I Need A treatment To Save My Life and My Doctor Says The Insurance Company is Deciding What They Will Pay For. When Did The Insurance Company Become My Doctor?

There are so many things that have affected medical treatment in the last thirty years or more. Technology has come so far and because of it we are living longer and we are paying much more for health care.

Living longer means less populous generations than the Baby Boomer generation will have to pay Social Security for that group and Medicare will have to pay longer per person than they did for our grandparents or maybe great grandparents.

When my grandfather had a heart attack in the 60’s and another in 1974 that was eventually fatal, rest seemed to be the big part of the treatment. Now if a heart attack is diagnosed and treated quickly enough with a stent and proper medications a pretty full life may be available for many more years. Rather than Cobalt 60 radiation therapy treatment from the 1970’s calculated by hand, high-energy xray radiation therapy is available and sensitive organs receive considerably less dose with higher more lethal dose delivered to tumors.

Being a lawyer I agree with litigation in reasonable medical malpractice circumstances. But I see doctors constantly running scared of being in a lawsuit. A friend of mine works in a medical field that supports emergency room services. My friend tells me of the nurse practitioners and physician assistants that support the ER doctors and like their MD or DO counterparts order a plethora of tests in fear of not having met the standard of care. Even under Obamacare’s attempt to cover everyone, many still have no health insurance and use the emergency room as a clinic, arriving many days after a slight fall or cold, etc requiring at times the use of multiple ER services. While my personal physician has known me for many years and can generally use reasonable approaches to diagnose any malady of mine, its not that way in other circumstances where a long term relationship has not been established and a fear of a lawsuit may drive the diagnosis of an illness or injury rather than more straightforward approaches learned in medical school or their years of experience.

Finally to your question. In higher technology areas of medicine such as radiology, radiation oncology, cardiology, etc. doctors are being checked on their approach to treatment by insurance companies. Included are specialties where the treatments are incredibly expensive such as when using chemotherapy.

Insurance companies may employ their own physicians or use a company such as Care Core.

What I am seeing are doctors determining based on studies, normal organ tolerance, and their years of experience in their specialty that their chosen modality for treatment will not be paid for by the insurance company because their doctor employed or contracted, possibly not credentialed in the area of practice in question has turned down payment for the modality best considered by your doctor. If nurses or billing personnel are unable to convince an insurance company of payment for a specific modality, then your doctor will have to put aside clinical duties in order to fill out paperwork or participate in a telephone call peer to peer review to plead your case for a certain treatment. I am told Medicare seems headed the way of the insurance companies.

For the past few years doctors and hospitals have sought to qualify under “Meaningful Use” in order to be paid additional funds under Medicare. Medicare is now moving away from the Sustainable Growth Rate formula for payment and Meaningful Use to MACRA and Quality Payment Programs. Supposedly this initiative will cause Providers to provide more cost efficient care and result in healthier patients. Ideally this sounds good, but I think in the interest of Providers staying afloat to pay their staff, etc. they may change the way they practice medicine geared towards “whatever it takes” rather than quality patient care. We will see.

This article is informative only and not meant to be all inclusive. Additionally this article does not serve as legal advice to the reader and does not constitute an attorney- client relationship. The reader should seek counsel from their attorney should any questions exist.

"No representation is made that the quality of legal services performed is greater than the quality of legal services performed by other lawyers."

Mailing address: Ronald A. Holtsford, Esq. • Ronald A. Holtsford, LLC • 7956 Vaughn Road, Box #124 • Montgomery, AL 36116 • (334) 220-3700 • raholtsford@aol.com

The views of this editorial may not express the views of The Alabama Gazette.