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As you may know, I am a family physician in a public (read "free") clinic. Most of our patients have no insurance. But, due to the primary care physician shortage, we also see people on a variety of health insurance plans who can not find other doctors in the area who are taking new patients. Therefore, I have a handful of clients who are on different Medicare and Medicaid HMOs.

Recently, I have noticed a confusing/annoying trend. Mountains of paperwork are being faxed to my office daily. Much of the paperwork is not worth the trees that are dying to make the fax paper. A typical fax will go something like:

"Did you know that patient X has disease Y? If so, why isn't he taking drug Z?" Never mind that he really is taking drug Z. Or is allergic to drug Z. Or drug Z is not  indicated for what he has. The insurers want us to fill out the form and send it back.

Why? Maybe the answer has something to do with a loophole in the new health care law. Insurers are required to spend 85% of premiums on health care and Quality Assurance.

When is "quality assurance" not health care? Here are some examples:

1. One insurer demands that a nurse get on the phone for 30 minutes each month and talk to one of their representatives before they will authorize payment for a refill of a medication that the patient has been taking for years. They ask the same medical questions over and over again each time we call. They reach the same conclusion--the medication is appropriate for the patient. We have tried to get an authorization for several months at a time. No luck. We have to call each month. And you can get the drug for $4 at most pharmacies, meaning that it is dirt cheap---so it isn't about saving money. Is the insurer adding the cost of these phone calls to its tally of health care expenditures for the patient? If so, it is paying itself for "Q&A" which is not helping the patient at all.

2. Today an rx for drug V was denied. Then, we were told that we could prescribe name brand V. This makes no sense at all. If the managed care plan has a contract with name brand V, then they can instruct their participating pharmacies to dispense name brand V whenever a member shows up with a prescription. Why go through the trouble of sending a fax telling the doctor that the rx was denied but an "alternative" (that is really the same medication) is recommended? I can't know for certain, but if the insurer can claim that this was a "Quality" issue, then it can send itself a bill---and call it health care.

3. Deny one test but recommend another. If you ask for a CT scan, they say "Get an MRI". If you ask for an MRI, they say "Get a CT scan." Typically happens in situations in which either test would be appropriate. Again, can be labeled "Quality assurance."

4. Ask for additional documentation. And more documentation. And  a diagnosis code. And more documentation. Finally, send a fax saying "No pre-authorization is required for service___" just to rub salt in the wound.

This has gone way beyond the usual "deny as many tests as we can get away with to save the HMO money" that I am used to. Most of this paperwork accomplishes nothing except it takes up the time of doctors and nurses who really need to be seeing patients. Note that none of the faxes ever suggest a test that might have been missed and needs to be ordered, like a mammogram or bone density scan or a diabetic eye exam. That would be Quality Assurance. What I keep seeing is time wasting nit picking.

Can any denial or delay of service be called QA? Can any computer generated letter mentioning a potential side effect of a drug decrease the amount of money the insurer has to spend on actual health care? Is anyone keeping track of how much money the various insurers are claiming to spend on Q&A?

Sorry for the rant, but the thought of filling out an hour's worth of paperwork so that some health insurance company can deny a Medicare patient hundreds of dollars of care  burns me up.

Originally posted to McCamy Taylor on Tue Jul 23, 2013 at 04:58 PM PDT.

Also republished by Community Spotlight.

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