Fraser Cobbe

Orange County Medical Society

Seminole County Medical Society

In previous columns we have expressed concern with the expansion of Utilization Guidelines, Prior Authorization and Peer Review processes being implemented by health insurance carriers. Most major health insurance carriers outsource their utilization guidelines to third-parties which provide a degree of separation between the insurance carrier and the insured (as well as the physician trying to care for that insured.) Policymakers, physicians and patients are expressing increased concern over the medical decision making by these third-parties as well as denials or delays in treatment and increased administrative costs.

Most recently we received a communication from a physician expressing concern about a total joint replacement treatment guideline initiated by eviCore. eviCore is a third-party contracted to implement utilization guidelines by carriers including Aetna and Cigna.

Our physician shared a story of recommending a total hip replacement to a 45-year old former hockey player who experienced such pain in his hip that he struggled to walk and could not put on shoes without assistance from his wife. The patient was denied a total joint replacement by his insurance company because he had not failed a trial of 24-weeks of walking on a cane.

The eviCore treatment guideline for knee or hip replacement quoted by the insurance company in denying the claim requires a patient to experience pain for a period of six months that substantively interferes with their quality of life and ability to perform activities of daily life before a hip replacement will be approved.

While six months of pain is probably an extreme example of the impact of insurer mandated guidelines, the chorus of concern continues to grow over insurance carriers and their contractors holding greater weight over the provision of medically necessary care.

Sound Off: We want to hear from you? If you are a patient or physician that has endured increased treatment delays or denials for medically necessary care due to guidelines implemented by an insurance carrier, we want to hear from you.

Click here to share your story: https://www.surveymonkey.com/r/D8NJQF9