Why Are Insurance Companies Telling Doctors How to Practice Medicine?

graphic of balance scale with doctor equipment and coins

When a doctor makes a decision for their patient, they draw on years of medical school training and hospital experience. Frequently, however, physicians have to double-check with insurance companies to make sure that their recommendation is “appropriate” before they can actually provide their patients with medicine and services.

And, if the insurer says so, the doctor may have to put the patient on a “cost-effective” alternative or withhold their prescribed treatment altogether.

As unbelievable as it sounds, it is becoming commonplace for doctors and their staff to have to fight with insurance companies in order to secure the care they believe their patients deserve.

How Do Insurance Companies Control Doctors?

Known as “utilization management” or “utilization review,” insurance companies have set up systems that allow them to evaluate and overrule doctors. According to the insurance industry, utilization-management tools allow payers to manage healthcare costs by assessing the appropriateness of patient-care decisions against so-called “evidence-based guidelines.”

Broadly speaking, the 4 most common utilization-management strategies are:

  • Prior Authorization (PA): Some medications and treatments require that physicians obtain PA before prescription. Without PA, insurance plans will not pay, regardless of what the doctor says.
  • Step Therapy: Also known as “fail first,” step therapy involves trying the least expensive options before “stepping up” to costlier drugs.
  • Quantity Limits: These set limits for a particular medication a patient may receive during a specific time-frame.
  • Nonmedical Switching: This is when a patient’s medication is switched for reasons other than the patient’s health and safety. It might happen when an insurer no longer covers a medication, and a stable patient will be forced to switch.

In theory, these tools provide a check on doctors overprescribing needlessly expensive treatments and medications. Unfortunately, in practice, utilization-management techniques are saddling doctors with time-consuming requirements and delaying necessary services for patients, who often suffer as a result.

As insurers broaden their use of these techniques, many patients have started to wonder if some companies have crossed over from promoting cost-effective healthcare decisions into bad faith insurance.

Putting Patient Safety Behind Profits?

Prior authorization requirements for medications and treatments were once reserved for a small fraction of new and expensive procedures. Increasingly, though, doctors and their staff are spending time getting ordinary drugs, tests, and services approved by insurance companies.

In Michigan, public health advocates are working with lawmakers to rein in these cost-cutting measures. The Michigan State Medical Society (MSMS) is advocating for a bill that would increase transparency by requiring insurers to post information about pre-approval rules on their website.

Dr. Bobby Mukkamala, a specialist surgeon in Flint, Mich. and head of MSMS, told ABC Detroit that prior authorization requirements are a needless hurdle that hurts patients. By the time Dr. Mukkamala is seeing his patients, he knows they will need a CT scan in order for him to make a decision about what to do next. Even so, he must seek PA from insurers.

“It’s a very inefficient use of our time,” he said, “and then the worst part of it is those CT scan requests get approved in excess of 90% of the time, more like 95%.”

Along with burdening doctors, the unnecessary red tape is delaying care to people who need it. In Mukkamala’s view, such prior authorization requirements are “really just a way to delay care in the hopes … that some people will give up and just not do it.”

Insurance Technicalities Tie Up Human Lives

When insurers stand in the way of a doctor’s decisions about care or treatment, it can have an immediate and negative impact on a patient’s health.

Edgar Allen Beem, a columnist with the Portland Press Herald, wrote about a terrifying experience he had trying to receive proper care for pancreatitis.

After treatment, Beem was still not feeling well, but a young doctor who was part of his team told him he had to leave the hospital. It didn’t make sense to Beem, or his gastroenterologist, who reminded him that he had severe pancreatitis, lost 50 pounds, and just started a new medication. Beem writes:

“When I objected to being discharged against my will, the young doctor brought a case manager to my bedside and they informed me that if I insisted on staying, I would have to pay out-of-pocket. I concluded the doctor cared more about pleasing the health insurance company than treating the patient.”

So Beem went home. The next day, he suffered a massive internal hemorrhage. He came back to the hospital in an ambulance and spent the next 6 days unconscious in the intensive care unit.

When Beem was denied care, he nearly lost his life, and the insurance companies were forced to pay more. The voices of both specialists and patients were silenced, and everybody lost.

These healthcare roadblocks cause real problems, and it’s a little hard to swallow the cost-cutting justifications because these insurers are so profitable. Beem notes that his insurer, Aetna, had roughly $2 Billion in profits before CVS bought it last year for $69 Billion.

Meanwhile, as patients suffer, executives and board members take home millions of dollars each year.

Step Therapies ‘Not Based on Clinical Data’

Everyone can understand the need for efficient and scientifically-based care decisions, but sometimes the incentives seem to be more about lower costs for insurers than anything else.

At the 2019 Annual Meeting of the American College of Rheumatology, Jessica Farrell, PharmD, and Madelaine Feldman, MD, spoke about the difficulties that utilization-management tools cause, and the lack of science guiding their use.

Rheumatologists treat various forms of arthritis, osteoporosis, and autoimmune diseases. Their patients come from a range of backgrounds and often require specific medication. Because of this, Feldman believes that specific sets of step therapy for every single patient “really shows that it’s not based on clinical data.”

It’s easy to see how forcing patients onto cheaper medication is good for insurance companies, but patients pay the price.

Because of step therapies, doctors are often forced to try a few drugs that they would not ordinarily recommend. They are also forced to “fail first” before “stepping up” to the medication the doctor originally prescribed.

During this time, Feldman said patients often see a worsening of their condition.

Patients Deserve Care, Not Bad Faith Insurance

When someone gets sick or hurt, they rely on the healthcare system in order to get better. When patients with legitimate claims are denied by their insurance company, it’s a crime.

The problem is that no one person can stand up to the institutional power of a large insurer. They have medical experts and lawyers who are standing by to deny the claims that insurance companies simply don’t want to pay.

Consider the story of a Washington State fire chief who was struck from behind by a motorist while he was on the job. Even though his department signed off on the incident, Washington’s Department of Labor and Industries (L&I) denied his worker’s compensation claim. Suddenly, this local hero was facing a long-term legal battle with no paycheck.

Unlike many similar stories, this one has a good ending. Three days after the local NBC affiliate reached out to L&I for comment, the department reversed its decision. It seems like once the story was about to go public, L&I second-guessed its decision to deny the claim of a public firefighter serving his community.

The truth is that some insurance claims are denied in bad faith. When that happens, it can put unimaginable pressure on a recovering patient and their family.

It’s simply not right.

An experienced legal advocate can make the difference between suffering and getting the care you need. If you have been denied in bad faith, it is not your fault. Call us right away and we will start working to get your claim the respect it deserves.

Author:Sokolove Law
Sokolove Law

The Sokolove Law Content Team consists of writers and editors who work alongside the firm’s attorneys and case managers. The team strives to present the most accurate and relevant information for those who need legal help.

Last modified: November 26, 2019

View 4 Sources
  1. ABC News WXYZ Detroit, “Michigan Bill Would Curb Pre-Approval Rules in Health Care.” Retrieved from https://www.wxyz.com/news/michigan-bill-would-curb-pre-approval-rules-in-health-care. Accessed on November 25, 2019.

  2. American Journal of Managed Care, “How Prior Authorization, Step Therapy Result in Medication Discontinuation and Worse Outcomes.” Retrieved from https://www.ajmc.com/conferences/acr-2019/how-prior-authorization-step-therapy-result-in-medication-discontinuation-and-worse-outcomes-?p=1. Accessed on November 25, 2019.

  3. NBC K5 News, “Denied 3 Times: Injured East Olympia Fire Chief Wins Fight With State.” Retrieved from https://www.king5.com/article/news/investigations/the-state-denied-his-claim-3-times-after-a-crash-almost-killed-him-now-the-east-olympia-fire-chief-is-getting-justice/281-ed1f7aff-7509-4e3a-993d-5bb63cb35533. Accessed on November 25, 2019.

  4. The Portland Press Herald, “The Universal Notebook: Health vs. Insurance.” Retrieved from https://www.pressherald.com/2019/11/05/the-universal-notebook-health-vs-insurance/. Accessed on November 25, 2019.