The Other Side of Insurance Denials: A Doctor Opens Up

A doctor who once worked to approve - or reject - insurance claims shares a truth from 'behind the scenes', anonymously.

I just saw a post of yours from several weeks ago regarding physician reviewers. The question was posed as to whether surgeons should be making determinations around psychiatric issues. You had noted that reviewers may be incentivized to deny.

I can share my brief experience trying on the role of physician reviewer.

Frequently, it didn’t matter what my medical opinion was. The review outcome was based upon a predetermined decision tree that didn’t allow for nuance.

“Was said requirement met?”

“Yes” or “No”?

I was never incentivized to make a determination either in favor of or against a request.

I was never pressured to answer one way or the other AND often the need to exercise my medical judgement was irrelevant due to the existing decision tree.

What I found frustrating was the lack of transparency around the guidelines. If physicians could just know the “rules” ahead of time, it could save so much time and effort while maximizing patient care.

Those are my 2 cents.

I know the conversation is old, but I did want to ‘defend’ the physician reviewers to the degree that they are not (at least in my singular experience) making decisions based on financial incentive.


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One Response

  1. This article is spot on. As a physician newly working in UM, I often say “why don’t we learn this”in clinical practice and feel like the system would benefit greatly from more transparency and simplification.

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