When Insurance Companies Play Doctor

Let me just state right up front that I am exceptionally grateful for insurance companies and for the fact that I can afford fairly good health insurance that puts a great medical team and some very expensive drugs within my financial reach. I know that it’s an incredibly difficult business, particularly with the shifting landscape of recent health insurance legislation. It has to be a very tricky balance of containing costs while meeting their fiduciary responsibility to those who are insured.

I get it.

All that aside, it makes me a bit crazy when it appears that insurance companies cross the line and actually start practicing medicine.

As an example, medication is a primary area that affects RA patients and insurers alike. What is and isn’t covered along with the step programs and pre-approvals is a quagmire that can hinder or even prevent a patient from receiving the treatment that the doctor has ordered. From various news stories and headlines I understand that some doctors can be overzealous in ordering tests or hospitalizations to either (a) cover themselves from potential malpractice suits or (2) help line their pockets because they have a financial interest in the testing facility or hospital. However, I think those are the exceptions and frankly, in my personal experience, I’ve never run across a doctor that orders unnecessary medications. So when a doctor orders a certain drug (such as an expensive biologic) because it’s a different kind of drug than all the other biologics that have been tried without success, it should be the doctor’s and patient’s decision.

However, I also recognize that insurance companies must set guidelines and at least pharmacy schedules are pretty black and white. You might not like them, but you can understand them.

Other things aren’t quite so straight forward.

Last month I saw a new doctor for some chronic heel/ankle pain. I had treated it myself for a few weeks with ice and anti-inflammatories but it really wasn’t improving. The doctor did an exam, took an X-ray and nothing apparent showed up, so he gave me a steroid injection, prescribed some stretching exercises for my overly tight Achilles tendon, and told me to continue with the home treatment I had been doing. He finally instructed me that if things weren’t considerably better in six weeks that he wanted to see me again and we’d need to do an MRI to see if the tendons were damaged or if there was other soft-tissue involvement.

Six weeks go by and the steroids helped but the ankle was still giving me issues. I called the doctor’s office and explained the situation and asked if the doctor wanted me to just go ahead and get the MRI done before I came in. Otherwise, I’d pretty much come in for an office visit, the doctor would probably tell me I needed an MRI before we could go any further, then I’d have to come back yet again once I had the MRI done. The nurse looked at my chart, agreed with the plan of action, then called me back about an hour later saying that the doctor also agreed and had written the order for the MRI. She said the scheduling nurse would verify my insurance coverage and call me back to get it scheduled.

Here’s where it gets interesting.

A bit later the scheduling nurse calls me to say the insurance company would not cover the MRI until I first had a follow-up office visit – which is exactly what we were all trying to avoid. So I scheduled the follow-up visit for a few days later, which cost me both an hour and a half’s worth of time and a $50 copay. But it also generated unneeded cost for the insurance company. While my copay was $50, the doctor is an orthopedic surgeon and his office visits cost hundreds of dollars, all of which, excepting my $50 copay portion, was paid by the insurance company. And in all honesty, both the doctor and I were scratching our heads because while the insurance required he take another X-ray (in which nothing had changed) and he re-examined my ankle, his original assertion that we needed an MRI to go any further remained unchanged. It was a total waste of both of our times and my dollars.

So I love insurance companies when they act like insurance companies. They negotiate and pay reasonable rates for medical services and products. They help keep these fees in balance while making quality medical care affordable for many of us. But when they play doctor and start ordering unneeded doctor’s visits, the result can be both disruptive and expensive.

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