Fraser Cobbe

Orange County Medical Society

Seminole County Medical Society

A key component of bending the health care cost curve is rooting out waste and nonvalue added processes in the care delivery system. Physicians continue to express concern at the avalanche of administrative processes being imposed by insurance carriers as doctors try to authorize and receive payment for medically necessary services they render to patients. In the eyes of many, the administrative burden has exploded in recent years and significantly drains limited resources and impacts the efficient operation of their practice.

Legitimate utilization review is understandable, but all too often is seems like process has defeated common sense. Below is the latest example submitted to our office:

"We have a claim denial we are working on where the MRI showed the patient had a medial meniscus tear. When the physician got into the procedure he found that it was not torn like the MRI showed and turned out she had horrible Chondromalacia, so he did a Chondroplasty. The insurance carrier is denying the claim because there wasn't prior authorization for the Chondroplasty.

On the initial call to the provider customer service number challenging the denial, I was told, if we find there was no tear as originally thought and what was authorized, we should stop the procedure, bill a diagnostic scope and reschedule the Chondroplasty procedure. I responded, 'I'm sure that you would not want to pay two anesthesia sessions, procedures, etc. Nor would the patient want two copays, deductibles, etc.' I just laughed and asked to be transferred to Provider Relations."

While this is a single and extreme example, it illustrates the frustration physicians and their administrative staff feels in dealing with insurance carriers. If you repeat this process and correspondence countless times each week, you can understand the waste and burnout these professionals feel while trying to help patients.

Insurance carriers certainly need to conduct appropriate utilization review, but a larger dose of common sense and collaboration would greatly help the efficient delivery of health care. It is time for payers to recognize the increased cost and take action to eliminate the administrative waste they are causing.