Inside knowledge of managed care helps the author get the services his patients need?without a fuss.
Inside knowledge of managed care helps the author get the services his patients needwithout a fuss.
A Massachusetts cardiologist was upset that a health plan wouldn't pay for ECGs done the same day as an office visit. He called the carrier to complain. His first message wasn't returned, so he left more, becoming angrier and more threatening each time. Finally, after leaving 12 messages over two days, he got an answer.
The insurance company sent recordings of the doctor's messages to the Massachusetts Board of Registration in Medicine. The board sent an official, with two police officers in tow, to the doctor's home at 10:30 one night to give him notice that his license had been suspended. It was reinstated only after a psychiatric evaluation.
Who hasn't become frustrated with the myriad people who run our medical lives? Raised voices and intimidating remarks often seem like the only way to get satisfaction. But having been on the other end of that phone line, I can tell you that threats don't work.
Until recently, I was a part-time utilization review physician for two insurance companies in California. I've spoken to my share of angry doctors. Many have yelled, a few have threatened to sue, and some have even asked for my license number to file a complaint with the medical board.
I was intimidated for the first month or two, but I gradually became adept at handling such situations. My employer trained me to deal with these calls, and I talked with other, more-experienced reviewers about their techniques. In one company, we reviewed and critiqued audiotapes of our difficult calls. After a while, I stayed calm even during the most abusive calls.
Like me, most reviewers are ready to handle anything you dish out. If you get abusive, they'll simply tell you they're going to hang up if you continue. Also, a summary of your conversation is forever stored in the patient's record. If you verbally abuse the employee, he will make a note about it that will color all your subsequent contacts with the company.
If you want to get results, try the following strategies instead.
As a reviewer, I was more likely to bend the rules with someone who was really nice, because he made me want to help.
I was also more likely to get results for a caller who was clear about what it was he wanted from me. So, before you pick up the phone, set a goal. Decide what you want, whether it's to be paid for ECGs or to get a procedure authorized. Once you've decided on your goal, evaluate whether it will be worth the time you or your staff will have to spend achieving it.
If you decide to launch a complaint, instruct your employees to take careful notes of the conversation. A staffer should note when she called, the name of the employee she spoke to, and what that employee said. The HMO representative is supposed to make a note in the computer of what he said, but he may get distracted and never do so or may mischaracterize the exchange.
I follow this advice myself in my own practice. I've called insurance companies to find out why I wasn't paid for a certain procedure and been told that no one there would have approved my request. But since my assistant and I started taking good notes, I've been able to say, "Joan told me the visit was approved on a one-time basis when I spoke with her at 2:15 on April 17th." That usually resolves the matter.
When the situation is not so easily fixed, the real trouble begins. We tend to get angry at the idea of someone denying our prerogative as a physician. These limits are unfortunate, but there is no point in browbeating a member-services representative. He has to follow the rules or he'll get in trouble with his boss.
Another important point is to make sure you speak to the right person.
While it often makes sense to speak directly to a supervisor, sometimes your initial contact person may approve a request that a supervisor wouldn't. Nurses at one place I worked would occasionally approve a procedure like a carpal tunnel release because they misunderstood the guidelines. Later, the doctor's office would call for approval for the same procedure on the patient's other hand and talk to a different nurse reviewer, who would send it to me because it didn't meet our criteria.
When I recommended more conservative therapy, the doctor would become apoplectic: "But we just operated on the left side two months ago. How come you approved it then?" I would tell him that I wouldn't have approved it, and that he was lucky he had talked to a nurse that didn't understand the criteria.
Generally, however, asking to speak to someone higher up the totem pole is a good idea. Here's an example of a successful negotiation from my own practice: An insurance company mistakenly assigned a new patient to our office long after we had closed our practice to new HMO patients. I advised the patient to call the insurance company to see what it would doknowing from experience that the carrier would probably pay for a single visit rather than send him elsewhere with an acute problem.
As I was finishing some paperwork, I overheard his conversation and realized he wasn't getting anywhere. I scribbled, "ask for a supervisor" on a piece of paper and handed it to him. He did sopolitelyand after a few minutes, the representative told him they would pay for the visit. As I expected, her supervisor approved the payment on a one-time basis.
The clerk didn't understand that her company couldn't penalize a customer for its own mistake, but the supervisor did. I knew that in these days of regulatory oversight of HMO actions, the company wouldn't want a complaint like this to reach a higher level. All I had to do was get to someone high enough in the organization who knew this.
So if you're getting nowhere, it usually pays to quickly ask for a supervisor. After that, go to the medical director. You may argue that you don't have time to talk to all these people, but I've found you can usually tell very soon whether you're going to get anywhere.
Don't forget to use all weapons at your disposal to argue your case. In California, for example, a new law prevents insurance companies from forcing patients to change medications they have been on for years. When knowledgeable doctors in this state call for formulary exceptions, they can quote this law to circumvent a long discussion where the insurance company attempts to force them into a substitution.
Find out about these new rules from reading the summaries of recently passed state laws that many insurance companies send physicians. These newsletters often contain useful information, so I recommend skimming the information briefly, rather than automatically tossing them into the trash.
I had the opportunity to see how insurance companies operate from behind the scenes, but you can obtain some of this information by asking questions. If you've kept the conversation courteous, you can ask the person who denied your request how the company makes these decisions, and who else you can talk to.
For instance, in the companies I worked for, the nurse had the authority to approve a request, but referred any denials to a physician. The physician reviewer then spoke with the requesting physician and could approve or deny.
You may feel like managed care has gotten your goat, but following this advice will help you accomplish your goals.
Gil Solomon. Insurance hassles: Dont get mad, get results. Medical Economics 2001;17:100.