Games insurance companies play

The Pediatric Insider

© 2014 Roy Benaroch, MD

Here I am, on my “day off,” trying to get an insurance company to pay for something for one of my patients. Or not pay for something—honestly, they’ll do whatever they’re going to do, they don’t care what I say—but I need to at least make it look like it’s not my fault. That’s the game, see. Confused? Let me explain.

Bob has been in speech therapy for a year, and has been doing well and making good strides. Though they had been paying for the therapy, now the insurance company is balking—their letter to mom says that they don’t feel that the therapy is “medically necessary” any more. (I suppose it’s not medically necessary to talk. Maybe they’ll give him a little chalk board to tie around his neck instead.)

So mom, understandably, contacts the insurance company. They tell her their decision is based on information they got from me. Me! They didn’t ask me for any information, and I haven’t heard a word about this. Anyway: Insco tells mom that they’ll have to start a peer-to-peer review, alleging that one of their doctors will speak with me. Mom calls me to pass along their phone number. I’m supposed to call them. That very phrase gives me chills. You’ll see why.

By the way, this is one of the biggest insurance companies in Georgia. I suppose I can’t say directly who they are, but their name rhymes with “Goo Moss/Goo Field”, if you catch my drift.

Anyway: I call “Rue Toss”, and find out that they’ll only accept phone calls between 9-12 and 2-5. When I’m most busy with, you know, scheduled patients. The sick kids I trained to take care of. These phone calls should take priority over patient time, if you ask “Moo Floss”.

I finally did get a chance to call them, this morning, of course on my day off (that’s pretty much the only time I could possibly be free during those hours.) And I listened to a 5 minute message—which ended with a recording for me to leave my name and number. I had to call at a specific time just to leave a message that could have been left at 2 AM! They promise to call me back within 48 hours.

And I guarantee they’ll call me right when I’m seeing actual patients. Or they won’t call me at all, though they’ll tell mom they tried to. Golly, your doctor just won’t speak with us!

The saddest part: they’ve already decided that they’re not paying for this service. I know this. In all of my years, these phone calls and appeals for things like speech therapy have never worked. This whole game has been created by the insurance company to make mom think that this is all my fault. Oh, says the insurance company, we decided this based on what your doctor told us. If he’ll just call us, we’ll reconsider. That’s a load of shit. They’ll waste my time, hope I give up, and do anything they can to make doctors look like the bad guys.

Man up, insurance. If you won’t pay, just tell your “members” that it’s not a covered service, and leave me out of it. You obviously don’t care what I recommend, so stop pretending that you do.

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3 Comments on “Games insurance companies play”

  1. jack Says:

    So how do you really feel about?


  2. jack Says:

    It .. sorry, was supposed to be ‘so how do you really feel about it?’ But my pinky hit return too quickly … 😦


  3. Dr. Roy Says:

    UPDATE: Insco did call be back the same day…. to put me on hold while they got their physician to talk to me. She was pleasant but had no questions whatsoever. She already had all of the information I had. I told her, yes, we want to appeal. That was the extent of that Useful Clinical Interaction that will surely improve the health of my patient.


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