Your Insurance Company Plays Doctor – Without a License

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I know in the state of Missouri, the insurers have no license to practice medicine, but they do anyway and we as a community let them.

Yesterday I spent the day writing letters to insurance companies to try to get payment reimbursed to my patients: for medications they have picked up at the pharmacy and their insurance refused to cover; to inform them that their letter telling me what I can and cannot give a patient is not welcomed; to tell me that I must write a drug for diabetes that I have never heard of instead of a well tested drug, (Juvamet) and the patient must take it for three months and fail it before he could have the “real thing”; to inform them that because they choose not to pay for my testosterone therapy for women and sometimes for men that they should butt out of sending me letters telling me what to do with my patient. When did insurance companies and Medicare become doctors and what gives those business people the right to tell me, a doctor who has over 30 years experience, how to practice medicine?

I know in the state of Missouri, the insurers have no license to practice medicine, but they do anyway and we as a community let them. You may not know it because you may not know what is happening behind the scenes, but your insurer plays doctor every day, behind your back!

The most egregious fake-doctoring by an insurer, called fraud in the real world, was displayed in a letter I received from one of the Blue Cross subsidiaries yesterday. I take care of head injury patients and replace their hormones and stimulate neurotransmitters with supplements so they can have a normal life and live a normal life span. A month ago I saw a young male patient (30s)who had had his life saved by medical care. When he was a young teenager he had a brain tumor that invaded his pituitary, and he was treated with surgery and radiation, which saved his life but resulted in destroying the part of the pituitary that stimulates testosterone (T) production, stimulates the thyroid, and makes growth hormone (GH). His follow up care provided a small amount of injected testosterone—not enough for a teenager—and they never replaced his growth hormone. Sadly this is where surgery often fails—we fail to fix what we caused after the surgery is successful.

The result is that he is 4 ft 10 inches and he had all of the symptoms of low testosterone and thyroid. He cannot feel or think or perform as an adult male. He has sought treatment but was always given levels of testosterone that were too low and he never felt right so he just stopped taking anything. He is miserable. I treated him with testosterone pellets, and thyroid, and will probably give him a GH stimulator to see if he can get his REAL life back. He had to pay for this therapy himself and I thought it would be obvious to his insurer that he needed his testosterone, thyroid and GH replaced and his insurance would reimburse him.

Here is where his Insurance decides that they know more than I do they deny payment because he doesn’t have adequate “diagnosis” for receiving testosterone, and the person playing doctor had never heard of his brain cancer, and they probably have no medical training and are just following a template provided by his insurer. This is the person playing doctor for the insurance company—an unqualified secretary! Your life is in her hands.

I spent the morning writing a detailed letter and sending his records so they would reimburse him for his every 6 month treatment with pellets. It is paid for on behalf of aging men, unless they use the excuse that they don’t pay for bio-identical testosterone, even when other forms haven’t worked and then they will not revisit the payment back to the patient. This man’s future quality of life depends on the “doctoring” of a computer plus a secretary. Why is this legal?

The rest of the morning I spent writing detailed letters to insurance companies for the following issues. One of my many physician patients has tried two types of diabetes medicines and he is also on testosterone, but he needs his diabetes treated and the third medicine I chose for him was denied for payment. The alternative is a drug I have never heard of and they demand a three month trial of this drug before they will pay for the one I want him to have. Why is that legal? I asked him if he’d try it and he agreed, just to get to the point where he can have the medicine I ordered in the beginning. This has delayed his adequate treatment for diabetes by over 6 months and it will delay it another three until he feels normal. Remember he is treating patients all day and if he doesn’t feel at the top of his game, others will suffer. His insurer isn’t a doctor so that fact is not considered. It is also not taken into account that he has been delayed several times due to his insurer playing doctor.

Another letter was to tell an insurer to stop torturing me with their rules! I wrote a prescription that “conflicted” with another drug this patient is on, and both I and the patient knew that I did that but we modified the dose to accommodate for the second drug. I am doctor and I can do that, because I KNOW what other drugs my patient is on and I have 8 years of medical training to depend on, so stop sending me stupid warnings from a computer!

Last letter that consumed my afternoon was to tell them that the generic medication that they use instead of brand for one of my patients is not the same as brand and it doesn’t work. The brand drug costs $1,200/ 3 months with insurance, and generic costs $900/ 3months, but the strength of the brand does not work unless my patient takes two of them. They refuse to change the generic company they dispense through Express Scripts even after I have talked to the pharmacist.

Your care is under attack by accountants and secretaries. Some folks that I know who are nurses say that their work for insurance companies in regard to developing guidelines is frustrating because they aren’t medical people, yet it is like a vacation because they rarely have to work! Soon they will provide you care over the phone so you don’t get the care you need…their goal is NOT to pay, even though you pay them. They also want to delay, delay, and that saves them money. If they frustrate you enough you and your doctor will quit trying and you will go away! Medical Care without a license….when will patients get “Mad as Hell and Tell Them They Won’t Take it Anymore”?

This Health cast was written and presented by Dr. Kathy Maupin, M.D., Bio-identical Hormone Replacement Expert and Author, with Brett Newcomb, MA., LPC., Family Counselor, Presenter and Author.

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