by Physicians Weekly | Aug 12, 2014
Any physician, especially primary care physicians, can tell you that they are frequently forced to make a decision based on a third party’s opinion. Most often, this will be an insurance company denying a prescribed medication or test; the discussion in the exam room evolves into a discussion of what is covered by the patient’s health plan—and what is not. The goal of providing the best medical care is often overruled by some of those decisions. Of course, the insurance company will tell you that they are not making medical decisions, and the patient can pay out of pocket if they would still like the medication or the diagnostic test. Most patients will chose to go with what their plan covers, either for financial reasons, or they feel they are paying an insurance premium, and their insurer should be paying for their medical care. All too often, I find myself playing the appeals game with the insurance companies in order to get appropriate care for my patients. For example, I recently saw a young asthmatic patient who was controlled on a certain inhaler for many years. They had tried others, but those had all failed to relieve the asthmatic symptoms. The insurance company decided that the patient would have to fail on a trial of one of the inhalers they had already failed on in the past before covering the current inhaler. Well, patients can end up in the ER or even die from an exacerbation of asthma. Clearly, this was not in the patient’s best interest. Why should third parties not be allowed in the exam room? *...
by SkepticalScalpel | Sep 10, 2012
The September 2012 issue of the AARP Bulletin has a story about a woman who sued an elder-law attorney for legal malpractice. Bear with me. It’s an interesting tale. In 2004, a man consulted an elder-law attorney to set up a trust that would distribute his assets fairly. He had a daughter from his previous marriage and his wife had five children from her previous marriage. The story is a bit complicated but his plan was that should he die first, the wife would inherit everything. Then when she died, his biological daughter was to receive whatever was left. But the lawyer made an error and the trust actually was written in such a way that all six children (his daughter and his wife’s five) would get equal shares of the estate instead of his daughter getting it all. Sure enough, the man died first and the mistake was discovered. Even though the wife was still alive, the man’s daughter sued the attorney for legal malpractice. He admitted the error but defended himself by saying the daughter had not yet suffered any damages so he owed her nothing. He also said the amount of money that might be left in the trust was impossible to calculate. Based on the life expectancy of the wife and the amount of money in the trust, it was estimated that the daughter should have been entitled to over $500,000 when the wife died. The court ruled that the lawyer’s reasoning had some merit but, because of the serious nature of the error, it awarded the daughter $472,000 in damages. Fine and dandy, right?...
by Physicians Weekly | Jun 29, 2012
Dear patients on insurance company X: I am very sorry to give you the bad news: effective immediately, we are no longer providers on your medical insurance plan. I am sorry about this because many of my favorite patients are on your insurance plan. It will miss seeing you. I am also sorry because this makes your already short list of possible doctors even shorter, making it much harder for you to get good care. There is a reason there aren’t many doctors on your plan: it just doesn’t pay enough to be worth it. I suspect that some of you must feel jilted, like you just got an unexpected “Dear John” letter. I hate giving this sudden bad news; I’ve been with many of you for more than 10 years, walking alongside of you through sickness and pain, births and deaths, sadness and joy. But what I hate the most is that all of this is happening because of money; it makes me feel selfish or petty. Please believe that we did everything we could to avoid this situation. Here are the things that drove us to this hard decision: 1. Your insurance was already paying us significantly less than average, and now wants to pay us even less. 2. Your insurance also requires us to do far more paperwork than most. 3. Their referral process is very complicated and frustrating. As a primary care doctor, I make my living by what I get paid for office visits. We don’t do a lot of procedures, we don’t see people in the hospital, and we don’t own a lab to make us...
