.

I've collected more than $3k so far this year in PA money. This will really help with staff bonuses at x-mas time.
 
callmeanesthesia said:
Think we’d have a case for a class action lawsuit? Every one of us who takes Medicare “Advantage” plans deals with it, and it costs us financially and our patients medically.
Click to expand...
I don't think we would have standing in a lawsuit like this. Patients maybe.

We don't have to accept the plans. I don't think government monopolies are usually scrutinized by other government agencies. And they're trying to move everyone to Advantage plans so...

It's gonna get waaay worse. This is the time when they're trying to make the Advantage plans look great. Wait till they don't care anymore.
 
diabolical - "It is owned by the insurance giant Cigna."
So the insurance companies contracts evicore, which is owned by another insurance company Cigna, to do their PA's. Love those kickbacks
 
powermd said:
I charge $15 for PAs and if P2Ps came up more often, I'd charge an extra $50 for these. As it happens, I like this patient a lot. Her blueberry muffins are amazing. I told the rep that Carelon may not realize it, but this sabotage of the patient's Medicare coverage works out for both of us. They get to keep whatever ill-gotten gains come from Medicare, and I am now out from under my contract with them on this injection- and can thus charge a fair cash rate. Everyone wins.

I've collected more than $3k so far this year in PA money. This will really help with staff bonuses at x-mas time.
Click to expand...
You charge the patient $15 for authorizations or you charge the patient a cash rate just because they won't pay the $15? How is that an advantage for them? How does that release you from the insurance contract? Maybe I'm just not following.
 
Ferrismonk said:
You charge the patient $15 for authorizations or you charge the patient a cash rate just because they won't pay the $15? How is that an advantage for them? How does that release you from the insurance contract? Maybe I'm just not following.
Click to expand...
He tried to get the auth. Insurance said no. Insurance wins because they keep money. Doc wins because the rejection allows for a cash pay option which actually reimburses something fair. Charging for PAs was not directly part of this story as far as I can tell.

The advantaged parties in this story do not include the patient which is, I suspect, the part that you misunderstood.
 
I would like to see penalties for inappropriate denials. Like when we meet all the criteria and document everything perfectly but it still gets denied, there is no responsibility for the reviewer to have any skin in the game. They just get to move on like there is no problem at all, but we have to do all this extra paperwork for free.
 
Did a p2p today on a denied lumbar TFESI with Aetna. Denial via evicore. Note documented perfectly. Repeat TFESI request when prior TFESI gave 8 months of 80% relief.

They first sent me to a nurse reviewer who asked me which specific activities the patient had impaired function in and also for physical exam findings. Exam findings were positive SLR on exam that was documented. I documented difficulty with prolonged standing and walking due to pain. She said she couldn’t approve it and had to send to p2p.

P2P doc states he was not provided with copy of the note, only provided with the reason for denial. I provide him the above information and he quickly approves. I ask him what I could have done better to prevent future denials in this manner. He says he doesn’t know.

Meanwhile patient care is delayed and my time is wasted. Awful.
 
Asclepius186 said:
Did a p2p today on a denied lumbar TFESI with Aetna. Denial via evicore. Note documented perfectly. Repeat TFESI request when prior TFESI gave 8 months of 80% relief.

They first sent me to a nurse reviewer who asked me which specific activities the patient had impaired function in and also for physical exam findings. Exam findings were positive SLR on exam that was documented. I documented difficulty with prolonged standing and walking due to pain. She said she couldn’t approve it and had to send to p2p.

P2P doc states he was not provided with copy of the note, only provided with the reason for denial. I provide him the above information and he quickly approves. I ask him what I could have done better to prevent future denials in this manner. He says he doesn’t know.

Meanwhile patient care is delayed and my time is wasted. Awful.
Click to expand...
Mission accomplished.
 
hyperalgesia said:
I don't think we would have standing in a lawsuit like this. Patients maybe.

We don't have to accept the plans. I don't think government monopolies are usually scrutinized by other government agencies. And they're trying to move everyone to Advantage plans so...

It's gonna get waaay worse. This is the time when they're trying to make the Advantage plans look great. Wait till they don't care anymore.
Click to expand...
Exactly, I don't accept these plans, it's not worth the wasted time and aggravation to get all of the prior authorizations for the same or reduced payment. There are more than enough traditional medicare patients out there without the hassle.
 
Asclepius186 said:
Did a p2p today on a denied lumbar TFESI with Aetna. Denial via evicore. Note documented perfectly. Repeat TFESI request when prior TFESI gave 8 months of 80% relief.

They first sent me to a nurse reviewer who asked me which specific activities the patient had impaired function in and also for physical exam findings. Exam findings were positive SLR on exam that was documented. I documented difficulty with prolonged standing and walking due to pain. She said she couldn’t approve it and had to send to p2p.

P2P doc states he was not provided with copy of the note, only provided with the reason for denial. I provide him the above information and he quickly approves. I ask him what I could have done better to prevent future denials in this manner. He says he doesn’t know.

Meanwhile patient care is delayed and my time is wasted. Awful.
Click to expand...
I have had many similar experiences. I say we record these calls and post them online for everyone to hear.
 
Asclepius186 said:
Did a p2p today on a denied lumbar TFESI with Aetna. Denial via evicore. Note documented perfectly. Repeat TFESI request when prior TFESI gave 8 months of 80% relief.

They first sent me to a nurse reviewer who asked me which specific activities the patient had impaired function in and also for physical exam findings. Exam findings were positive SLR on exam that was documented. I documented difficulty with prolonged standing and walking due to pain. She said she couldn’t approve it and had to send to p2p.

P2P doc states he was not provided with copy of the note, only provided with the reason for denial. I provide him the above information and he quickly approves. I ask him what I could have done better to prevent future denials in this manner. He says he doesn’t know.

Meanwhile patient care is delayed and my time is wasted. Awful.
Click to expand...
you could have your PA or prior auth person just request the p2p from the get-go and just schedule the P2P.
Better still, call the patient for a follow-up visit to discuss prior authorization results/sit in on the p2p.

This way, you get compensated for your time by billing for the office visit and get the procedure approved, albeit a little later than you would like.
painfree23 said:
I have had many similar experiences. I say we record these calls and post them online for everyone to hear.
Click to expand...
Aetna and Cigna schedulers actually told me that its their policy not to have me record the call and that the peer would not talk to me on a recorded line LOL.
 
Asclepius186 said:
Did a p2p today on a denied lumbar TFESI with Aetna. Denial via evicore. Note documented perfectly. Repeat TFESI request when prior TFESI gave 8 months of 80% relief.

They first sent me to a nurse reviewer who asked me which specific activities the patient had impaired function in and also for physical exam findings. Exam findings were positive SLR on exam that was documented. I documented difficulty with prolonged standing and walking due to pain. She said she couldn’t approve it and had to send to p2p.

P2P doc states he was not provided with copy of the note, only provided with the reason for denial. I provide him the above information and he quickly approves. I ask him what I could have done better to prevent future denials in this manner. He says he doesn’t know.

Meanwhile patient care is delayed and my time is wasted. Awful.
Click to expand...
All that nonsense for a procedure that probably pays 200 in the office
 
Status Sciaticus said:
you could have your PA or prior auth person just request the p2p from the get-go and just schedule the P2P.
Better still, call the patient for a follow-up visit to discuss prior authorization results/sit in on the p2p.

This way, you get compensated for your time by billing for the office visit and get the procedure approved, albeit a little later than you would like.

Aetna and Cigna schedulers actually told me that its their policy not to have me record the call and that the peer would not talk to me on a recorded line LOL.
Click to expand...
This seems illegal . They can record our call for quality purposes but we can’t record them??
 
painfree23 said:
This seems illegal . They can record our call for quality purposes but we can’t record them??
Click to expand...
Not a lawyer but if any company gives you the "this call is being recorded" line, you are also allowed to record. The law simply seems to state that people need to consent to being recorded (in two party consent states. Elsewhere this argument is moot). They have already done so in this case as they are recording. It doesn't seem like they get a say in whether or not you record as well, nor do you need to notify them seeing as they already informed you about (and thus consented to) being recorded.
 
I’ve thought about making a social media account and posting ridiculous denials and insurance interactions such as this. Maybe such an account already exist. Somehow we need to let the general public know how ridiculous this has become
 
clubdeac said:
I recently just started bringing patients back in for an office visit for the p2p. It’s been effective and very entertaining to say the least. I highly recommend it
Click to expand...
Do u bill for this and do you tell the “peer” that the patient is in the room?
 
painfree23 said:
Do u bill for this and do you tell the “peer” that the patient is in the room?
Click to expand...
Yes and yes. It really catches them off guard. One tried to get me to get the patient off the line (it was a video visit) and the patient protested that they had the right to know why their care was being denied. They stayed on and we got approval. It was great
 
clubdeac said:
Yes and yes. It really catches them off guard. One tried to get me to get the patient off the line (it was a video visit) and the patient protested that they had the right to know why their care was being denied. They stayed on and we got approval. It was great
Click to expand...
How do you bill this? Also do you tell the reviewer that the patient is on the line before you start or just let them find out when patient speaks up? I’m really interested because I do too many of these and all “for free”
 
painfree23 said:
How do you bill this? Also do you tell the reviewer that the patient is on the line before you start or just let them find out when patient speaks up? I’m really interested because I do too many of these and all “for free”
Click to expand...
I let them know at the beginning and I just bill it as a level 3 or rarely 4 fu office visit
 
clubdeac said:
I let them know at the beginning and I just bill it as a level 3 or rarely 4 fu office visit
Click to expand...
Sorry for all the questions - so in ur note you state patient is there for follow up regarding peer to peer? Do u document a new exam etc?
 
painfree23 said:
Sorry for all the questions - so in ur note you state patient is there for follow up regarding peer to peer? Do u document a new exam etc?
Click to expand...
Have a PA do it and bill by time. That way the PA has an incentive to maximize the time of the physician reviewer and double whammy for the insurance company.

I have no idea if that would work but it's Machiavellian at least lol
 
the dirty trick is that the peer is almost never the same person who denied the claim. so the peer can just claim ignorance and has no responsibility. "it wasnt me who denied the claim".

the theater of bringing in a patient for a P2P may make you feel some level of vindication, and it may give the patient some satisfaction, but it is STILL not worth the time, effort, or frustration
 
SSdoc33 said:
the dirty trick is that the peer is almost never the same person who denied the claim. so the peer can just claim ignorance and has no responsibility. "it wasnt me who denied the claim".

the theater of bringing in a patient for a P2P may make you feel some level of vindication, and it may give the patient some satisfaction, but it is STILL not worth the time, effort, or frustration
Click to expand...
If the choice is to not do the peer to peer then I agree, don’t do it, it’s not worth the time. But if the decision is to either do the peer to peer for free or do it for 1.3 or 1.9 wRVUS, I pick the latter. Either way I’m spending my time arguing for the patient
 
clubdeac said:
If the choice is to not do the peer to peer then I agree, don’t do it, it’s not worth the time. But if the decision is to either do the peer to peer for free or do it for 1.3 or 1.9 wRVUS, I pick the latter. Either way I’m spending my time arguing for the patient
Click to expand...

I bill a 99214 for the peer to peer BS. Makes it more worth it.
 
clubdeac said:
If the choice is to not do the peer to peer then I agree, don’t do it, it’s not worth the time. But if the decision is to either do the peer to peer for free or do it for 1.3 or 1.9 wRVUS, I pick the latter. Either way I’m spending my time arguing for the patient
Click to expand...

bedrock said:
I bill a 99214 for the peer to peer BS. Makes it more worth it.
Click to expand...
what is the follow-up indication you are listing on the chart for billing?
 
Status Sciaticus said:
what is the follow-up indication you are listing on the chart for billing?
Click to expand...
May be a stretch but you could hit 2/3 points by saying patient still has bothersome and functionally limiting pain due to intervention denial. Document discussion and rationale for procedure with p2p. After approval again document risks with patient specific identifiable risk factors and voila you made it a level 4
 
Status Sciaticus said:
what is the follow-up indication you are listing on the chart for billing?
Click to expand...
Continued uncontrolled pain and functional limitation due to denial. P2P with patient present to help understand rationale for denial and reinforce that it is in fact medically necessary and clinically indicated
 
clubdeac said:
May be a stretch but you could hit 2/3 points by saying patient still has bothersome and functionally limiting pain due to intervention denial. Document discussion and rationale for procedure with p2p. After approval again document risks with patient specific identifiable risk factors and voila you made it a level 4
Click to expand...

I figured you could do follow-up to assess pain improvement/status prior to reconsideration as well "just to be sure" immediately prior to p2p for updated information.
 
You must log in or register to reply here.

Similar threads

P
DOJ v United Health Care
Replies
11
Views
2K
hyperalgesia
hyperalgesia
bedrock
The “right” to healthcare
Replies
13
Views
1K
SSdoc33
S
M
American Board of Pain Medicine - 2025 Exam - Study Forum
Replies
2
Views
1K
DOctorJay
DOctorJay
P
A Legacy of Lies Is Stalling the Quest to Cure Alzheimer’s
Replies
8
Views
1K
Ducttape
D
Ligament
Pending disaster in American health care system; shortage of supplies
Replies
8
Views
1K
SSdoc33
S
Top