One frustrating aspect for spine surgeon Bethwel Raore, MD, is peer-to-peer reviews and getting insurance coverage for his patient's care.
Dr. Raore, of Apex Spine & Neurosurgery in Bethlehem, Ga., joined the "Becker's Healthcare Podcast" to discuss where he wants more accountability from health insurance companies.
Note: This is an edited excerpt. Listen to the full conversation here.
Question: How do those plain denials affect your relationship with your patients? How do you navigate explaining these complex challenges while still trying to provide the care that they ultimately need?
Dr. Bethwel Raore: It is very sad. Recently I had a patient in the office who was absolutely frustrated, and the only person standing between the patient and the surgery is me. It's the physician who's delivering the information. They don't have the insurance company's person to come and tell them, "Hey, we've denied your surgery." I'm the one who has to deliver that information. So most of the time, the backlash is on the physician and the physician's office.
You get everything from rage to tears to threats, and several of these patients are in pain. They're in anguish. I have a patient who is in so much pain they can't even walk, and the MRI has been denied three times. Now you wonder, what is the recourse for this patient? They're mad. It is by no means a good thing. Sometimes I almost wish that the insurance person would come and tell the patient, "Hey, by the way, I'm the insurance. I'm the one paying for it, and I'm not going to pay for this, so you can't get the treatment that your doctor has recommended."
Q: What changes would you like to see in an ideal world, implemented in the peer-to-peer review process for some of these insurance claims in the future?
BR: I think that a lot of changes need to be made in this process. For instance the insurance company can deny care without repercussions. One of the worst players … regarding their role are the physicians and the nurses who work for the insurance companies. These are the people who took the Hippocratic oath to take care of the patient, but they will deny them coverage. They will deny imaging. They will deny medication that the patient wants to get, or that their physician has recommended, but they absolutely have no responsibility when this disease progresses. Then when there's a death, they have no malpractice exposure in all of this. This is ridiculous. The insurance companies are able to achieve what they're achieving because other physicians and other nurses and healthcare providers are participating.
I'll just finish with this one situation where a middle-aged female who's pretty active in her community has some back pain. At some point the primary care provider orders an MRI and that's been denied. They say, go to physical therapy, and she's going to therapy, and the MRI request is denied again. The circus of MRI denial goes for about five to six months, and by the time I am seeing the patient she has a foot drop. When we got the MRI through the emergency room, she had metastatic cancer destroying the sacral and L5 vertebral body.
When you dig further you're thinking, "What could have happened six months ago when this should have been found?" Could it have been avoided? Yes. This brings the whole picture of what we are seeing right now. This issue deserves a conversation, which it is now getting.