Insurers can set your head to spinning fastv

Insurers can set your head to spinning fast

A while ago, my wife awoke with her third episode of incapacitating vertigo of the summer. The first two times, she had responded to hydration, anti-emetics, and antihistamines. But this episode seemed more severe, so we went to an experienced ENT. He gave her stronger drugs and ordered blood tests, an audiology exam, and an MRI. When we went to schedule the MRI, my insurance carrier's radiology benefits manager denied the claim. I find this amazing.

When a board-certified specialist orders an exam, which is clearly within his area of expertise and in which he has no financial interest, how can someone with only minimal information on the patient deny the claim? The answer is always the same: money.

A new beast has appeared on our playing field, the radiology benefits management firm (RBMF). Some RBMFs play like they're in a rugby match. They talk about "quality," but these companies exist for only one reason-profits.

The RBMF is yet another example of healthcare dollars going to people who provide absolutely no healthcare. It is, however, a really good scam. A large insurer might spend a billion dollars on imaging. It contracts with an RBMF that agrees to cut that billion by 5%, or $50 million. The RBMF then sets up tremendous roadblocks through preauthorization, which may decrease utilization by 10% or more. A hundred million healthcare dollars are "saved," and half go to the RBMF. The other $50 million go to the insurance company bottom line. In the case of a company like Blue Cross, that's almost enough to pay the CEO's annual bonus. Meanwhile, $100 million worth of medical care is not provided.

The boldness of the scammers is impressive. They constantly preach how they are eliminating unnecessary imaging and making ordering physicians accountable. I don't buy it. They pay physicians and nurses to limit the number of exams done. They are not providing healthcare-their sole purpose is limiting it. Who has determined that the people at the RBMF know more than my wife's ENT with 20 years' experience in private and academic medicine? No one.

The whole process of preauthorization is basically a financial roadblock. For a busy physician, time is money. Every time a precert is denied, the referring physician faces a personal financial decision. Is the test important enough to spend more money (in the form of unbilled work hours) to try and get it done? The referring physician has already spent money employing the person who made the initial request that was denied. How appealing is it to spend more? Insurance companies and RBMFs know this. They know that by simply denying a high enough percentage of precerts, they can make bundles.

The results of my wife's MRI are not life-shaking to her ENT. Why should he be expected to spend his money to get it done? If there is a delay in the diagnosis of her eighth nerve schwannoma, it won't kill her. No one at the RBMF is waking up vomiting over it, so a delay is really no big deal.

I don't know any of the CEOs of these companies or the insurance industry. But I dealt with enough powerful people when I worked in Washington, DC, to learn firsthand that they are quite willing to set up standards for the rest of us that they will never live under themselves. I'll bet my first-born son that if one of their spouses couldn't walk or stop throwing up for a day or two, and her physician ordered an MRI, it wouldn't get denied.

Dr. Tipler is a private-practice radiologist in Staunton, VA. He can be reached by fax at 540/332-4491 or by e-mail at btipler@medicaltees.com.