Deep Throat . . . er . . . Pocket?

When my phone rings at 7 am, it usually means something's wrong. Today, it meant something very different.

A gentleman who would not give his name said he works for Care Corps International, a third-party payer that also does medical necessity reviews for insurance companies. In other words, he is the first-line reviewer deciding whether a request for prior authorization for anything from a drug to a test to a procedure will be approved. He saw my name and phone number in AARP Magazine in an article about health insurance denials of coverage and he wanted to tell me the "other side of the story."

He called to complain about doctor's offices. He said offices with "employees with foreign-sounding names" provide less good care. He said he often calls a doctor's office for more information and, instead of getting a medical professional on the phone, he gets "someone without a high school education." He remembers one call that will "stay with [him] always," in which he asked a doctor's office about the patient's symptoms and the person on the other end of the line said "huh," apparently not understanding the question.

He complained that his company often faxes a request for additional information to a doctor's office, and all they get back is the same information they were given in the first place. He was very annoyed that doctors won't take the time to call them back and explain their treatment plan. When he has questions he can't get answered, he explained, the claim gets denied unnecessarily. And it's the doctor's fault, not his or the insurance company's.

Oh -- and by the way -- especially when someone's on Medicaid, he said he believes "we" should have a say in the medical care they get.

When I suggested that these reviewers are a big part of the problem, leading to unnecessary denials because their requests for additional information are so burdensome, he blurted out the following. He is audited monthly. He has to dispose of a certain number of cases per hour. Each health plan has different criteria for medical necessity, so he has to keep track of all of them. If his "certification rate" -- the rate at which claims are approved or denied -- is too low, he can lose his job.

I don't know about you, but I'm not thrilled with the thought that medical necessity decisions are being made (1) by someone with a bias against foreign-sounding names; (2) by someone with a bias against people on public programs like Medicaid; (3) by someone who denies medical necessity because the person at the other end of the line doesn't understand his questions; (4) by someone whose job performance is measured by the number of claims he processes per hour; and (5) by someone who has to "certify" (or not) a certain number of claims per hour. Nor am I thrilled to be reminded that, a good part of the time, our doctors' offices don't provide reviewers with the information they need to approve the claims (which is why I ALWAYS tell patients they have to gather and submit their medical records with their appeal).

My anonymous caller -- who said he didn't expect anybody to answer the phone at 7 am, and had planned only to leave a message -- thought he was giving me information that should make me blame medical offices, when all he did was further confirm that patients are getting screwed from all sides.

And think about it. Why are the criteria for medical necessity different for each insurance company? If we're talking medicine -- science -- shouldn't the criteria be the same?

But of course, we're not talking medicine. We're talking money. Jennifer