“Health” Insurance companies have begun moving into the realm of delivering, or even more specifically - rationing, “healthcare” more and more over the past 10-20 years. Once upon a time, the doctor made the medical decisions for a patient - he or she knew the patient well, weighed risks and benefits, had a conversation with the patient and chose the best course of action. Today, the doctor’s role has been diminished in large part due to the interference of insurance companies.
If I want to order an MRI of my patient’s shoulder (of course following clinical guidelines on timing and indication) I cannot just send an order and have the patient get the MRI. Nowadays, I have to ask permission first. When I call the insurance company, I am usually sent to a “third party” - a company who handles prior authorization requests for that insurer. When I finally connect with a person (which often takes more than 30 minutes) I have to play a game of cat and mouse, answering questions in just the right way so that the non-medical-person on the other end checks off the right boxes that allows the automated system to determine whether my medical order for my patient is “approvable.”
If I’m lucky, it ends there. But many times that information is collected and passed along to another party who reviews my medical decision making and the information I have collected from my patient to decide whether our request is worthy of “coverage.” When coverage is finally granted - i.e. when the non-medical personnel who works for the third party who works for the insurance company deems my order for a patient of mine satisfactory and worthy of approval - I am able to pass that approval along to the local imaging place who often speedily schedules the patient for the test.
I wish I could say this is unique to ordering medical imaging. It is not. I encounter this routinely with medication prescriptions, cardiac testing, and sometimes even specialty referrals or labs. At every step of the way, the patient’s “health” insurance is choosing to block the direct care from me, as the patient’s primary care doctor, to the patient, causing us both to jump over hurdles. Many doctors just don’t have time for this practice and so, when such an authorization is denied they simply accept the insurance company’s decision and the patient cannot get the test/medicine/image.
In Direct Primary Care practices, like here at Direct Doctors, we have the least involvement with insurance companies as possible. What this means is:
You may not have a reason to think you would ever care about your insurance company having your diagnoses on a list or making your doctor jump through hoops to get the “coverage” you believe you’re already paying for, but we have seen many instances where patients appreciate what we do. If it matters to you to have the utmost privacy in your medical health and history, we’re happy to discuss more about how we practice primary care differently. Set up your first appointment with us here!
Lauren Hedde, DO; James Hedde, DO and Mark Turshen, MD are Family Physicians and Co- Founders of Direct Doctors, Inc. a Direct Primary Care Practice.