Doing our part: Become an Independent Reviewer

Unfair insurance denials have caught public attention recently, with patients and physicians alike frustrated with underhanded insurance practices denying care to persons in needs. The questionable ethics of these practices has been well described. Here is one such report published last year that is alarming. Check it out here.

Well, how can we rectify these misdeeds? One way of doing our part is to sign up to be an independent insurance reviewer.

Patients who feel they've received an unjust health insurance denial have the right to appeal the denial to an independent reviewer. An independent reviewer is a physician that is not a paid employee of the insurance company but is asked to review the denial and grant judgment on whether the denial is justified. I've been performing such reviews for a couple of years now and I find it a good way to keep insurers honest. Here's an example company here

I've seen many such unfair denials and was able to rectify the wrongdoing. Many a times an insurance company fails to adhere to its own policies. By reading the fine print, you can correct the error.  Sometimes it's an insurance company applying a very narrow definition to a medical record and ignoring other important facts of the case.  It's also a good way to see what patients experience when we, as physicians, don't take responsibility for the appropriate documentation.

Don't get me wrong, many times the insurance companies are right, and you see firsthand the waste of sloppy medicine. Often providers request high dollar, unproven, treatments before even trying well established, evidence-based, lower-cost therapies. In those cases, the insurance companies are correctly demanding evidence-based care, and you must uphold the denial. The providers are then forced to revise their care plans. You get to see the dysfunction firsthand both ways and work to correct it.

I've also found these reviews reinforce my own knowledge of treatment evidence in my own practices. Insurances companies routinely sight the medical studies that defend their policies. It's a win-win.

In summary, while it does require patience and attention to detail, often combing over fine print and policy documents, I've found it immensely satisfying to play a part in fixing a situation and helping a patient in need. Yes, it's a grass roots, one-patient-at-a-time, effort. But it does make a difference to those that need the help.

Cheers,

Benjamin J. Blow, M.D.