Physician Prior Auth Reviewer...ethics

[mgriffiths]

One of my many frustrations is that physicians who approve and deny prior authorization are generally shielded from any liability related to their decisions.  This is especially frustrating with news articles like this:

https://www.forbes.com/sites/robertglatter/2018/02/11/former-aetna-medical-director-admits-to-never-reviewing-medical-records-before-denying-care/?sh=22215c8535e5

 

Well, today I received word that a prior auth review physician I reported for ethics violations, poor medical decision making, and practicing outside his license received a disciplinary "strike" and their license is under further review.  This specific individual was actually out of state from where I live, but basically I had a patient who had a history of cancer, thought to be in remission, with a suspicious bone lesion found incidentally on XR.  Follow-up MRI was performed, and while inconclusive continued to be concerning, so in consultation with the radiologist, an orthopedic oncologist, and myself a bone scan with SPECT was recommended.  This was denied by insurance and in an attempt to expedite I performed a peer-to-peer which again was denied.  Upon the final determination I requested the physician reviewer's name.  Only after providing it (which they always do when I ask) I tell them I will be including their name in the patient's chart and also providing their name to the patient.  This person I decided to google and lo and behold the little  was an OPHTHALMOLOGIST!!  An ophthalmologist reviewing and determining the medical necessity of an orthopedic imaging order.

To make a long story short...immediately following the peer-to-peer I filed a grievance with the insurance company and directed my patient to as well. The next day I reported the physician to his state medical board for gross negligence and the unethical practicing of medicine outside his area of expertise.  After a somewhat tense 72 hours the scan was approved and patient is currently undergoing treatment.  Last I knew the patient is doing well and has a good chance to go back into remission.  The physician reviewer on the other hand may lose his license.  I would hope remove him from being able to serve in prior auth review...but unfortunately I doubt it.  But, overall a win, however small.

[ventana]

strong work.....

 

my less dramatic story

19 years ago

new grad

L5 Radic with loss of reflex

MRI denied, reviewer stated he wanted PT

Same thing - asked for name and license, then profession - freeking retired pathologist.  Only time I have ever politely ripped into a doc (Was a 1 yr PA) demanding when the last time he even saw a living patient and that I would be providing the patient with him name and license number.  TaDa MRI approved.....

 

sad it has not changed....