I used to say “coverage is not care!” Now I say “coverage is a deterrent to care!” It has come to this.

So, it has come to this… You write a prescription for your patient for a medication that has perfectly eliminated the patient’s symptoms for years, but the patient’s insurance company has hired a company to “manage” the patient’s “prescription benefit.” So, the prescription becomes nothing but a request triggering a letter that the patient must ask the doctor to call the secondary company “to arrange a review.” Under the expressed threat, quote, in bold print: “If your doctor doesn’t call and get approval, you’ll be responsible for the full cost of the medication(s).”

I love my patients. They come to me for help. I have spent my life studying, training, and serving them. The prescriptions I write for them are not subject to 3rd party opinion. But, I acquiesced and called. First, no one answered after prolonged ringing, and I got a robot message to try again later. Then I called back, and after multiple layers of prompts, finally got a human and then was disconnected. So, I called back the 3rd time enduring the multiple layers of time-wasting prompts and got back to a person who then began collecting personal data about my patient and me- what is the patient’s insurance identification number, name, birthday, zip code, diagnosis, what did I write the prescription for? Name of drug, spelling, instructions, amount, refills, what’s a vial, how is that written, what’s my name, office address, phone number, NPI (national provider identifier), DEA number… Then I had to answer questions the clearly non-medical person was reading from scripted prompts. I informed the person I don’t write prescriptions for fun; I write them when they are indicated, and who is he to intervene- effectively denying care and potentially harming the patient- which amounts to practicing medicine without a license… The person gave the classic scripted apology, that they sense my frustration… But whatever.

In all, I wasted 25 minutes that should have been spent caring for other patients. This scam is a flagrant squandering of money, time, and resources—why? So the insurance company can increase their bottom line. We are forced to buy insurance; the insurance company gets our $, they keep our $, and they increase their bottom line every time they deny our care. Imagine if the money they spent on 3rd party agents of delay and denial of care was instead spent actually facilitating access to care! This is one insane, perverse, unethical mess.

This underlying insanity, perversion, and unethical pattern of doing business is why I opted out of Medicare and all agreements with 3rd party insurers. I work solely for my patients. They can file claims for my services as an “out of network doctor” if they choose, or they can file with their secondary insurer to use those benefits instead of Part B Medicare. My fees are reasonable, fair, and less than some copays now.

Imagine paying huge premiums for plans with $100.00 copays, $5000.00 deductibles, and benefit delays and denials- from restricted networks and formularies…this is where we are. This is why we must rise up in mass resistance and say NO MORE, doctors and patients united to restore sanity and the ethical practice of medicine based on the private, individualized patient-doctor relationship. What a waste. What a screw job. I used to say over and over again, “coverage is not care,” but these days it’s worse; coverage is now a deterrent to care. We must stop bending over and stand up strong for good.

Here is the copy of the letter with private patient data extracted. This is nothing more than a scam- theft of precious medical resources that is harmful to patients:

review letter

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4 thoughts on “I used to say “coverage is not care!” Now I say “coverage is a deterrent to care!” It has come to this.

  1. Hi Kristen…I don’t know how much we might have in common otherwise. A lot or a little. But your post is outstanding in every way and truly represents the horrifying, mind numbing conundrum faced by caring physicians across the country. You said it just right and with appropriate passion and indignation. The problem is getting worse, literally by the month. The solution will have to cross all party, philosophic and economic lines. For this problem, everyone with a special interest, on all sides, is going to have to give up the ghost and swallow a dose of reasonable morality for once. I’m not holding my breath.

    • Hi Dr. Mark,
      Thank you for taking time to read and comment. I agree with your comments 100%. What we do have in common is our shared rite of passage through medical education to a life in patient care. Only those who like us have survived this long, arduous, tumultuous journey can relate on the necessary level. We will have to take a bold stand together as physicians for the sake of our patients. The patients are waiting for us to stand for them. The time is now.

      • You’re so very right. I suppose we chip away at it. We could definitely use a more effective voice. Lord knows our professional advocates aren’t helping much —

  2. Yes, this is nonsense and illegally practicing without a license and these pencil pushers should be sued, arrested, or whatever. As a chiropractor, I am not allowed to opt out of Medicare and have to put up with non-chiropractic garbage that does not follow my state’s scope of practice.

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