CPM Summer 2018 - 19

daup h i n c m s  .o
.o rg

Why am I here? Reality is managed care
organizations and insurers save money. In
the course of doing so, some have made
lots of money, which makes them an easy
target because the methods of doing so,
when executed badly are simply bad. But
insurers would not exist if they did not save
money over the old world of free market
Fee for Service. Employers and government
would eliminate insurers and go back to the
good old days.
How, you may ask? Join me as I reveal
the secrets of managed care.
The magic word is "Medical Necessity." A
simple concept, it simply says things should
be done that are medically necessary. I've
written articles on how important it is to
define that term carefully, but in short, it
means things should be paid for when they
are needed, effective, in the right place, at
the right time, for the right duration. The
twist added by insurance companies is it
should be a "covered service." That means
that a bunch of actuaries calculated what
it should cost to give medically necessary
care to a group of people, and what services
should be paid for by the insurer. That
involves a delicate balance between lots of
services, and minimum services, affordability
and regulations. The Affordable Care Act
specified a very specific set of "minimum"
services that must be paid for, and discussion
on the appropriateness of that set is another
article well written by many others.
Like the current partisan world of politics,
there are folks on both side of the aisle
(insurers and physicians), who take an
extreme view and blame the other side for
all the woes of the healthcare world.
I will point out that there are abuses on
both sides. That does not mean we can get
rid of, control or eliminate either side. The
solution needs to be bipartisan. But I drift off.
We jokingly call the insurer side the "Dark
Side." Let me share a few tales.

Medical Necessity used to be determined
by the Medical Director making decisions on
cases. In most insurers now, they use national
or regional standards and guidelines created,
vetted, and with input from local or national
physicians with the expertise to offer a valid
opinion. The appeals process serves to control
the occasional abuse. When done right, the
process works (and the national news about
the medical director who never reviewed a
chart is an aberration, not standard.)
I called a board-certified pediatrician once
who had discharged a child early, who had
to be readmitted. We had ruled that the
hospital should not be paid for two separate
hospitalizations, when the child had to be
readmitted within a day or two of discharge.
She had failed to follow AAP guidelines
on treatment of hyperbilirubinemia while
the baby was inpatient the first time. She
appealed the decision, so I called to ask on
what basis. Her reason, "Those guidelines
don't apply to me."

An ENT proposed to operate for a fairly
common problem. I denied, and he appealed.
Not being an ENT, I reviewed based on
expert opinion and current standards of
care, offered to me in guidelines. I asked
why he wanted to operate. His reply, "I've
been doing it that way for 25 years." I'm
sorry, doctor, but the standards of care have
changed in 25 years, and that's not current
best practice.
Insurers save money over the Fee for
Service world by controlling costs with
negotiated contracts. They may have the
market power if large enough to control
your income. But they also do not pay
for care that is not Medically Necessary.
Contracts help, but successful companies
also eliminate unnecessary payment for care
that is not indicated.
If you believe what you propose to do is
necessary, and you have been denied, ask for
the criteria used. If you can argue your care,
appeal. Yes, it is painful and time consuming,
but you can force change if the criteria are
wrong, or if there are unique circumstances
for this individual patient. But don't ask for
something that is not needed, inappropriate,
or not a contemporary standard of care.

It's a raw fact that about 10% of requested
prior authorized services are denied. (And
if you think prior authorization is asked for
unnecessarily, let that sink it, because they
wouldn't do it if it didn't "Pay.") Insurers
would lose their edge if physicians never
asked for medically UNnecessary services,
and we might even be able to return to the
"good old days." Until physicians stop asking,
A colleague in Orthopedics, whom I and only doing what is Medically Necessary,
respected from my clinical world, sent a that will never happen. Let's cross our aisles
case in for review. He proposed to operate and ask how we can work together to do that.
for low back pain. I searched the record for
evidence of neurological signs, impingement,
Meanwhile, I'll keep working on the
severe pain with an operable cause like a dark side trying to make things better
disc impingement that failed to respond to for the hundreds of thousands of memtherapy. Failing to find it, and before denying bers we have under our plan. In practice,
it, I called. The reason given for proposing I influenced the care of a couple of thousand.
to operate, "Well, you know... Sometimes
if you just open them up they do get better."

Opinions are my own and do not represent any opinions or official position of my employer.
Central PA Medicine Summer 2018 19


Table of Contents for the Digital Edition of CPM Summer 2018

CPM Summer 2018 - 1
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