The Newest Assault to Patient’s Access to Treatment: Health Insurer’s Paper Review of Medical Necessity
By Lauren E. Adler, Jacob W. Gent
October 26, 2017
As providers, you have probably already experienced firsthand the headache that comes from dealing with a Personal Injury Protection (PIP) auto insurer and its hired gun, the Independent Medical Exam (IME). Over here, we pointedly call it the “Insurance Medical Exam,” because it most certainly is not an independent assessment of a patient’s treatment needs, and almost always stinks of the auto insurance company’s intention to cut off your patient’s benefits prematurely.
Compared to PIP insurers and their sinister IMEs, health insurance companies can sometimes seem friendlier, or at least more inclined to provide access to needed care for patients, subject to deductibles and co-payments.
Unfortunately, health insurers seem to have caught the IME virus. Lately we have seen certain health insurers outsourcing a patient’s claims to third party vendors, such as eviCore and Healthways, to paper review a health care professional’s treatment recommendations. These vendors bring in paid physicians to review chart notes and “pre-authorize” medical treatment that you, the provider, have recommended, even treatment that is already covered by the policy. The review process delays payment, disrupting the patient’s treatment, negatively impacting recovery, and adding additional stress to the patient in an already difficult situation. The review is done behind closed doors without examining the patient, and the result is almost always a “medical determination” that further treatment for the patient is no longer needed or necessary—far before the treating provider recommends discharge. In most cases, this means the patient is left out in the cold and cannot get the care they need.
In implementing this shady practice, health insurance companies were well aware that it would raise objections and would likely result in legal action against them. To cover themselves, they now insert contract-type language into their policies which gives the insured “notice” of the third-party review practice, meaning a patient agrees to it by signing up for the policy.
For example, a typical Premera policy now includes the following:
Premera has developed or adopted guidelines and medical policies that outline clinical criteria used to make medical necessity determinations. . . . . Practicing community doctors are involved in the review and development of our internal criteria.
Premera reserves the right to deny payment for services that are not medically necessary or that are considered experimental/investigative. . . . When there is more than one alternative available, coverage will be provided for the least costly among the medically appropriate alternatives.
Premera’s website states:
Effective July 1st 2016, members enrolled in Premera’s or LifeWise’s program will require an authorization from eviCore healthcare. Starting June 17th, 2016, providers can submit clinical information and request authorization through the eviCore provider portal. eviCore healthcare will evaluate the clinical information and determine medical necessity.
Many patients have already fallen prey to this new unfair practice by their health insurers, and have complained to the Washington State Office of the Insurance Commissioner (OIC). Unfortunately, the OIC has determined that third party vendors are, for now, permissible, so long as an insured is made aware of the conditions when signing up. However, the OIC has kept the door open on this issue, stating that it needs to hear from more patients and providers on how this practice is harmful. If it gets enough feedback from the public, it may take action.
Patients and providers alike must object to the OIC on this, loudly and uniformly. If your patient is hurt, they should be able to receive health benefits due to them under the policy they paid for. There are enough bad actors in the insurance world without adding vendors like eviCore and Healthways as yet another way to deny medically reasonable and necessary treatment.
We encourage patients, their family members, and health care professionals to file a complaint online with the Office of the Insurance Commissioner here:
If the response is strong, the OIC will take action to shut this corrupt practice down. Please make your voice heard and encourage your patients to do the same. Together, we can fight back to make this practice unlawful in Washington State.