Behind the Scenes of an Insurance Denial

I have a college student with a half year of abdominal pains in the liver area. It's an annoying condition and occasionally prevents him from going out with his friends. It is getting worse and it's becoming more and more pronounced, but still not debilitating. He's very worried about it, thinking it might be cancer or something. I'm less worried, but I can't come up with a plausible explanation for his pain. We checked the routine abdominal related blood work and everything is normal. We checked the urine, and that's fine. We ruled out hernias, and his pain is too high for that anyway. His liver ultrasound came back normal, and I can't find anything wrong on exam. Still, his pain is worsening. He's not the type to see the doctor when he gets sick, so I know that when he comes in to see me for a second visit, something's wrong. So now, I'm more worried about a growth of some sort in his abdomen. I order a CT scan to get a better look and make sure we're not missing something.

I know that his insurance company will need a good reason to pay for the CT scan. The only reason I can give is increasing abdominal pain over a period of months. He's not throwing up, having bloody diarrhea, or losing weight. If he had any of those, I would have put that down as a diagnosis in an instant, because I know they would pay for a CT then. But I couldn't lie on the referral for a CT scan, so I wrote down increasing pain. They denied it, predictably. My referral receptionist spent about 20 minutes on the phone initially to call the insurance company to speak to someone. Then because the simple diagnosis didn't trigger the right buttons, the insurance company clerk asked my referral receptionist for more reasons. She came to find me, had to wait for me to finish with a patient, and ask me for more justifications. I'm a terrible liar, so I didn't lie. My receptionist then went back to the phone to finish talking to the insurance company clerk who said that she would ask the medical director for the approval. My receptionist has now spent 40 minutes of her time working on this referral.

A few days later, both the student and I get a denial letter in the mail. I also get the same letter by fax. It says that I can appeal the decision. I would just have to call the 1-800 number. When I call, I am on hold for about 10 minutes to talk to the insurance company's medical director. (I can't call after work hours because they only work from 9-5, so I have to run late for an appointment to wait on hold.) The medical director asks me why we need a CT scan. I tell him that the ultrasound and blood tests are negative, but the patient continues to have pain, so I want to do more testing. The medical director then tells me that since the previous testing was normal, we probably don't need a CT scan. He said that the patients symptoms did not justify a CT scan. I tell him more about the patient. He says that he can't give medical advice but that he can't authorize the CT.

By denying requests, the insurance company saves a lot of money. It costs them perhaps 30 minutes of administrative time to deny one request, which might save them a $1000 CT scan. The insurance company pays a secretary and a doctor to do that denial, spending about $300. Hey, they just made $700 with one denial! Hire more denial specialists!

The patient came in today to ask about his denial letter. It took my receptionist about 5 minutes to explain the situation to the patient and another 5 minutes to come tell me about it. I've spent 30 minutes on this problem, and my receptionist has spent 40 minutes on this problem. That's a cost of at least $300 for our office, which our patients have to pay for.

Meanwhile, the patient won't be getting a CT scan. I hate to leave him hanging, since I can't figure out what's wrong with him. So my only other option is to refer him to see a gastroenterologist. I'm pretty sure that's a waste of time and money because he'll see the physician's assistant at the GI doctor's office who won't have any better ideas than I do. The insurance company will then pay for the GI doctor ($500) to repeat my blood tests ($300) and a likely endoscopy ($1000) when a simple CT scan would have answered all of everyone's anxieties. But perhaps the insurance company will try to deny payment for some of those services too. I'm still not sure what to do next with him.

In all of my dealings with Medicare (a government-run plan), they have never denied a test. I've never had to talk to a Medicare denial specialist because they don't exist. I know that if I order a test, it will be covered. There is no waste in this denial nonsense.

I get so frustrated with the amount of insurance paperwork. In private practice, it added an hour to my day. A full hour of frustration: changing medications to suit a new formulary, filling out the form for a 3 month supply of medications, justifying why a prescription medication is needed over an over-the-counter type, and dealing with denials. It's fraud if I stretch the truth so something would be covered. I want to help my patients as much as possible, but I don't want to be accused of fraud either. It's a difficult position for me, and I hate being caught in the middle of it.