A voice from the other end of the doctor-insurer conversation
As a physician who spends some of my time working as a medical director for health insurance companies, I was eager and trepidatious to read Dr. Tessa Adzemovic’s Dec. 7 Ideas piece, “A phone call speaks to all that’s wrong with American medicine” — eager to learn something about her perspective of the “peer-to-peer” discussions regarding insurance coverage in which I engage several times a day but apprehensive that it would be overwhelmingly negative.
Coverage for a patient’s treatment is often denied because the information to substantiate the request is absent or has been misinterpreted by a previous reviewer; then my role is to try to clarify any omissions or misunderstandings to see whether we can get to yes.
Sometimes my job is to explain that due to an employer’s coverage decision or government insurance program regulations (MassHealth or Medicare) the treatment cannot be covered. It might be because the treatment is investigational or experimental or involves a doctor who is not in the insurance network when equivalent care is available within the network. I work with an open mind, hoping to find the information necessary to either satisfy the protocols that health insurers employ or identify a reason to override them.
Get The Gavel
I sympathize with Adzemovic’s assertion that she has not had time to eat breakfast or lunch and that the time she spends talking to me takes her away from her patients, but I feel that the blame for that rests with her employer, not me. And I am insulted by her aversion to considering me a peer and the overwhelmingly disrespectful tone she takes in attacking physicians like me who choose to bring our training, expertise, and humanity to the table in an effort to resolve the somewhat incompatible goals of restraining unsustainable health care costs and providing quality care.
Perhaps with time and experience, Adzemovic will temper her approach to the peer-to-peer experience. Until then I will cringe if her name appears on my list of calls to make.
Dr. Robert Bargar
Laguna Niguel, Calif.
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